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Based on document review, camera video review and interview, it was determined for 3 of 26 (Pt #1, Pt #2, Pt #3) patients on the 2nd floor Youth Unit, the facility staff failed to ensure that patients receive care in a safe setting. This has a potential to affect all patients on the unit, with a current census of 26. Therefore, the Condition of Participation 42 CFR 482.13 Patient Rights was NOT met, as evidenced by:

Findings include:

1. The Hospital staff failed to ensure that patients receive care in a safe setting by providing proper supervision and staffing ratios in order to provide protection for the patient's emotional health and safety as well as his/her physical safety. See A 0144

Based on document review, camera video review and interview, it was determined for 3 of 26 (Pt #1, Pt #2, Pt #3) patients on the 2nd floor Youth Unit, the Hospital staff failed to ensure that patients receive care in a safe setting by providing proper supervision and staffing ratios in order to provide protection for the patient's emotional health and safety as well as his/her physical safety. This has a potential to affect all patients on the unit, with a current census of 26, as evidenced by:

Findings include:


1. Pt #1's record was reviewed on 1/4/2021 at 2 PM. Pt #1 was a voluntary admission to the 2nd floor Youth Unit on 11/30/2020 with an admission diagnosis of disruptive mood dysregulation disorder. Pt #1 was on suicide and assault precautions with every 15-minute monitoring. The patient progress note dated 12/7/2020 at 8:50 AM, by Registered Nurse (E #8) was reviewed. The note stated "Pt requested to speak to this RN that pt. had been raped by a peer on Saturday Night 12/5/2020 at midnight. Pt reported that Pt #1 went to peer's (Pt #2) room on Saturday night at midnight. Pt #1 reported that Pt #1 went to peers' room because peer asked Pt #1 to have some "fun". Pt stated that when patient went into peers' room, peer entered the room, shut the door and said, "were going to fuck". Pt stated that the reply was "no" when peer said this, and peer asked again to have sex and pt. told peer "no". Pt stated that peer then pulled Pt #1 pants down and threw pt. on floor, peer put penis inside Pt #1 and proceeded to penetrate pt. roughly and repeatedly".

According to Pt #1's record; Registered Nurse (E #8) contacted Pt #1's mother on 12/7/2020 at 9:15 AM. Local police department was contacted on 12/7/2020 at 8:30 AM. A police investigation was initiated on the unit on 12/7/2020 . A DCFS (Department of Children and Family Services) hotline report was made on 12/7/2020 and was investigated on 12/8/2020 by DCFS employee. On 12/7/2020 Pt #1 was accompanied by E #8 to a local hospital for evaluation. A SANE (sexual assault) nurse completed a sexual assault exam on 12/7/2020 2:10 PM. Pt was discharged from the local hospital and returned to the facility. Pt #1 received a psychiatric discharge evaluation. After being evaluated by Pt #1's attending psychiatrist, Pt #1 was discharged home in care of a parent on 12/7/2020.

According to Pt #1's record, the Progress note dated 12/8/2020 written by MHT (Mental Health Technician-E #7) was reviewed. The Progress Note stated "On the morning of Monday Dec. 7th pt's roommate (Pt #4) approached staff to inform them that pt. (Pt #1) had told Pt #4 that Pt #1 had gone into peer's room (Pt #2) in the middle of the night and Pt #2 pressured Pt #1 to have sex. Pt #4 reported that pt. (Pt #1) was "in pain but did not know how to tell staff and was afraid of getting in trouble." Staff (E #7) immediately notified hospital administrator. Pt (Pt #1) approached staff in the hallway and stated "I need to talk to you about what happened. Pt (Pt #1) was tearful. Staff had the E #8 sit down with Pt #1. Pt (Pt #1) reported that Pt #1 went into peer's room. Pt (Pt #1) reported to staff that while in the room peer (Pt #2) told Pt #1 "I want to fuck you" pt. (Pt #1) stated that Pt #1 was resistant and told pt. (Pt #2) no. Then Pt #2 pulled my pants down and threw me on the floor and had sex with me. ...Pt (Pt #1) reported having bleeding and soreness and was transported to the ED to be examined, police were called to do an investigation."

