HospitalInspections.org

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 processes regarding the use of restraints were followed. This potentially places any patient requiring restraints on the 2 South Behavioral Health unit, at risk for harm or serious injury. As a result, the Condition of Participation 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure that the attending physician and/or licensed practitioner (LIP) who is responsible for the care of the patient was consulted as soon as possible after the completion of the 1-hour face-to-face evaluation during a restraint episode resulting in an injury. See deficiency at A-182.

A. Based on document review and interview, it was determined that for 1 of 3 non-licensed personnel files (E#3) reviewed for background checks, the Hospital failed to ensure that patients were free from abuse by not screening non-licensed personnel for records of abuse.

Findings include:

1. The Hospital's policy titled, "Employment Background Screening" (dated 12/2020), was reviewed on 12/1/2022, and required, "Offers of employment should be contingent upon obtaining an application and background investigation through the Human Resources Department ("HR")..."

2. The "Employee Checklist" (used as a checkpoint to ensure the required onboarding is complete), included, "Healthcare Worker Registry" as required paperwork for new hires.

3. The personnel files of 3 Mental Health Associates/MHA (non-licensed ), were reviewed on 12/1/2022. One of the MHA's, (E #3), date of hire was 1/10/2022. E#3's personnel file lacked a health care worker registry check, as required.

4. On 12/1/2022 at approximately 11:30 AM, an interview was conducted the Director of Human Resources (E #11). E #11 stated that it is a requirement for non-licensed personnel to be ran through the State's Healthcare Worker Registry (HCWR) upon hire. E #11 acknowledged that E #3 did not have a HCWR on file.


B. Based on document review and interview, it was determined that for 1 of 5 (Pt #1) clinical records reviewed for abuse allegations, the Hospital failed to ensure that a patient was free from abuse, by not reporting an abuse allegation to the Illinois Department of Public Health (IDPH), as required.

Findings include:

1. The Hospital's policy titled, "Suspected Abuse/Neglect (Child), dated 10/2021, was reviewed on 11/30/2022, and required, "...Patient Protection from Abuse Act...Action steps: Any staff member who has reasonable cause to believe that any patient with whom he/she has direct contact with has been subjected to abuse in the hospital shall promptly report it to Hospital Administration. Upon receiving a report, hospital administration shall initiate an internal investigation and notify IDPH. The report shall outline the steps taken to ensure patient safety, investigation steps and findings..."

2. The clinical record of Pt. #1 was reviewed on 11/30/2022 and 12/1/2022. Pt. #1 was admitted to the Psychiatric Hospital on 10/6/2022, with diagnoses of bipolar disorder and attention deficit/hyperactive disorder. - RN (Registered Nurse) Seclusion & Restraint Notes from 10/6/2022-10/21/2022 were reviewed and indicated that on 10/20/2022, Pt. #1 hit his head on the bedframe during a physical hold episode involving a Mental Health Aide/MHA (E#1). A reddened/bruise was noted on Pt. #1's forehead following the event.

3. The Hospital's Abuse Log (dated 6/17/2022-11/7/2022), included an abuse allegation regarding Pt #1 (dated 10/21/2022), which included, "Pt was found unresponsive and sent out 911 to [medical hospital] for eval. Pt reported to ED [emergency department] staff that he was pushed the previous day by MHA. Other MHAs present were interviewed and reported that they heard a 'thud' in the room and pt reported he hit his head on the bedframe when staff pushed him down on bed. Staff reported that he put pt in a small patient hold and they fell to bed as they walked in room. Pt hit head. He released hold and notified RN. Ice pack applied. Pt was noted to be running halls a few minutes later. Later in ED, DCFS [Department of Child Family Services] investigator interviewed pt who denied that he was injured in any way or mistreated [at this Hospital]. Pt requested to return to [this Hospital]. DCFS investigator to [this Hospital] and reported case will be unfounded and closed."

4. An interview was conducted with the Attending Psychiatric/Chief Medical Officer (MD#1) on 12/1/2022, at approximately 9:20 AM. MD#1 stated that staff reported that Pt. #1 "wiggled out" of a hold when trying to get Pt. #1 to the bed and then Pt. #1 hit his head on the bedframe. MD#1 stated that Pt. #1 alleged that staff deliberately slammed his (Pt. #1's) head on the bedframe. MD#1 stated that he (MD#1) thought Pt. #1 said something to staff here before he left to the medical hospital. MD#1 stated that the medical hospital also reported that Pt. #1 made an allegation against staff. MD#1 was unsure if Pt. #1 was interviewed regarding the allegation.

