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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 ensure that a physical hold restraint was safely implemented, obtain a physician order following a physical hold restraint, investigate an allegation of abuse in a timely manner, and provide abuse training to staff. This potentially placed 17 patients on the 2B Behavioral Health Unit at risk for injury. 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 initiation of a timely investigation, upon notification of an allegation of abuse. See deficiency cited at A145-A.

2. The Hospital failed to ensure abuse training for all employees was conducted. See deficiency cited at A145-B.

3. The Hospital failed to ensure that a physician order was obtained following a physical hold restraint. See deficiency cited at A-168.

4. The Hospital failed to ensure that a physical hold restraint was safely implemented. See deficiency cited at A194.

A. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) abuse allegations reviewed, the Hospital failed to ensure the patient's right to be free from all forms of abuse, by initiating a timely investigation upon notification of an allegation of abuse.

Findings include:


1. The Hospital's policy titled, "Abuse; Patient from Abuse", (approved by 2/5/19), was reviewed on 12/23/19, and included, "1. Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that a patient with whom he or she has direct contact has been subjected to abuse in the hospital must promptly report the information to the Risk Management/Legal Department. 2. Upon receiving a report, the Risk Management/Legal Department will promptly conduct an internal review to ensure the alleged victim's safety...Law enforcement authorities should be contacted as appropriate. 3. The hospital will submit a substantiated report of abuse (Report) to the Illinois Department of Public Health (IDPH) within 24 hours."

2. The clinical record for Pt #1 was reviewed on 12/23/19. Pt #1's ED (emergency department) Provider Note (dated 11/26/19 at 6:08 PM), included, "21 y/o [year old] male with Hx [history] of bipolar disorder [psychiatric condition that causes extreme mood swings] and MDD [major depressive disorder] presents to the ED for psych [psychiatric] eval [evaluation]. ED Course: Pt to be admitted to [behavioral health unit] under MD #1 (Psychiatrist)..."

- The Behavioral Health Psychosocial Assessment (dated 11/29/19 at 12:12 PM), documented by the LCPC (Licensed Clinical Professional Counselor/ E#3) included, "Other trauma: incident on the unit/pt [patient] reports that he was thrown to the floor after staff was twisting his body and pt tried to untwist his body. And he remembers that someone stomped him on his face: reported to a nurse, but not sure who, and was sent to the ER [emergency room]." There was no documentation of an abuse investigation until 12/2/19.

-A letter provided by the Hospital indicated that Pt #1's abuse allegation investigation was initiated, and sent to Illinois Department of Public Health on 12/2/19 (3 days after abuse allegation from the patient).

3. On 12/24/19 at 9:52 AM, an interview was conducted with E #3. E #3 stated, "I met with Pt #1 to do his psychosocial assessment. The patient told me about an incident when he was thrown to the floor and stomped by an employee. The patient described the employee to me. I talked to the nurse about the abuse allegation, after I left Pt #1's room. The nurse was aware and said that there was a report made already."

4. On 12/24/19 at 10:55 AM, an interview was conducted with the Behavioral Health Director of Nursing/E #11. E #11 stated, "If a patient says that they are thrown to the floor and then stomped in the face, then this would be considered an abuse allegation. We would immediately begin an investigation and any staff that was involved would be suspended pending investigation."

5. On 12/24/19 at 12:11 PM, an interview was conducted the Director of Clinical Effectiveness/ E #1. E #1 stated, "if a patient alleges assault during the hospital stay, Security should be notified immediately. After Security comes to the patient's room, then they will offer the patient the option to notify the local police department. If there is an abuse allegation, the Risk Management Team should be notified right away, as we are on-call 24/7."

6. On 12/24/19 at 12:28 PM, an interview was conducted with the Senior Risk Manager (E #2). E #2 stated that when the patient's [family member] called the Hospital about Pt #1, then we started the abuse investigation. E #2 stated there was a breakdown in communication after E #3 told the nurse about the abuse allegation (on 11/29/19).




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B. Based on document review and interview, it was determined that for 4 of 7 (E #4, E #6, E #7, and E #8) personnel files reviewed for abuse training, the Hospital failed to ensure patients right to be free from all forms of abuse by providing abuse training to all staff.

Findings include:

1. On 12/24/19, the Hospital's policy titled, "Abuse; Patient protection from Abuse" dated 2/5/19 was reviewed. The policy required, "Procedure: 5. All employees (new and existing) will be trained in the detection and reporting of abuse of patients and retrained at least 2 years thereafter."

2. On 12/24/19, the personnel files for a Registered Nurse (E #4), and three Behavioral Health Technicians (E #6, E #7, and E#8) were reviewed. The personnel files for E #4, E #6, E #7 and, E #8 lacked documentation of any abuse training.

3. On 12/24/19 at 12:40 PM, an interview was conducted with the Director of Nursing of Behavioral Health E #11. E #11 stated that employees have abuse training during new employee orientation and every two years. E #11 stated that E #4 did not complete the abuse training, but E #4 is scheduled to complete the computerized abuse training by the end of December 2019. The Hospital did not provide documentation of abuse training for E #4, E #6, E #7 and E #8.

