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Based on document review and interview it was determined that the Hospital failed to protect and promote patient rights by failing to follow abuse policy during an investigation of alleged sexual abuse. This places current and future patients at a potential risk for 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 to place a patient on sexually acting out (SAO) precautions after an allegation of abuse. See deficiency A145 A.

2. The Hospital failed to ensure patients' rights to be free from all forms of abuse by failing to place staff on administrative leave during the course of an abuse allegation. See deficiency A145 B.

An Immediate Jeopardy was identified on 02/25/2022, due to Hospital's failure to ensure Pt. #1's rights to be free from all forms of abuse by not thoroughly investigating 2 allegations of abuse reported by Pt. #1. This places a potential risk for of 37 patients on census and future patients admitted to 2 South for abuse. An Immediate Jeopardy was identified on 02/25/2022, at 42 CFR 482.13, Patient Rights, and was announced on 02/25/2022 at 3:45 PM, during a meeting with the President/CEO, Director of Nursing, and the Director of Performance Improvement and Risk. The Immediate Jeopardy was not removed by the survey exit date of 03/01/2022.

A. Based on document review and interview it was determined that for 1 of 1 (Pt.#2) patient with an allegation of sexual abuse, the Hospital failed to ensure patients' rights to be free from all forms of abuse by failing to place a patient on sexually acting out (SAO) precautions after an allegation of abuse, as required per policy.

Findings include:

1. The Hospital's policy titled, "Sexual Allegation, Aggression and Sexual Victimization: Prevention Response & Notification Plan" (revision date 3/21) was reviewed and included, " ...Sexual Misconduct: Verbal and/or physical contact of a sexual nature regarding as offensive or provocative; intentional touching without consent ... Nursing staff - places patient on SAO (sexually acting out) -aggression or risk of victimization precautions ..."

2. On 02/23/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 11/18/2021 with a diagnosis of Disruptive Mood Dysregulation Disorder. Pt. #2's clinical record indicated that from 11/18/2021, Pt. #2 was on Assault/Homicidal Precautions dated 11/18/2021.

-The Social Service Progress note dated 02/23/2022 at 1:37 PM include, "SW (social worker) was informed 02/23/2022 by administration that allegations against patient had been made on 02/17/2022. Pt's previous roommate stated that Pt. #2 has been exhibiting inappropriate behaviors with her. Previous roommate alleged that Pt. #2 tried to kiss her, when questioned. Pt. denied all allegations. Roommates were separated from each other ...will be placed on SAO precautions and Q (every) 5 at night ..."

Pt. #2 was placed on SAO precautions on 02/24/2022 for reports of sexually inappropriate behavior toward roommate (Pt. #1) on 02/18/2022 (6 days after the reported incident).

3. On 2/23/2022 at 1:30 PM, an interview was conducted with the Director of Nursing (E #1). E #1 stated that late in the evening on 02/17/2022, she received a phone call from E #7 (Nursing Supervisor). E #7 reported that Pt.#1 was making a sexual allegation against her roommate (Pt. #2) and that the police were at the Hospital to conduct an interview. E #1 stated that Pt. #2 was only on assault precautions (every 15-minute checks).

4. On 02/25/2022 at approximately 11:30 AM, the findings were discussed with Director of Performance Improvement and Risk (E #4). E #4 stated that Pt. #2 was not placed on SAO precautions until 02/24/2022 because the hospital was unaware of any "kissing" being involved."

B. Based on document review and interview it was determined that for 1 of 2 (Pt.#1) allegations of abuse, the Hospital failed to ensure patients' rights to be free from all forms of abuse by failing to place staff on administrative leave during the course of an alleged sexual abuse investigation, as required by policy.

Findings include:

1. On 02/25/2022, the Hospital's policy titled, "Sexual Allegation, Aggression and Sexual Victimization: Prevention Response & Notification Plan" (revision date 3/21) was reviewed and included, " ...Sexual Misconduct: Verbal and/or physical contact of a sexual nature regarding as offensive or provocative; intentional touching without consent ...Response to Sexual Allegation - Initiate investigation including interview of the patients involved, any witnesses and staff directly responsible for observation rounds at the time of the event ...Response to Sexual Allegation - If allegation is staff/patient - place staff on administrative leave during the investigation of the incident/allegation ..."

2. On 02/23/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital by paramedics on 02/14/2022 due to homicidal ideation's, self-injurious behavior, and suicide attempt. The clinical record included the following:

-Nurses note dated 02/17/2022 at 10:40 PM included, "...Pt. came up to staff earlier and stated that a staff member came into her room last night and was doing some 'funky shit in my room'..."