2. Pt #2's record was reviewed on 1/4/2021 at 2:30 PM. Pt #2 was a voluntary admission to the 2nd floor Youth Unit on 12/4/2020 with an admitting diagnosis of disruptive mood dysregulation disorder. Pt #2 was on self-harm, suicide, assault and elopement precautions with every 15-minute monitoring. The Patient Progress Note dated 12/7/2020 5:30-9:30 PM, "Pt sat and spoke with me about the incident on Saturday w/ (with) pt. (Pt #1). Pt states it was a mistake, but they did have sex. Pt claimed it was not forced by either party". Pt #2 was placed on one to one supervision with nursing staff since incident was reported on 12/7/2020. Pt#2 was moved to room #245. Room #245 was closest single room to nursing station. Pt #2 was placed on Personal Boundaries Precautions on 12/7/2020 at 4 PM. On 12/7/2020 at 6 PM Pt #2 was "placed on Sexual Aggression precautions related to personal boundary issues and sexual abuse allegation made by a peer, which included 1:1 supervision." Pt #2 was discharged to the hospitals RTC (Residential Treatment Center) on 12/8/2020 for disruptive behavior and Pt #2 need to be treated in a long term program."

3. Pt #3's record was reviewed on 1/4/2021 at 3:00 PM. Pt #3 was a voluntary admitted to the 2nd Floor Youth on 9/28/2020 with the diagnosis of major depressive disorder. Pt #3 was on self -harm, suicide and sexual vulnerability/victimization precautions requiring 1:1 supervision and every 15-minute precautions. The Case Management Patient Progress Note dated 12/8/2020 stated "Caseworker was informed that (Pt #3) tampered with cameras on the unit over the weekend and appeared to be helping a peer plan an event that resulted in that peer being accused of a crime. Caseworker agreed that pt. needs to be remain matched to either a group home or RTC level of care but would not be suited to a lower level of care." P# 3 was placed on Boundary Precautions 12/7/2020, including one on one supervision. Pt #3 was discharged on 12/14/2020 to Spero Group Home. Pt #3 was not interviewed by staff about the sexual assault allegation per the request of the DCFS investigator. "


4. Video reviewed on 1/4/2021 at approximately 1:00 PM. The video cameras are clear at 10:00 PM on 12/5/2020. At 10:01 PM Pt #2 rubs toothpaste over lens without staff knowledge when MHT (E #10) enters hygiene closet. Then at 10:02:20 PM Pt #3 puts what appears to toothpaste on the lens facing Pt. #3's room 222, without staff knowledge. At 10:12 PM Pt #1 comes out of Pt #1's room to talk with Pt #2 and Pt #3 and MHT (E #3). At 10:15 PM, Pt. #2 is seen applying what appears to be toothpaste to camera #2 to cover the view of Pt #2's room #242, without staff knowledge. Then at 10:25 PM, Pt #2 is sitting in an employee's chair, while the E #3 is checking laundry. Pt #1 then comes out of Pt #1's room #238. Pt #3 jumps on Pt #1 and tugs patient's hair. Pt #1 then sits on Pt #2 lap, whom was sitting in a chair, then Pt #1 gets off of Pt #2's lap. Pt #2 and Pt #3 then runs to the other side of hallway to look in the RN station through the window on a door. Then Pt #2 and Pt #3 run back to their side of unit near their room. Pt #1 trails behind them running. The interaction between Pt #1, Pt #2, and Pt #3 continues. Pt#2 and Pt #3 spilled water on the floor, then Pt #2 approaches the MHT (E #5) in the hallway. E #5 steps into the linen closet and obtains towels and hands them to Pt #3 At 11:10 PM, while E#5 is collecting the wet towels, which Pt #2 and Pt #3 used to clean the water, Pt #2 hand motions to Pt #3 whom is who was taking to Pt #1 in the doorway of room 238. Pt #3 hand motions to Pt #1, then Pt #1 goes into Pt #2's room 242, which is next to Pt #1's room #238. Both Pt #1 and Pt #2 are in Pt #2's room for approximately 7 minutes and 36 seconds. E #5 was performing rounds and entered Pt #1's room at 11:18; PM. At 11:18:15 PM, Pt #1 is observed exiting Pt #2's room and entering Pt #1's room, where E #5 was doing rounds. Pt #1 was past the door casing, so E#5 was unable to see that Pt #1 had come from Pt #2's room. Pt #1 was in Pt #2's room from 11:10 PM-11:18 PM. According to Pt #1's record, E #5 reported that E #5 noticed Pt #1 wasn't initially in there. (Pt #1's room 11:18 PM) "I was looking around the room and, in the bathroom, and couldn't find Pt #1." E #5 reports that when Pt #1 appeared in Pt #1's room. "Pt #1 had "blood on pants, but patient said that it was because patient was on my period, so I got Pt #1 tampons and things to take a shower."