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 the use of a restraint was in accordance with the order of a physician.

Findings include:

1. The Hospital's Restraint-Seclusion Policy (approved 1/10/18), was reviewed on 12/23/19, and included, "...In an emergency application situation, the order must be obtained either during the emergency application of the restraint or immediately after the restraint has been applied."

2. The clinical record for Pt #1 was reviewed on 12/23/19. Pt #1's ED Provider Note (dated 11/26/19 at 6:08 PM), included, "21 y/o [year old] male with Hx [history] of bipolar disorder [psychiatric condition that causes extreme mood swings] and MDD [major depressive disorder] presents to the ED for psych [psychiatric] eval [evaluation]. ED Course: Pt to be admitted to [behavioral health unit] under MD #1 (Psychiatrist)..."

- The document titled, "Notice Regarding Restricted Rights of Individuals", included, "Physical Hold ...On 11/26/19 at 2040 [8:40 PM] Individual [Pt #1] was placed in physical hold [a restraint in which the staff restricts a patient's movement]."

- Pt #1's Physician Orders were reviewed from (11/26/19-11/27/19). The orders reviewed did not include a restraint order for Pt #1, when the patient was placed in a physical hold.

3. On 12/23/19 at 3:05 PM, an interview was conducted with the Behavioral Health Program Director (E #5). E #5 stated that the nurse should get an order for the restraint, and the nurse can get the order even after the emergent situation. E #5 reviewed Pt #1's clinical record for the physician order for the physical hold that was placed on 11/26/19, and verified that there was not an order present.

Based on document review and interview, it was determined that for 1 of 4 (Pt #1) clinical records reviewed for restraints, the Hospital failed to ensure that a physical hold restraint was safely implemented.


Findings include:


1. The Hospital's policy titled, "Restraint-Seclusion", (approved 1/10/18), was reviewed on 12/24/19, and included, "...Restraints should not be used as means of coercion, discipline, convenience, or retaliation by the staff or in a manner that causes physical pain or harm to the patient. Holding a patient in a manner that restricts the patient's movement against the patient' will is considered a restraint..."

2. The "Nonviolent Crisis Intervention Participant Workbook" was reviewed on 12/24/19, and included, "...Some restraints are more dangerous than others. For example, facedown (prone) floor restraints...are extremely dangerous."

3. The clinical record for Pt #1 was reviewed on 12/23/19. Pt #1's ED (Emergency Department) Provider Note (dated 11/26/19 at 6:08 PM), included, "21 y/o [year old] male with Hx [history] of bipolar disorder [psychiatric condition that causes extreme mood swings] and MDD [major depressive disorder] presents to the ED for psych [psychiatric] eval [evaluation]. ED Course: Pt to be admitted to [behavioral health unit] under MD #1 (Psychiatrist)..."

- Clinical Notes Report (dated 11/26/19 at 11:46 PM), documented by the Registered Nurse/ E #4, caring for Pt #1 on 11/26/19, included, " ...Pt uncooperative during the admission process ...Unable to redirect the pt so he was escorted to his room by BHT's [Behavioral Health Technician] (E #6) and (E #7). Once in the room the pt was informed that a body check needed to be done. Pt continued to be uncooperative and third BHT (E #8) entered the room, the pt was placed in a hold after many failed attempts to get the pt to remove his clothes for the body check. E #7 and E #6 had the pt in a standing position, one on the left side holding the pt's arm and the other on the right side holding the right arm. As they held the pt, BHT (E #8) informed the pt again that the body check was going to done. He attempted to remove the pt's clothes and the pt kicked him in the chest and tried to swing his arms around to hit him. At that moment (E #7 and E #6) had to take the pt down to the floor as he was getting out of control...During reassessment of the pt vitals taken, pt was also noted to have a wound to his chin that is in need of medical attention. MD #1 re-paged and notified that the pt sustained injury, and orders received to discharge to ED."

- Pt #1's Seclusion and Restraint: One Hour Face to Face Evaluation, included, "Initiation of Intervention: 11/26/19 at 2030 [8:30 PM]. Describe any abnormal findings from Systems Assessment: Injury noted to patient's chin open wound. Bruise noted under right eye."

- Pt #1's Skin Asmt (Assessment), dated 11/27/19 at 04:40 AM, included, " ...laceration in chin area, stitched with 4 dissolvable stitches per ED staff. Skin tear type 3-Total flap loss exposing entire wound bed ..."

- Pt #1 Psych Summary, dated 11/29/19 at 2:03 PM, documented by the Psychiatrist (MD #1), included " ...Course of Hospital Treatment: The patient had one episode of acute agitation, but had to be restrained. Apparently, the patient got injured, chin was broken, requiring stitches during the restraining episode ..."

- The ED Provider Free Text, dated 12/19/19 at 1:46 PM, documented by the ED Physician (MD #2), included, "Late Entry: [Pt #1] was seen in the ED for a chin laceration he sustained after admission on 11/27/19. The patient sustained a 3 cm [centimeter] laceration [a deep cut or tear in skin] under his chin ...The laceration was closed with 4 simple interrupted 4-0 vicryl sutures [stitches used to hold a wound together]. The patient was returned to his behavioral health inpatient bed ..."

