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Based on document review and interview, it was determined that the Hospital failed to protect and promote patient's rights by failing to adhere to the Hospital's abuse and restraint policy. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that an investigation of an abuse allegation was done in a timely manner or that an incident report was completed. See deficiency at A-145 (A).

2. The Hospital failed to remove alleged staff from duty pending investigation of an abuse allegation. See deficiency at A-145 (B).

3.The Hospital failed to report an abuse allegation to the State agency, as required. See deficiency at A-145 (C).

4. The Hospital failed to ensure that there was clinical justification for a physical hold restraint on a patient. See deficiency at A-154.

A. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) patients reviewed for abuse allegations, the Hospital failed to ensure that patients remain free from abuse, by not initiating an abuse allegation investigation in a timely manner or completing an incident report.

Findings include:

1. The Hospital's policy titled, "Abuse Reporting: External and Internal Events" (dated 1/16), was reviewed on 9/13/2022, and required, " ...Procedure for Reporting Internal Event: A. When suspected patient abuse and or/neglect is reported, the Program Director and Nurse Manager shall immediately report the situation to the Hospital Liaison. Hospital policy and state law requirements will be followed for investigation, additional reporting and documentation ...C. The Program Director shall complete a POIR [internal incident reporting form] and submit in accordance with [Hospital Company] policies.

2. The clinical record for Pt #1 was reviewed on 9/13/2022. Pt #1 presented to the Emergency Department (ED) on 9/3/2022 with a diagnosis of aggressive behavior. Pt #1 was transferred to an inpatient medical/surgical unit (3 East) on 9/3/2022, and then discharged home on 9/7/2022.
Pt #1's Nursing Notes from the 3 East inpatient RN's included the following notes on:
- 9/3/2022 at 2:26 PM, " ...has some patches of redness on her legs, claims she was beaten up downstairs."
- 9/3/2022 at 9:44 PM, " ...Pt received in bed ...Pt c/o pain to her right ribs. Pt stated she was beat up downstairs. She has bruises to arms and legs ..."
- 9/4/2022 at 12:50 AM, "Patient states that she was beaten up in the ER. Patient says she has pain on her right side ..."
- 9/5/2022 at 6:33 PM, " ...C/O pain to right side of abdomen ..."

A Social Services Note (dated 9/6/2022 at 1:58 PM), included, "Social Worker spoke to attending physician regarding patient. Attending Physician and Social Worker both met with patient. Patient alleges she was beaten up by ED staff. Attending physician will order CT (Computerized Tomography -Imaging) of thorax abdomen and pelvis. Social Worker spoke with Security Supervisor. Security Supervisor is aware of allegations and are following up."

3. The Grievance from Pt #1 (dated 9/6/2022), included, " ...Patient states that [she] was injured in her ribs by ED staff several days ago and that her doctors are not taking her concerns about rib pain seriously ...Pt Adv[advocate] provided some materials to Asst Sec Dir (Assistant Security Director) and handed them to him in person when briefly discussing situation. Pt Adv advised CEO of allegation from patient. Pt Adv performed brief chart review. Risk assumes leadership of investigation and leadership."

4. The Hospital's Incident Reports from 8/2022-9/13/2022, were reviewed. There were no documented incident reports regarding Pt #1, as of 9/13/2022.

