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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure staff provided services post-injury/altercation; including medical assessments and nursing assessments. See deficiency at A-145 A.

2. The hospital failed to ensure staff filed an incident report by the end of shift as required per policy . See deficiency at A-145 B.

3. The hospital failed to notify the state within the required 24 hours timeframe. See deficiency cited at A-145 C.

4. The hospital failed to follow policy and suspend staff alleged of abuse until investigation was completed. See deficiency cited at A-145 D.

A. Based on document review and interview, it was determined in 1 of 1 (Pt #1) patients' records reviewed who were involved in altercations, the hospital failed to ensure that staff provided services post-injury/altercation; including medical assessments and nursing assessments. This has the potential to affect all patients who are serviced by the facility.

1. On 10/24/23 at approximately 10:45 AM, the policy titled, "Restraint and Seclusion (effective 05/2022) was reviewed. The policy stated, "... (pg 15) Documentation.... The assessment, as appropriate to the type of restraint or seclusion, will include but is not limited to: signs of injury associated with the application of restraints or seclusion..."

2. Pt #1's medical record was reviewed throughout the survey (10/24/23 thru 10/25/23). Pt #1 presented to the Emergency Department (ED) on 09/26/23 at 9:43 AM. Pt #1's chief complaint was abdominal pain. At 10:05 AM nursing note states, "patient yelling from room 'help me' went into room. Patient yelling at RN for pain medicine....10:16 AM: Patient was threatening bodily harm to nursing staff.... Patient then stated he is going to come out of the bed hit him in the face. NP stated to do what he needed to do, but he needed to stop cussing at the nurses and let us treat him, patient then jumped out of the bed punched NP in the face and slammed him into another RN who was slammed hard into the wall. NP struck the patient... Patient held against the wall in a therapeutic hold by NP, this RN and security until patient calmed and police arrived... " The record lacked post incident/restraint (therapeutic hold) injury assessment.

3. An interview was conducted with ED RN (E #9) on 10/25/23 at 2:45 PM. E #9 stated, "I heard all the commotion. I saw the provider holding the pt against the wall and there was blood from the pt's nose. I yelled at them to stop. I gave him some gauze for his nose. I do believe he had a cut on his forehead. No, I didn't do a nursing assessment. I didn't do anything else with him (no assessments, AMA or refusals). My only involvement was to get everybody away from each other."


B. Based on document review and interview, it was determined in 1 of 1 (Pt #1) incident reports, the The hospital failed to ensure staff filed an incident report by the end of shift as required. This has the potential to affect all patients who are serviced by the facility.

1. On 10/25/23 at approximately 9:00 AM, the policy titled, "Event Reporting Policy (effective 03/2023) was reviewed. The policy stated, "I Policy: A. Events are to be reported into the Patient Safety Evaluation System (ERS) or on an EVENT REPORT... (pg 6) Additional Reporting Events: A. Physical injury of patients, visitors, medical staff or students.

2. The event report log was reviewed on 10/24/23 at approximately 11:00 AM and included an abuse allegation related to Pt #1. The event report was completed by the Chief Clinical Officer (E #3) on 09/27/23 at 2:00 PM. The report stated, "... Section 4: Risk/Safety Event... E. Behavioral Incident.. Abuse/Neglect Alleged... Unprofessional Behavior Medical Staff (MD, Do, NP,CRNA, PA)... Pt was struck by NP."

3. Interviews were conducted on 10/25/23 between 9:00 AM and 1:00 PM with all RN's (E #5, E #6, E #7, E #8 and E #9) involved with Pt #1's incident. All RN's verbally stated incident reports should be filed immediately or by the end of shift and all denied submitting an incident report related to Pt #1..

C. Based on document review and interview, it was determined in 1 of 1 (Pt #1) abuse allegation records, the hospital failed to notify the state within the required 24 hours timeframe. This has the potential to affect all patients who are serviced by the facility.

1. A review of Illinois licensure regulations related to abuse reporting was reviewed on 10/25/23 at approximately 10:00 AM. "Title 77, SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES; PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.260 PATIENTS' RIGHTS; Section 250.260 Patients' Rights" stated. "5) Upon receiving a report under subsection (c)(3), the hospital shall submit the report to the Department within 24 hours after obtaining such report."

2. A review of the incident report was conducted on 10/24/23 at approximately 12:00 PM. The report included an email notification to IDPH on 10/4/23.

3. An interview was conducted with the Chief Quality Officer (E #1). E #1 stated, ""I thought the notification to IDPH was done before, but it wasn't sent until 10/4. The notification should have been done before then."


D . Based on document review and interview, it was determined in 1 of 1 (Pt #1) patients' abuse allegation records reviewed who were involved in altercations, the hospital failed to follow policy and suspend staff alleged of abuse until investigation was completed. This has the potential to affect all patients who are serviced by the facility.

1. On 10/24/23 at approximately 10:30 AM, the policy titled, "Patient Suspected or Alleged Abuse (effective 05/2022) was reviewed. The policy stated, "... Protection:... Employees of this facility who have been accused of abuse will be removed from patient care areas immediately and until the results of the investigation have been reviewed by Administration in collaboration with other departments as appropriate."

2. The event report log was reviewed on 10/24/23 at approximately 11:00 AM and included an abuse allegation related to Pt #1. The event report was completed by the Chief Clinical Officer (E #3) on 09/27/23 at 2:00 PM. The report stated, "... Section 4: Risk/Safety Event... E. Behavioral Incident.. Abuse/Neglect Alleged... Unprofessional Behavior Medical Staff (MD, Do, NP,CRNA, PA)... Pt was struck by NP."

3. An interview was conducted with Chief Quality Officer (E #1) and E #3 on 10/24 at approximately 11:30 AM. E #1 stated, "(Director of Clinical Operations - E #2) was informed on 9/27 that pt was struck by a provider. The provider was placed on administrative leave immediately when we were made aware." E #3 stated, "There was a call placed by the ER Medical Director to CEO (E #10) asking if (NP E #13) was on suspension or if (E #13) could come back to work. (E #10) said (E #13) could come back. (E #2) and I got a call that ( E #13) was working. We went down to the ED. (E #13) had been there a short period of time. (E #13) was sent home and didn't return. (E #13) submitted a resignation on 10/3."

4. An interview was conducted with the E #10 on 10/25/23 at approximately 10:20 AM. The CEO stated, "I found out about it 24 hours after the event. I was getting conflicting stories of the event. I notified the ED Director and the Chief Medical Officer approximately 30 minutes after my notification. The next morning, I went to the CMO. The CMO, Chief Operating Officer and ED Medical Director spoke. We didn't know for sure what exactly happened. All we knew for sure was pt ended up with a bloody nose. I believe (E #13) was suspended before my involvement. I wanted to make sure we got medical staff leadership involved as (E #13) is under their responsibility. CMO and ED Medical Director wanted (E #13) to come back. That's when we let (E #13) come back for a couple hours before we reviewed the video footage. Once the video footage was reviewed, we removed (E #13) from pt care again."