4. On 12/24/19 at 10:15 AM, an interview was conducted with the Behavioral Health Technician (E #8). E #8 stated, "I was in the room when we had to do a contraband check on the patient. I was face to face with the patient when I had to explain to him why we needed to do the check. I then went behind the patient to remove his shorts. Pt #1 then kicked me in the chest. After that, E #6 and E #7 took the patient down to the floor. Pt #1's position was prone (facedown). We are not taught, with CPI training [Crisis Prevention Institute/non-violention crisis intervention], to put patients on the ground or in the prone position."

5. On 12/24/19 at 9:40 AM, an interview was conducted with the Clinical Director of Behavioral Health (E #12). E #12 stated, "On the morning of 11/29/19, the nurse on the [Behavioral Health Unit] told me that Pt #1's [family member] called and was concerned about the injury that the son [Pt #1] sustained during the restraint. I agree that an injury should not occur during restraint."

6. On 12/24/19 at 10:55 AM, an interview was conducted the Behavioral Health Director of Nursing/ (E #11). E #11 stated, "I was made of aware of the situation with [Pt #1]. The staff told me that the patient didn't want to do a body search and they had to put him in a physical hold. Generally, a patient should not sustain injuries during restraints."

Based on document review and interview, it was determined that for 1 of 4 (Pt #1) clinical records reviewed, the Hospital failed to ensure that the necessary documentation was included in the patient's medical record, as required to monitor the patient's condition.

Findings include:

1. The Hospital's policy titled, "Charting; Daily Patient Assessment Record" (approved 7/10/17), was reviewed on 12/24/19, and included, "The Daily Patient Assessment/Nursing Care Record in the health information system (HIS) is used to document assessment findings and routine care. The information is permanent in the medical record. Changes occurring after shift assessment has been completed should be documented in the clinical notes in the HIS. Changes in the patient assessment should be documented in the clinical notes. Any procedures/treatments ordered by the physician should be documented. Additional procedures/treatments should be added in the space provided."

2. The clinical record for Pt #1 was reviewed on 12/23/19. Pt #1's ED (emergency department) Provider Note (dated 11/26/19 at 6:08 PM), included, "21 y/o [year old] male with Hx [history] of bipolar disorder [psychiatric condition that causes extreme mood swings] and MDD [major depressive disorder] presents to the ED for psych [psychiatric] eval [evaluation]. ED Course: Pt to be admitted to [behavioral health unit] under MD #1 (Psychiatrist)..."

-Email communication, dated 11/27/19 at 5:53 AM, documented by the Registered Nurse (E #10) caring for Pt #1 post-incident, included, "On 11/26/19 at 23:46 [11:46 PM], patient left the unit accompanied by staff and transporter to go to the ED. MD #1 ordered patient to go the ED, post chin injury [that the] patient obtained during physical restraint by staff. Patient returned back to the unit on 11/27/19 at 00:40 [12:40 AM]. The patient's chin wound was never addressed by the ED doctor. I called the ED to speak with the charge nurse and asked why the patient's chin wound wasn't addressed. I asked to speak with the ED doctor to ask him why the chin wound wasn't addressed. Per the doctor, he only looked at the patient's lip. He didn't know anything about the gash under the patient's chin. The doctor asked me to send the patient back so he could address the chin wound. Patient left the unit accompanied by staff and transporter at 1:20 AM to return to the ED, in order for the wound to be addressed. Patient returned to the unit at 3:30 AM. Four dissolvable sutures were required to close the chin wound." The clinical record lacked documentation from the 2 subsequent ED visits.

3. On 12/23/19 at 1:45 PM, an interview was conducted with the Director of Clinical Effectiveness (E#1). E #1 stated, "Pt #1 was seen in the ED three times during this hospitalization [from 11/26/19-11/29/19]. There was no documentation from the nurses, for the two additional ED visit [11/26/19 at 11:46 PM and 11/27/19 and 1:20 AM] encounters. We identified that the standard of care was not met with the lack of documentation. There especially should have been documentation since an invasive procedure [sutures] was done, and this is why we notified MD #2 to do a late entry note [on 12/19/19-23 days after date of service]. There was only one ED encounter for Pt#1, noted in the system. There should have been a new encounter each time that patient went down the ED. We reached out to MD #2 in order to do a note, after we did a chart audit on Pt #1's medical record."

4. On 12/24/19 at 11:29 AM, an interview was conducted with the ED Physician (MD #2). MD #2 stated that, "I recall [Pt #1]. Pt #1 was a psychiatric patient that sustained an injury on the Behavioral Health Unit. [Pt #1] had an oral abrasion and a laceration under the chin. The staff sent him down to the ED for evaluation. I examined and sent him back after, because no further work-up was needed. The Behavioral Health staff then sent the patient back down to the ED because they said that the patient's chin was still bleeding. The patient then got 4 sutures in the ED and went back up to unit. I didn't chart on the patient because the encounter [visit] was closed and I wasn't able to document. I charted on the 12/19/19 (23 days after date of service) because there needed to be documentation of the care was provided to the patient."