5. On 9/13/2022, the Director of Safety, Security, and Risk Management (E #3), presented documentation of 3 interview statements from the 3 ED staff that were alleged in abuse of Pt #1. E # 3 stated that he got the 3 staff interview statements, but no incident report or further investigation was done, as the allegation was unfounded. The interview statements from the 3 ED staff, included the following:
- On 9/6/2022 (3 days after the incident), from the ED Tech (E#5): "I walked into the room 5 minutes after patient arrived. [The assigned RN/E #4] asked me to assist with giving the patient a catheter. The patient was flailing her arms and kicking myself and E#4 while the rails were lowered to try to help her. [An ED RN/E #6] was holding her arms to keep her from hurting the staff and herself. Prior to trying to administer the catheter the railing were up, and the patient was fairly calm."
- On 9/8/2022 (5 days after the incident), from the assigned ED RN (E #4): "On Saturday Sept 3, 2022, [Pt #1] came in by ambulance. ED provider [MD #1] ordered a urine sample and pt. refused to comply ...I let the pt know urine sample was needed and offered to assist with bedpan and commode, pt. placed on bedpan but she stated she wanted the commode. Pt. accepted commode. At this time I asked [E #6] for assistance placing patient on commode. At that time pt. became aggressive, combative and refused to provide urine sample. [MD #1] informed of pt. refusal to comply. [MD #1] provided verbal order for straight catheter to obtain urine sample. When pt. placed back in bed became even more aggressive and combative towards me and [E #6]. At this time I asked [E #5] for assistance placing straight catheter to obtain urine sample. Pt continued to be combative and aggressive, flying around in bed. Once urine sample was obtained pt. jumped out of bed and attempted to throw a chair, at which security was called for assistance ...Behavior continued until transfer to 3 East."
- On 9/8/2022 (5 days after incident), from an ED RN (E #6): "On 9/3/22 ... [E #4] asked me if I would assist her in [Pt #1's room] .... We went into [Pt #1's room], [E #4] spoke to the patient and informed her that the doctor wanted urine ...The patient said that she could not walk. [E #4] left and got a bedpan and we assisted the patient on the bed pan in bed. After a few minutes the patient said, 'I can't use this'...After a while we assisted the pt. back to bed and at that time the pt. became combative, swinging and punching at us. I restrained her arms as to prevent her from hitting us and tried to tell the patient to calm down but she kept fighting. I moved to the head of the bed while restraining the patient's arms ...Patient was straight cath by E #4 ..."
- A summation of events (dated 9/8/2022), documented by the Director of Safety, Security, and Risk Management (E #3), included, " ...These statements were provided to me by the E.R. staff on the day in question. After full disclosure from all parties concerned, the facts clearly show that there was no evident abuse to the patient, therefore the accusations made were groundless and unfounded."

6. On 9/13/2022 at 2:45 PM, an interview was conducted with the Assistant Director of Security (E #9). E #9 stated that he was made aware of Pt #1's allegation on 9/6/2022 (3 days after alleged incident). E #9 stated that when he found out, he spoke with the patient, and she expressed belief that she was assaulted in the ED. E #9 stated that the patient said that she tried to tell other people and they wouldn't listen to her. E #9 stated that when he was speaking to the patient, he saw some wounds on the patient's legs, but they looked like old wounds. E #9 stated that after he talked to the staff involved, it would have been impossible to kick Pt #1 in the ribs because he was holding her down by the arms. E #9 stated that according to the ED staff, Pt #1 was non-compliant with providing a urine sample and was aggressive. E #9 stated that he didn't fill out an incident report because he wasn't there on Sept 3rd and if there was truly an allegation of abuse, the staff would have filled one out before the 3rd.

7. On 9/14/2022 at 9:50 AM, an interview was conducted with a 3 East RN (E #7). E #7 stated that when she admitted Pt #1, the patient was claiming that she was beat up downstairs by the ED staff but couldn't tell who it was. E #7 stated that Pt #1 did have bruises on her legs. E #7 stated that she told her colleagues about what Pt #1 said but did not tell the MD or the Nursing Supervisor because it was late in the afternoon. E #7 stated that an allegation of abuse should be reported to the Nursing Supervisor and an incident report should be filled out once we find out about the allegation

8. On 9/15/2022 at 9:00 AM, an interview was conducted with the Interim Chief Nurse Executive (E #11). E #11 stated that the alleged incident involving Pt #1 was brought to her attention on 9/8/2022 (5 days after the incident). E #11 stated that once the staff is made aware of an abuse allegation, they are to report it immediately.

B. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) patients reviewed for abuse allegations, the Hospital failed to ensure that patients remain free from abuse, by not removing alleged staff from duty pending investigation of an abuse allegation.

Findings include:

1. The Hospital's policy titled, "Abuse Reporting: External and Internal Events" (dated 1/16), was reviewed on 9/13/2022, and required, " ...E. The Program Director shall immediately suspend and [contracted company] employee or any Hospital employee involved in the incident over which [contracted company] has oversight from all future patient care until the incident has been investigation has been resolved..."

2. The clinical record for Pt #1 was reviewed on 9/13/2022. Pt #1 presented to the Emergency Department (ED) on 9/3/2022 with a diagnosis of aggressive behavior. Pt #1 was transferred to an inpatient medical/surgical unit (3 East) on 9/3/2022, and then discharged home on 9/7/2022.