5. On 1/5/2021 at 12:30 PM, the policy titles "Support Code" (revised 7/15/19) was reviewed. It indicated under "C. every effort will be made to protect patients/residents, staff, visitors and the facility, while using a supportive approach and the least restrictive response required to manage the patient/resident's behavior."

6. On 1/5/2021 at approximately 1:00 PM, the policy titled, " Patient Safety Risk Assessment" (last revised by staff, 3/1/2019) was reviewed. The policy states under " Procedure: All staff is expected to be aware of the Patient Safety Risk Assessment in their work area (s). and report any newly identified items to the Unit Supervisor and the Director of Performance Improvement and Risk Management."

7. On 1/6/2021 at approximately 10:00 AM the "The Youth Guidelines" were reviewed. The Guidelines indicate the expectation is the patient is to "stay in your room after evening transition unless you are told to come out".

8. On 1/6/2021 at approximately 10:30 AM, the " Track II East (Boys) Programming Guide was reviewed. It defines, "9 PM as lights out/bedtime"

9. On 1/6/2020 at 11:00 AM, the "15-minute Rounding Form " for Pt 1, Pt #2 and Pt #3 for 12/5/2020 was reviewed. The Rounding Form indicated: 15-minute monitoring was completed. Pt #1 was in Pt #2's room from 11:10 PM-11:18 PM. Therefore, Pt # 2 and Pt #3 was in the hall at 11:05 PM and Pt #1 was in Pt #1's room at 11:05 PM. Pt #2 was in Pt #2's room and Pt #1 was returning to Pt #1's room as staff was conducting the next 15-minute checks on Pt #1 and Pt #2.

10. On 1/6/2021 at approximately 11:15 AM, the policy titled "Appropriate Staffing Levels" (revised by staff July 2020) was reviewed. Staffing ratios for day and evening shifts for Youth Inpatient is 1:4. Staffing for overnight shifts are 1:10. On 12/5/2021 the 3-11 shift census was 26, staffing was 8 staff, 3 staff left at 7 PM, 2 staff left early at 22:15 PM, while Pt #2 and Pt #3 were in hall being disruptive. This was out of ratio per policy (1:4) as the unit was short 1 staff member from 7-11 and short 2 staff members from 10:15 to 23:00. Review of the staffing grids dated 12/7/2020-1/3/2021 found adequate staffing.