5. Interviews were conducted with the Chief Compliance Officer (E#9) on 11/30/2022, at approximately 2:05 PM and again on 12/1/2022, at approximately 12:05 PM. E#9 stated that sometime after Pt. #1 was sent to the medical hospital, they (this Hospital) were notified that Pt. #1 made an allegation against staff saying that staff (E#1) had pushed him and he bumped his head. E#9 stated that the Hospital did not report the allegation of abuse to the State Department of Health because it was not intentional and it was unfounded. E#9 stated that Pt. #1 had recanted his allegation, per the DCFS investigator (Z#1) who went to see the patient at the ED. E#9 stated that Z#1 told us that it was unfounded. E#9 stated, "We still started our investigation regarding the allegation that evening, we spoke with staff and we determined that it was not intentional and therefore did not meet the definition of abuse, and was unfounded." E#9 stated that allegations of intentional abuse should be reported to IDPH. E#9 acknowledged that Pt #1's abuse allegation was not reported to IDPH since there the abuse allegation/incident was not intentional. E#9 stated that the Hospital would report the allegation of abuse if they were still unsure about the determination within the 24-hour reporting timeframe. E#9 stated they have reported at least 9 other allegations of abuse in the last couple months. E#9 stated that the Hospital did not interview Pt. #1 regarding the incident.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #1) reviewed for restraint use resulting in an injury, the Hospital failed to ensure that the attending physician and/or licensed practitioner (LIP) who is responsible for the care of the patient was consulted as soon as possible after the completion of the 1-hour face-to-face evaluation during a restraint episode.

Findings include:

1. The Hospital's policy titled, "Proper Use and Monitoring of Physical/Chemical/Restraints and Seclusion" (revised 10/2020), was reviewed on 12/1/2022 and required, " ...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician/LIP or trained RN ... The evaluation will be documented in the medical record to include the following: ... An assessment of the patient's immediate situation; ...An assessment of the patient's medical and behavioral condition ... If the evaluation is conducted by a trained RN, he/she must consult with the attending physician/LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments ... Notification of the Clinical Leadership: The Chief Medical Officer and DON [Director of Nursing] shall be notified if any of the following occur: ...Any serious injury to the patient during restraint/seclusion episode ..."

2. The Hospital's policy titled, "Minor Emergency Treatment" (revised 6/2012), was reviewed on 12/1/2022 and required, "Patients ... who are involved in an accident or incident and sustain injuries that require treatment or evaluation beyond the capabilities of [Psychiatric Hospital] will be transferred to a local Urgent Care Center/Emergency Room ... The RN assesses the minor emergency, including injuries/illnesses not severe enough to warrant admission to a hospital but requiring evaluation or treatment on an immediate basis or at least within the next few hours and that it is beyond the capabilities of this facility. Possible examples: lacerations requiring stitches, sprains or possible fractures. The Charge Nurse notifies the nursing supervisor or designee, the attending physician or internist ... The Physician will give the order for appropriate disposition ..."

3. The clinical record of Pt. #1 was reviewed on 11/30/2022 and 12/1/2022. Pt. #1 was admitted to the Psychiatric Hospital on 10/6/2022, with diagnoses of bipolar disorder and attention deficit/hyperactive disorder.

- RN (Registered Nurse) Seclusion & Restraint Notes from 10/6/2022-10/21/2022 were reviewed and indicated that on 10/20/2022 at 9:42 PM (documented by Director of Nursing/E#5): Pt. #1 was placed in a physical restraint (hold) for 1 minute due to patient charging and hitting at 1:1 staff. E#5 noted that Pt. #1 had a complaint of injury and included " ...Patient remained combative and resistive during intervention causing patient and staff member to slip and fall on bed. Patient hit forehead on foot of bed during intervention. Patient c/o [complains of] pain to center of forehead. Area reddened. Patient provided ice pack for area ..." On 10/20/2022 at 10:18 PM (documented by RN/E#4): Pt. #1 was placed in a physical restraint (hold) for 11 minutes due to running into peers rooms and swinging on staff. The body diagram included documentation by Mental Health Aide/MHA (E#1) stating, "At 22:05-22:15 [10:05 PM to 10:15 PM] patient fell on the edge of the bedframe and injured his forehead and has a bruise line. This happened when staff was escorting patient to his room." The One Hour Face to Face Evaluation, signed by RN/E#6 on 10/20/2022 at 10:25 PM, included "Bruise on forehead" and indicated that On-call Psychiatrist (MD#3) had been consulted after completion of the evaluation. The record lacked documentation that the Attending Psychiatrist/Chief Medical Officer (MD#1) and Attending Medical Doctor (MD#2) were notified and consulted regarding the head injury.

