HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt. #11) clinical record reviewed for allegation of sexual abuse, the Hospital failed to report the allegation of abuse to State Agency, to ensure patient was free from all forms of abuse or harassment.

Findings include:

1. The Hospital's policy titled, "Abuse or Neglect of Patients" dated 08/2020 was reviewed and included, "...policy expands upon the specific requirements for caregivers who are licensed or certified through the State of Illinois to report any situation as suspected abuse or neglect occurring to patients ...while anyone can call in a report to the state agencies directly ...it is hospital practice that the Director of Quality be alerted to avoid duplication of reports ..."

2. On 4/20/2021, the Hospital's document titled, "Grievance Log" dated 10/01/2020 - 04/20/2021 was reviewed. The log included, an allegation of sexual abuse (Pt. #11) event #2021-10434 dated 02/08/2021. The Hospital received an allegation from Pt. #11's mother indicating that, patient (Pt. #11) had told her mother that, she was "raped" today by "two Indian men." The allegation was investigated by E #11 (Manager of Patient Family Relations). The grievance log included closure letter dated 02/11/2021, with an analysis of the investigation made regarding the allegation of abuse. The closure letter was mailed to Pt. #11's family member. However, the grievance log lacked the documentation about notifying to IDPH (Illinois Department of Public Health).

3. On 04/20/2021, the clinical record of Pt. #11 was reviewed. Pt. #11 was admitted to the Hospital on 01/25/2021 at 3:50 PM, with a diagnosis of respiratory failure. Pt. #11 was discharged from the hospital on 02/08/2021.

4. On 4/20/2021 at approximately 1:30 PM, the Manager of Patient and Family Relations (E #11) was interviewed. E #11 stated that, Pt. #11's allegation of abuse was reviewed and closure letter was mailed to the family member. E #11 stated that she was not sure why the case was not reported to IDPH.

5. On 04/21/2021 at approximately 10:00 AM, an interview was conduced with E #12 (Director of Quality and Patient Safety). E #12 stated that Pt. #11's allegation of abuse was not reported to IDPH, since Pt. #11 allegation of sexual abuse was unfounded.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for turning and repositioning at Hospital Campus B, the Hospital failed to ensure that the registered nurse supervised and evaluated the care for each patient by ensuring that turning and repositioning interventions were documented.

Findings include:

1. On 4/20/2021, the Hospital's job description for Registered Nurse (effective 1/2011) was reviewed and included, "General Summary... according to the established policies... renders competent... individualized care to every patient and their family. Utilizes the nursing process to assess... implement and evaluate the delivery of individual patient care..."

2. On 4/20/2021, the Hospital's policy titled, "Meditech Documentation Standards" (effective 11/2001) was reviewed and included, "... Each caregiver is individually responsible for documenting... patient care interventions...B... 2. PCTs (patient care technicians) document... care provided for each assigned patient for the amount of time they are assigned to the patient..."

3. On 4/20/2021, the Hospital's policy titled, "Skin Prevention and Reporting" (effective 3/2018) was reviewed and included, "... Procedure. A. Skin Risk Stratification Tool... The assessment... serves as a guide for staff to determine the skin breakdown risk and applying respective modalities to mitigate skin integrity disruption...Risk Stratification Tool... Moderate Risk (Braden Score of 13-14)... High Risk (Braden Score of less than 12)... Risk Stratification Intervention... Moderate and High Risk: Turn and offload patients frequently (every 2 hours)..."

4. On 4/20/2021, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 3/27/2021 with a diagnosis of CVA (stroke) with residual right sided weakness, contracted right lower extremities, and right hip pressure ulcer with infection. Pt. #1' Braden Risk Assessment dated 4/20/2021 indicated a score of 12 (High Risk). The clinical record lacked documentation that Pt. #2's turning and repositioning interventions were done on 4/19/2021 from 8:00 PM through 6:00 AM on 4/20/2021 (10 hours).

5. On 4/21/2021 at approximately 9:30 AM, findings were discussed with E #3 (Nurse Manager). E #3 stated that the nurse should have checked that the turning and repositioning were documented. E #3 added that if there was no documentation, it means that the interventions were not being done. Further, E #3 said that if the interventions were not being done, the nurse should have evaluated the root cause of the problem.

Based on observation, document review, and interview, it was determined that for 1 of 1 (Pt. #13) patient observed for medication administration at Hospital's Campus A, the Hospital failed to assess the naso-gastric tube placement prior to medication administration, to ensure that acceptable standards of practice was followed.

Findings include:

1. On 04/20/2021 at approximately 11:30 AM, during the observational tour of the B1 Unit, a Registered Nurse (E #10) administered medication via Pt. #13's naso-gastric tube (feeding tube inserted through the nose). E #10 did not assess the naso-gastric tube placement prior to administration of medication.

2. On 04/20/2021 at approximately 11:45 AM, the clinical record of Pt. #13 was reviewed. Pt. #13 was admitted to the Hospital on 03/04/2021 at 4:40 AM with a diagnosis of respiratory failure. Pt. #13's clinical record included physician's order dated 03/06/2021, "Nepro (tube feed) 40 ml/hr (milliliters per hour) non-stop, with water flush ...Levodopa/Carbidopa (medication for tremors) 25 mg (milligram) two tablets daily ..."

3. On 04/20/2021 at approximately 12:00 PM, the Hospital's adapted Lippincott procedure titled, "Enteral Tube Drug Instillation" dated 11/2020 was reviewed and included, "...tracing the tubing from the patient to its origin to make sure ...verify enteral tube placement using ...observe for change in the external tube length ...aspirate tube contents ...after verifying proper tube placement ..."

4. On 04/20/2021 at approximately 12:05 PM, the Registered Nurse (E #10) was interviewed. E #10 stated that, she failed to assess the tube placement prior to medication administration, since she had just inserted the naso-gastric tube the day before on 04/19/2021.

5. On 04/20/2021 at approximately 12:10 PM, the Nursing Director (E #9) was interviewed. E #9 stated that the nurse should have checked the naso-gastric tube placement.