11. The "Hospital's Root Cause Analysis' for the 12/5/2020 incident was reviewed on 1/6/2021, the following deficiencies were identified by the hospital:

a. "2 staff left early while horse playing in hall. Staff member reported "didn't have teachers voice" did not feel in control. Did not request additional assistance from house supervisor."
b. "Camera- identified camera issue but didn't notify anybody to fix. Staff did not resolve tampering with cameras; Limiting ability to manage patient disruptive behaviors before further escalation.
c. Walkie talkie not used- some not working."
d. "4 staff scheduled till 19:00 this was out of ratio per policy (1:4) with a census of 26. At time of event unit had 6 employees on unit between 23:00- 23:30. This is indicative of a shift change, which remains below ratio for 26 Patients. 2 employees left at 22:15 PM. although 11-7 shift was in ratio for staff/patient -issue- - 2 staff left early from prior shift with patients remaining up and disruptive "
e. "House Supervisor was not called upon to assist in de-escalating the patient following shift report. This was not done until approximately midnight."
f. "Boundary issues with other peers: staff did not separate patient from other female; lack of reporting boundary issues thru HPR Incident system, therefore patient not put on precautions; and staff distracted by patient request."
g. "Staff should have called for additional assistance to minimize distractions"...

12. On 1/5/2020 at approximately 10:30 AM, the telephone interview conducted by Risk Manager (E #2) with Registered Nurse (E #6) was reviewed. E #6 was interviewed regarding an incident that occurred on 12/5/2020 at 11:00 PM. E #6 stated that (E #6) "notice the cameras were whitish but did not check camera lenses."

13. On 1/5/2021 at approximately 1:30 PM, the telephone interview conducted by E #2 with E #5 was reviewed. E #5 was interviewed regarding an incident that occurred on 12/5/2020 at 11:00 PM. E #5 stated that "I know that they (camera lenses) were fuzzy, but I didn't know why. I did not check the cameras. I don't have my teacher voice, so I should have spoken up." (concerning the disruptive behavior and camera visibility) "

14. On 1/5/2021 at approximately 1:30 PM, the personnel record of E #3 was reviewed. E #2's interview with E #3 regarding the 12/5/2020 incident was reviewed. E #3 stated "I made arrangements for them to go to bed at 1100, but they did not listen. (Pt #1 Pt #2, Pt #3)

15. An interview was conducted with the E #2 on 1/6/2020 at approximately 10:30 AM. E #2 stated that E #2 was notified of the allegations of sexual Assault on 12/7/2020, when the incident was reported to staff. E #2 stated "the expectation is all patients will be in their rooms at 9 PM, based on the judgement of staff. Based on the patient's environment and the MHT's personal knowledge, if they (MHT) need additional assistance to control or manage the patient's behavior then they should utilize the Support Code Process. (process of calling for more staff when the patients are disruptive). Staff should have checked the cameras. We developed and implemented a corrective action plan immediately, including Pt #2 was placed on one to one with nursing staff, since the incident was reported. Pt#2 was moved to room #245 without any other issues." Room #245 was closest single room to nursing station. Pt #2 was placed on personal boundaries precautions on 12/7/2020 at 4 PM. On 12/7/2020 at 6 PM Pt #2 was placed on sexual aggression precautions related to personal boundary issues and sexual allegation made by a peer. Pt #2 was discharged to The hospitals' RTC (Residential Treatment Center) on 12/8/2020 for disruptive behavior and the need to be treated in a longer term program. Pt #3 was placed on one on one supervision and was discharged on 1/14/2021. Pt #1 was discharged on 12/8/2020."

16. An email dated 12/8/2020 was sent from E #2 to IDPH (Illinois Department of Public Health) reporting the abuse allegation. According to the e-mail: An immediate action plan was complete on 12/7/2020 to address immediate potential risk. A plan of correction was initiated on 12/7/2020 to address all deficient practices which was completed 12/10/2020. An internal investigation including a camera review on the night of the alleged incident was completed by the LCSW on 12/10/2020. Root Cause Analysis conducted on 12/10/2020