- Psychiatric Progress Notes from 10/6/2022-10/21/2022 were reviewed and did not include any documentation related to the incident when Pt. #1 hit his head against the bedframe. An Addendum Psychiatric Progress Note written by MD#1 on 10/24/2022 at 1:59 PM included, "Patient was involved in a CODE BLUE [medical emergency] on 10/21/2022, 3 in the evening after he was noticed to be having some seizure-like activity and body shakes and jerks. 911 was called and patient was transferred to [medical hospital] ER [emergency room] ... Earlier on 10/20/2022 patient was involved in an incident where while trying to control his aggression patient and his one-on-one staff fell on his bed in his room and patient sustained a minor injury to his forehead. This and the patient was not shared with me on 10/21/2022. It is not clear if this has any bearing on patient's CODE BLUE incident noted above ..."

- Medicine Progress Notes from 10/6/2022-10/21/2022 were reviewed and did not include any documentation related to the head injury sustained on 10/20/2022. MD#2's Progress Note on 10/21/2021 included, "Code blue was called for unresponsiveness at 3:40 PM for possible seizure ... Pt will transfer to [medical hospital]."

4. Pt. #1's record from the medical hospital included, "[Pt. #1] who resides at [Psychiatric Hospital] as a ward of the state, who presents with witnessed seizure. He had an episode where he felt that he could not breath and was brought to his room for evaluation. In his room he had a witnessed seizure which consisted of generalized tonic clonic movements in bilateral upper and lower extremities, deviation of the eyes to the right, and foaming at the mouth. This event was reported to last for one minute and resolved ... He reported that he does not remember the event ... His nurse and EMS [ambulance] reports that he was post-ictal and non-responsive for 30 minutes after the event ...He was admitted ... to Pediatrics for seizure rule out."

5. An interview with the Attending Medical Doctor (MD#2) was conducted on 11/30/2022, at approximately 3:00 PM. MD#2 stated that Pt. #1 reported a history of seizures as a child; however, Pt. #1's adoptive father stated that he never witnessed any seizure activity since the age of 4 and Pt. #1 was not on any medications for seizure. MD#2 stated she was called for Pt. #1's code blue on 10/21/2022. When asked if MD#2 was aware of a head injury sustained on 10/20/2022, MD#2 did not recall being notified of the injury and stated "it would be in my notes if I did." MD#2 reviewed her notes and stated that she saw Pt. #1 earlier on 10/20/2022 regarding right foot pain from previous injury when playing basketball. MD#2 stated that they had an x-ray done on his foot and it was negative. MD#2 stated that she would expect the nurses to notify her if the patient sustained any new injury. MD#2 stated that for a head injury, "We generally send them out right away."

6. A telephone interview was conducted with the Registered Nurse (E#4) on 12/1/2022, at approximately 9:05 AM. E#4 stated that she was not present on the unit when the incident occurred. E#4 stated that the MHAs did not report to E#4 that Pt. #1 had hit his head and E#4 did not perform any assessments or treatment of Pt. #1's injury. E#4 stated that she would have expected staff to notify her of the injury right away. E#4 stated that she was not made aware of the head injury until the next day, after Pt. #1 was sent out to the medical hospital. E#4 stated that if it was reported to her, she would have notified the Medical Doctor right away to evaluate the patient.

7. An interview was conducted with the Attending Psychiatric/Chief Medical Officer (MD#1) on 12/1/2022, at approximately 9:20 AM. MD#1 stated that on 10/21/2022, Pt. #1 exhibited some seizure-like activity, a code blue was called, and Pt. #1 was sent out to the emergency department for evaluation. MD#1 stated that he found out about the head injury sustained on 10/20/2022 after the code blue/transfer. MD#1 stated that staff reported that Pt. #1 "wiggled out" of a hold when trying to get Pt. #1 to the bed and then Pt. #1 hit his head on the bedframe. MD#1 stated that Pt. #1 alleged that staff deliberately slammed his (Pt. #1's) head on the bedframe. MD#1 stated that nursing staff are able to initiate a code green (behavioral emergency) and are expected to contact him and/or the on-call Psychiatrist regarding the need for a physical hold. MD#1 stated after the episode, nursing staff should report if any injuries were sustained. MD#1 stated that in this case, since the patient sustained a head injury, the expectation would be that the medical doctor was called as well to evaluate the patient. MD#1 stated that even when a patient punches the wall, we'd order a scan to make sure there is no fracture/serious injury.

8. A telephone interview with the on-call Psychiatrist (MD#3) was conducted on 12/1/2022, at approximately 10:55 AM. MD#3 stated that he was notified of Pt. #1's escalating behavior and need for restraint episodes the evening of 10/20/2022; however, did not recall receiving report that Pt. #1 had hit his head on the bedframe. MD#3 stated that if it's reported the patient bumped his head, generally the medical doctor will be notified. MD#3 stated that if the medical doctor cannot be reached for whatever reason, MD#3 would make the decision to send the patient out to the nearby medical hospital out of an "abundance of caution." MD#3 stated that anytime he hears the words "fall" or "hit head", he would send the patient out to be evaluated at the medical hospital to make sure the patient is safe and there are no serious injuries.