3. The Grievance from Pt #1 (dated 9/6/2022), included, " ...Patient states that [she] was injured in her ribs by ED staff several days ago and that her doctors are not taking her concerns about rib pain seriously ...Pt Adv[advocate] provided some materials to Asst Sec Dir (Assistant Security Director) and handed them to him in person when briefly discussing situation. Pt Adv advised CEO of allegation from patient. Pt Adv performed brief chart review. Risk assumes leadership of investigation and leadership."

4. On 9/13/2022, the Director of Safety, Security, and Risk Management (E #3), acknowledged and presented 3 interview statements from the 3 ED staff that were alleged in abuse of Pt #1 (E #4, E #5, and E #6).

5. On 9/15/2022 at 9:10 AM, an interview was conducted with the ED Manager (E #10). E #10 stated E #4 and E #5 were still at work on 9/6/2022 (day that she was made aware of allegation). E #10 stated that they both were off the unit for a while when Security was interviewing them. E #10 stated that she did not send home the RN (E #4) because she did not want to leave the unit unsafe. E #10 stated that she had E #4 pulling medications and as an extra body in case a CODE (emergency) came in.

6. The files of E #4, E #5, and E #6 (employees identified in abuse allegation) were reviewed on 9/14/2022 and did not indicate that the employees were suspended or removed from care during the abuse investigation.

7. The ED's Daily assignment sheets on 9/4/2022, 9/5/2022, and 9/6/2022, included E #4, E #5, and E #6 assigned to patient care for at least one or more of those days.

C. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) patients reviewed for abuse allegations, the Hospital failed to ensure that patients remained free from abuse, by not reporting an abuse allegation to the State agency, as required.

Findings include:

1. The Hospital's policy titled, "Abuse Reporting: External and Internal Events" (dated 1/16), was reviewed on 9/13/2022, and required, " ...Procedure for Reporting Internal Event: A. When suspected patient abuse and or/neglect is reported, the Program Director and Nurse Manager shall immediately report the situation to the Hospital Liaison. Hospital policy and state law requirements will be followed for investigation, additional reporting and documentation ...D. The Program Director will be responsible for overseeing that all notices required by state law are filed."

2. The clinical record for Pt #1 was reviewed on 9/13/2022. Pt #1 presented to the Emergency Department (ED) on 9/3/2022 with a diagnosis of aggressive behavior. Pt #1 was transferred to an inpatient medical/surgical unit (3 East) on 9/3/2022, and then discharged home on 9/7/2022.

3. The Grievance from Pt #1 (dated 9/6/2022), included, " ...Patient states that [she] was injured in her ribs by ED staff several days ago and that her doctors are not taking her concerns about rib pain seriously ...Pt Adv[advocate] provided some materials to Asst Sec Dir and handed them to him in person when briefly discussing situation. Pt Adv advised CEO of allegation from patient. Pt Adv performed brief chart review. Risk assumes leadership of investigation and leadership." Pt #1's clinical record lacked documentation that this allegation of abuse was reported to the State agency, as required.

4. On 9/14/2022 at approximately 2:45 PM an interview was conducted with the Director of Quality Management (E #2). E #2 stated that an allegations of abuse should be reported to IDPH (Illinois Department of Public Health) within 24 hours. E #2 acknowledged that a report had not been sent to the State agency.

Based on document review and interview, it was determined that for 1 of 3 (Pt #1), clinical records reviewed for restraints, the Hospital failed to ensure that a patient was free from restraint, by not having clinical justification for the use of physical hold on a patient.

Findings include:

1. The Hospital's policy titled, "Use of Restraint Policy & Procedure" (dated 2/2022), was reviewed on 9/13/2022, and required, "It is the policy of [Hospital] to limit the use of restraint to only those situations that are clinically justified and only after all alternative measures have been considered...To ensure the rights, dignity and well-being of the patient is supported and maintained...A restraint is any manual method, physical or mechanical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, or head freely..."

2. The clinical record for Pt #1 was reviewed on 9/13/2022. Pt #1 presented to the Emergency Department (ED) on 9/3/2022 with a diagnosis of aggressive behavior. Pt #1 was transferred to an inpatient medical/surgical unit (3 East) on 9/3/2022 and then discharged home on 9/7/2022.
- The Integrated Initial Assessment from the Social Services (dated 9/3/22 at 11:02 AM), included, " ...Patient Quote: 'They want to stick that thing in my pee-pee [insert a catheter] ...They wouldn't let me sign AMA [against medical advice] ..."
- A Social Services Note (dated 9/6/2022 at 1:58 PM), included, "Social Worker spoke to attending physician regarding patient. Attending Physician and Social Worker both met with patient. Patient alleges she was beaten up by ED staff..."