17. The "Immediate Potential Risk Identified Review" and "Immediate Action Plan." was reviewed on 1/5/2020 at 9:00 AM. The documents included:
a. "Action Plan #1 covers education to staff - "Post Incident Training" Youth Unit 83.33% staff completed as of 1/5/2021. All staff (10) whom working on 12/5/2020 completed. Post Incident training covers Continuous Monitoring, Communication (walkie talkie) Shift reporting updates (shift reports and incident reports of current patients to determine and identify those warranting boundary precaution based on boundary violations), Boundary Reporting(includes managing behaviors) Camera Monitoring and Environmental Rounding (camera).
b. Action Plan #2 Provide additional walkie talkies- completed 12/9/2020.
Action Plan #3 Implement Stop Think Talk Unit Program for improved focus and education on SOA (Sexual Acting Out) prevention strategies with patients. Centralize location of all forms with description for references and provide ongoing reinforcement of utilization of group materials. Goal: Implementation Completion date 1-15-2021.
c. Action Plan # 4 Add second monitor to live feed view to increase awareness of camera tampering on youth unit. Completed 12/9/2020.
d. Action Plan #5 Revise environmental rounds form to prompt staff to include a review of cameras unobstructed/tampered. Provide education to staff on updated forms and purpose of checking for tampering. Report compliance in patient s until compliance of 95% or higher is achieved for 3 consecutive months. (Form revised 12/9/2020).
e. Action Plan #6: Implement daily 3-day review of staffing grid during morning FLASH reports with hospital administration. This process is to identify staffing vacancies. Has implemented a process but currently (as of 1/4/2021) not tracking or tending.
f. Action Plan #7: Review options for Workstations on Wheels for positioning in hallways and improved oversight. Obtain quotes. Goal: Completion date 1/15/2021. As of 1/4/2021 in research phase.
g. Action Plan #8: Submit request for environmental change to add in swing doors to youth unit to separate by gender. Anticipated Completion Date 1/15/2021; ongoing response to be tracking through PSC. As of 1/4/2021 E#2 stated that this is a corporate expense, currently in a process to be approved. "

18. A review of the corrective action plan completion status was conducted on 1/6/2021. The following was noted:
a. A review of the Environmental Rounds/Safety Check was performed on 1/6/2021. The Environmental Safety checks from 12/10/2020 thru 12/30/2020 indicated the camera safety checks were not being completed as required. "Post Incident Training" which includes camera monitoring and environmental rounding for 2nd floor youth staff is 83.33% complete as of 1/4/2021. The training is 100% complete for all staff members involved or working on the youth unit.
b. E #2 met with employees, E #3, E #5, MHT E #11 and E #6 on 12/7/20-12/9/2020 to review details of the 12/5/2020 incident. E #2 provided coaching/corrective counseling for identified deficits related to the 12/5/2020 incident.
c. Second monitor of live feed view to increase awareness of camera tampering on youth unit was completed on 12/9/2020.
d. As of 1/5/2021 the process is in effect for the patients warranting boundary precautions. However, but there is insufficient tracking or trending
e. As of 1/5/2021 there is no plan for monitoring bedtime at 9:00 PM.
f. Submitted request for environmental change to add in swing doors to youth unit to separate by gender. Anticipated Completion Date 1/15/2021; ongoing response to be tracked. As of 1/4/2021, E#2 stated that this is a corporate expense, currently in a process to be approved.
g. As of 1/4/2021, the facility had evidence of a one-time communication dated 12/9/2020 regarding the daily reporting of staffing ratios. There is no documentation of tracking or trending of this data. As of 1-5-2021 "Post Incident Training" which includes daily shift reporting updates for 2nd floor youth staff is 83.33% complete as of 1/4/2021. The training is 100% complete for all staff members involved or working on the unit 12/5, 12/6 and 12/7/2020.
h. On 1/5/2021, two (2) RN's and one (2) MHT whom were working the 2nd floor youth Unit were interviewed regarding education of continuous monitoring, communication (walkie talkie), shift reporting updates (shift reports and incident reports of current patients to determine and identify those warranting boundary precaution based on boundary violations), boundary reporting (includes managing behaviors), camera monitoring and environmental rounding (camera) and sexual assault allegation. All stated they had received education.
J. Pt #2 was placed on precautions, moved to another room, placed on one on one supervision and then discharged on 12/8/2020 to a higher level of care. Pt #3 was placed on one on one supervision and was discharged 1/14/2021.