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Based on document review and interview it was determined that the Hospital failed to protect and promote patients rights by failing to follow abuse policy during an investigation of alleged physical abuse. As a result, the Condition of Participation, 42 CFR 483.13 Patient Rights was not in compliance.

Findings include

1. The Hospital failed to ensure that patients were free from all forms of abuse, by not removing staff from duty, during an ongoing investigation of alleged abuse. See deficiency at A-145A.

A. Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for allegations of abuse, the Hospital failed to ensure that a patient was free from all forms of abuse, by not removing staff from duty, during an ongoing investigation of alleged abuse.

Findings include:

1. On 07/06/2022 at approximately 11:00 AM, the Hospital's policy titled, "Response to Allegation of Abuse or Neglect on Hospital Premises" dated 07/2020 was reviewed and indicated, " ...All patients have right to be free from all forms of abuse or neglect, and protected if abuse or neglect is alleged or suspected to have occurred on hospital premises ...any person alleged to have committed abuse or neglect will be removed from patient care until a preliminary investigation is completed ..."

2. On 07/05/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a direct admit to 2 South Medical Unit on 05/03/2022 at 1:47 PM, with diagnoses of respiratory failure and encephalopathy (brain damage).

Pt. #1's clinical record included the following:

-The nursing progress note dated 05/23/2022 at 10:11 AM, included, " ...mother c/o [complained of] pt. [Pt. #1] being hit in the face by a nurse the night prior while she was getting her dressing changed and requested to be toileted ...mother states call light was removed from patient after the occurrence and there was a CNA (Certified Nurse Assistant/E#4) present during the occurrence ...mother spoke with the night Nursing Supervisor (E #2) ...who told her that there would be an investigation ...I advised I would make supervisor aware of situation and she would be contacted ...supervisor made aware."

3. On 07/06/2022 at approximately 9:00 AM, the Hospital's document titled, "Patient Grievance #22-574" dated 05/22/2022, documentation by the Nurse Manager (E #5), was reviewed and included, " ...per the night supervisor, patient alleged that a caregiver slapped her while she was crying during her care and that there was a CNA present in her room at the time ... (E #5) interview with the patient (Pt. #1) ... at 11:45 AM, I went to speak with the patient [Pt. #1] she stated the at night Registered Nurse (E #1) slapped her while he (E #1) and CNA (E #4) were providing care for her ...and that E #4 witnessed the event ...I asked the patient if at all she recollect any event that may trigger such action ...she [Pt. #1] said there was no event that led to it ...I apologized to the patient ...the supervisor (E #2) already communicated his (E #2's) decision not to have both [E #1 and E #4] work on the unit until the patient was discharged. In addition, I told her that we were going to investigate the event and follow the process and that I would be checking on her routinely ...called her [Pt. #1's] mother to update her ...initially was very upset ...call me if they have any other concerns ..." The grievance documentation included interviews with staff: night Registered Nurse (E #1), night CNA (E #4), and notes from leadership team and risk management notes. The allegation of abuse incident/event was unsubstantiated on 06/08/2022.

5. On 07/06/2022 at approximately 10:45 AM, the Hospital's 2 South Staff Schedule for night Registered Nurse (E #1) dated 05/20/2022 - 06/08/2022 was reviewed and included, "[Name of night Registered Nurse - E #1] work schedule as follows: 05/21/2022 - 11:00 PM - 7:00 AM; 05/22/2022 - 11:00 PM - 7:00 AM; 05/23/2022 - 11:00 PM - 7:00 AM; 05/25/2022 - 11:00 PM -7:00 AM; 05/26/2022 - 11:00 PM - 7:00 AM; 05/31/2022 - 11:00 PM - 7:00 AM; 06/01/2022 - 11:00 PM - 7:00 AM; 06/02/2022 - 11:00 PM - 7:00 AM; 06/05/2022; 06/08/2022." In summary, the work schedule indicated E #1 was working in the Hospital on 05/21/2022 between 11:00 PM - 7:00 AM and continued to work in patient care areas on another unit, while the investigation was still in progress until 06/08/2022.