- Social Service Progress note dated 02/18/2022 at 10:11 AM (entered by E #9) included, "...Patient discussed incidents...involving...staff, during admission...A staff touched my (breast) and pushed me on my bed. Then told me to get up. That stuff is scary. It was during the day still, but I think it was some time after lunch"] ..."

3. On 02/23/2022, the Hospital's Incident Report completed by the Risk Manager (E #3) dated 2/18/2022, was reviewed indicated that on 02/17/2022 at 11:45 AM, "Patient (Pt. #1) reported that a staff member placed his hand on her back, and she felt uncomfortable. She reported the staff ... (physically described a male staff). The only staff working in her care that fit her description was interviewed and denied this intervention with the patient. No sexual assault reported."

4. On 02/23/2022 at 11:00 AM, the Hospital's document titled "BH (Behavioral Health) Intensive Analysis" (undated) was reviewed and included, "...Brief Description of Event: Patient (Pt. #1) complained that a staff member walked her into her room for no reason; Staff interviewed and stated he was redirecting patients to their rooms as he normally does, during relaxation time...Camera review Findings ...Video review inconclusive unable to identify time and specific date ..."

5. On 2/23/2022 at 9:00 AM, an interview was conducted with the Director of Performance Improvement and Risk (E #4). E #4 stated that on 02/17/2022, he was made aware that Pt. #1 reported that there was an incident with a staff member described as Program Specialist (E #6). E #4 stated that E #6 continued to work after the allegation of abuse was reported and was not put on administrative leave because the Hospital did not classify it as a claim of abuse because Pt. #1 stated that E #6 placed his hands on her back to guide her and placing your hand on someone's back not assaultive.

6. On 2/24/2022 at 10:30 AM, an interview was conducted with the Social Worker (E #9). E # 9 stated that Pt #1 discussed 2 incidents involving peer and a staff member. E #9 stated that Pt. #1 had indicated that a staff member touched her breasts and pushed her to the bed. E #9 stated that E #9 stated that he reported the incidents on 2/18/2022 to E#3 (Risk Manager) after his session with Pt. #1.

7. On 2/25/2022 at approximately 10:30 AM, a second interview was conducted with E #4. E #4 stated he did not suspend E #6 when the investigation was initiated due to Pt. #1 was not cooperative. E #4 stated, "That would have placed E #6 indefinitely on suspension." E #4 stated he was not aware that Pt. #1 had reported to E #9 an allegation of sexual abuse nor was he aware that E #3 had been made aware by the social worker.

C. Based on document and interview, it was determined that for 1 of 2 (Pt. #1) allegations of abuse, the Hospital failed to ensure patient rights to be free from all forms of abuse by not reporting the allegation of abuse to State Agency as required.

Findings include:

1. The Hospital's policy titled, "Sexual allegations, Aggression and Sexual Victimization: Prevention Response & Notification Plan (revision date 3/21)" was reviewed and included, "...Notification: Person discovering the incident/event: ...Notify Illinois Department of Public Health (IDPH) for Staff/Pt. sexual assault allegations and DCFS (Department of Children and Family Services) Hotline for minors..."

2. On 02/23/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital by paramedics on 02/14/2022 due to homicidal ideation's, self-injurious behavior, and suicide attempt. The clinical record indicated the following:

-Nurses note dated 02/17/2022 at 10:40 PM included, "...Pt. came up to staff earlier and stated that a staff member came into her room last night and was doing some 'funky shit in my room'..."

- Social Service Progress note dated 02/18/2022 at 10:11 AM (entered by E #9) included, "...Patient discussed incidents...involving...staff, during admission...A staff touched my (breast) and pushed me on my bed. Then told me to get up. That stuff is scary. It was during the day still, but I think it was some time after lunch"] ..."

There was no documentation that the Illinois Department of Public Health was notified as required.

3. On 02/24/2022 at approximately 9:00 AM, an interview was conducted with the Director of Performance Improvement and Risk (E #4). E #4 stated that the allegation was not reported to IDPH because there was initially no reports sexual misconduct or penetration. E #4 stated that he was unaware that Pt. #1 made an allegation of sexual abuse against E #6 until 02/24/2022 and E #6 continued to work as scheduled.

4. On 2/24/2022 at 10:30 AM, an interview was conducted with the Social Worker (E #9). E #9 stated that Pt #1 discussed incident that involved a staff member. E #9 stated that a staff member touched her breasts and pushed her on her bed. E #9 stated that he reported the incidents on 2/18/2022 to E#3 (Risk Manager) after his session with Pt. #1.