3. On 9/13/2022, the Director of Safety, Security, and Risk Management (E #3), presented 3 interview statements from the 3 ED staff that were alleged in abuse of Pt #1. E # 3 stated that he got the 3 staff interview statements from the alleged staff. The interview statements from the 3 ED staff, included the following:
- On 9/6/2022 (3 days after the incident), from the ED Tech (E#5): "I walked into the room 5 minutes after patient arrived. [The assigned RN/E #4] asked me to assist with giving the patient a catheter. The patient was flailing her arms and kicking myself and E#4 while the rails were lowered to try to help her. [An ED RN/E #6] was holding her arms to keep her from hurting the staff and herself. Prior to trying to administer the catheter the railing were up, and the patient was fairly calm."
- On 9/8/2022 (5 days after the incident), from the assigned ED RN (E #4): "On Saturday Sept 3, 2022, [Pt #1] came in by ambulance. ED provider [MD #1] ordered a urine sample and pt. refused to comply ...I let the pt know urine sample was needed and offered to assist with bedpan and commode, pt. placed on bedpan but she stated she wanted the commode. Pt. accepted commode. At this time I asked [E #6] for assistance placing patient on commode. At that time pt. became aggressive, combative and refused to provide urine sample. [MD #1] informed of pt. refusal to comply. [MD #1 provided verbal order for straight catheter to obtain urine sample. When pt. placed back in bed became even more aggressive and combative towards me and [E #6]. At this time I asked [E #5] for assistance placing straight catheter to obtain urine sample. Pt continued to be combative and aggressive, flying around in bed. Once urine sample was obtained pt. jumped out of bed and attempted to throw a chair, at which security was called for assistance ...Behavior continued until transfer to 3 East."
- On 9/8/2022 (5 days after incident), from an ED RN (E #6): "On 9/3/22 ... [E #4] asked me if I would assist her in [Pt #1's room] .... We went into [Pt #1's room], [E #4] spoke to the patient and informed her that the doctor wanted urine ...The patient said that she could not walk. [E #4] left and got a bedpan and we assisted the patient on the bed pan in bed. After a few minutes the patient said, 'I can't use this'...After a while we assisted the pt. back to bed and at that time the pt. became combative, swinging and punching at us. I restrained her arms as to prevent her from hitting us and tried to tell the patient to calm down but she kept fighting. I moved to the head of the bed while restraining the patient's arms ...Patient was straight cath by E #4 ..."

4. On 9/13/2022 at 12:45 PM, an interview was conducted with the ED RN (E #4). E #4 stated that if a patient is becoming aggressive, the staff should try to verbally de-escalate the situation. E #4 stated that restraining a patient should be the last resort. E #4 stated that she was the primary nurse for Pt #1 and that the patient needed to give a urine sample. E #4 stated that when she came in on day shift, she was given report that the patient was unable to urinate to give a urine sample. E #4 stated that they assisted the patient to the commode, but the patient didn't want to use it. E #4 stated that after we offered the bedpan, and she didn't use that either, MD #1 gave a verbal order to straight cath the patient for a urine sample. E #4 stated that the patient did not want this done and was refusing, but they proceeded because there was a verbal order from the doctor. E #4 stated that E#5 and E #6 assisted her when she straight cath Pt #1, as one held her hands down and the other held her feet down. E #4 stated that a patient can refuse treatment. E #4 stated that holding someone down is considered a restraint.

5. On 9/13/2022 at 1:25 PM, an interview was conducted with the ED Physician (MD #1). MD #1 stated that he recalls Pt #1 and remembers that she couldn't urinate, and he ordered a straight cath to get obtain the urine sample. MD #1 stated that if a patient refuses care or a test, he would talk to the patient to try to persuade them and let them know the importance of the test. MD #1 stated that he wouldn't force a procedure unless it was critical.

6. On 9/14/2022 at 10:05 AM, an interview was conducted with a Security Officer (E #8). E #8 stated he and another security officer were called to assist with Pt #1 in the ED (on 9/3/2022). E #8 stated the staff needed to do their job and she was kicking at them, E #8 stated that he held down Pt #1's legs until the staff performed their care.

7. On 9/15/2022 at 9:00 AM, an interview was conducted with the Interim Chief Nurse Executive (E #11). E #11 stated that a patient has the right to refuse care and should not be restrained for the staff to provide this care.