6. On 07/05/2022 at 1:30 PM, the Nurse Manager (E #5) was interviewed. E #5 stated that he spoke with the patient (Pt. #1) regarding the incident to inquire as to what happened on 05/22/2022. E #5 stated that he did not suspend any employees from work. E #5 stated that the Nursing Supervisor (E #2) had made arrangement and allocated the staff to work on another patient unit.

7. On 07/05/2022 at 2:30 PM, the night Nursing Supervisor (E #2) was interviewed. E #2 stated that he reported the allegation of abuse to the Nurse Manager (E #5) of the Unit. E #2 stated that he made changes to the schedule and transferred the staffs both the CNA (E #4) and night RN (E #1) to another unit for patient care.

B. Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) abuse allegations reviewed, the Hospital failed to ensure patient rights to be free from all forms of abuse, by not having a physician immediately perform an exam on Pt #1 following the allegation of physical abuse.

Findings include:

1. On 07/06/2022, the Hospital's policy titled, "Response to Allegation of Abuse or Neglect on Hospital Premises" dated 07/2020 was reviewed and indicated, " ...All patients have right to be free from all forms of abuse or neglect, and protected if abuse or neglect is alleged or suspected to have occurred on hospital premises ...the organization shall provide appropriate medical attention based on assessment of patient ..."

2. On 07/05/2022, Pt #1's clinical record was reviewed. Pt #1 was admitted to the Hospital on 05/03/2022 with the diagnoses of respiratory failure and encephalopathy. Pt. #1's clinical record lacked the documentation of night Nursing Supervisor (E #2) and Nurse Manager (E #5) offering evaluation and assessment of Pt. #1's jaw by the medical physician for evaluation.

3. A safety event report dated 05/23/2022 noted "Pt #1 reported night registered nurse (E #1) slapped her while providing care and was witnessed by the certified nursing assistant (E #4) ..."

4. On 07/05/2022 at 1:30 PM, the Nurse Manager (E #5) was interviewed. E #5 stated that on 05/22/2022 at approximately 11:45 AM, he (E #5) spoke with the patient (Pt. #1) regarding the allegation of abuse event. E #5 stated that he forgot to offer the patient to be seen by a physician, since he feels that the staff did not slap the patient (Pt. #1).

5. On 07/06/2022 at 11:00 AM, the Executive Director for Patient Safety and Patient Relations (E #7) was interviewed. E #7 stated that they should have offered an assessment by the physician following the allegation of physical abuse, since it's part of the protocol.


C. Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for allegation of abuse, the Hospital failed to ensure the incidents of abuse was reported to the Illinois Department of Public Health, in accordance with applicable local, State or Federal law.

Findings include:

1. On 07/05/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a direct admit to 2 South Medical Unit on 05/03/2022 at 1:47 PM, with diagnoses of respiratory failure and encephalopathy (brain damage).

-Pt. #1's clinical record included the allegation of physical abuse on 05/22/2022 4:30 AM. The incident #22-574 included, Pt. #1 alleged being slapped on face by the Registered Nurse (E #1) was reviewed and analyzed by the hospital. The incident log indicated the documentation notifying the local state agency on 06/01/2022.

2. The Hospital's policy titled, "Patient Safety Event Reporting/Sentinel & Never Event Management" dated 07/2020 was reviewed and included, " ...upon receiving a report regarding abuse the Patient Safety Department shall submit the report to the Illinois Department of Public Health within 24 hours after obtaining such report ..."

3. On 7/05/2022 at 3:30 PM, the Executive Director of Patient Safety and Patient Relations (E #7) was interviewed. E #7 stated that the alleged staff should have been on suspension until the investigation was complete. E #7 stated that there is need to re-educate all the staff and nurse-manager regarding abuse and neglect policy and processes. E #7 stated that allegation of abuse should have been reported to the state agency within 24 hours of the occurrence.