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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 the alleged staff from further patient contact, during the investigation of an alleged physical abuse. See deficiency at A-145A.

Based on document review and interview, it was determined that for 1 of 3 patients' grievances (Pt. #10) reviewed, the Hospital failed to ensure that the patient's complaint/grievance was reviewed and resolved.

Findings include:

1. On 7/14/2022, the Hospital's policy titled, "Patient Complaint/Grievance" (dated 2018) was reviewed and included, "... Definitions: A patient grievance is a formal or informal written/verbal complaint that is made to the Hospital by a patient, (or the patient's representative), when a patient issue cannot be resolved promptly by staff present. In the event that complaint cannot be resolved promptly by staff present... it is to be considered a grievance...Procedure... 2. Upon notification, the Patient Advocate shall investigate the complaint... 3. The Complaint/Grievance form will document responsibility for resolution of the complaint..."

2. On 7/15/2022, the Hospital's complaint log from May 2022 through July 2022 was reviewed. The log indicated that on 5/31/2022, Pt. #10 filed a complaint that included, "(Complained of a) nurse rude behavior... (Pt. #10) stated when nurse pulled her (Pt. #10's) covers back, it caused (the intravenous needle) to come out." As of 7/15/2022, there was no documentation that Pt. #10's complaint was reviewed and resolved.

3. On 7/15/2022, Pt. #10's clinical record was reviewed. Pt. #10 was admitted to the Hospital on 5/27/2022 with a diagnosis of COPD (chronic obstructive pulmonary disease).

4. On 7/15/2022 at approximately 10:30 AM, findings were discussed with E #2 (Patient Advocate). E #2 could not provide documentation that Pt. #10's complaint was reviewed and resolved. E #2 stated, "I should have documented it."

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical records reviewed for allegation of abuse, the Hospital failed to ensure that patients were free from all forms of abuse, by not removing the alleged staff from further patient contact, during the investigation of an alleged physical abuse.

Findings include:

1. On 07/14/2022 the Hospital's policy titled, "Guidelines for Victims of Suspected Abuse" dated 11/19/2022 was reviewed and included, " ...abuse means any physical ...injury ...intentionally inflicted by a hospital employee...and clinical standards of care...Upon receiving a report of suspected abuse...hospital administrator ...removing the suspected violators from further patient contact during the hospital's internal review and notifying appropriate authorities..."

2. On 07/14/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought in by the Chicago Fire Department (CFD) to the emergency room (ER) on 05/30/2022 at 1:40 AM, with a chief complaint of psychiatric emergency. Pt. #1 was admitted to the 1 West Medical-Surgical unit on 05/30/2022 at 10:16 AM, with diagnoses of perirectal abscess (inflammation of the rectum) and acute psychosis (type of mental condition). Pt. #1's clinical record included the following:

-The physician's order for restraints and seclusion dated 05/30/2022 at 2:45 AM, included, " ...Check off alternatives attempted prior to restraints...redirection, medication, aggressive behavior that threatens the safety of others...type: locked wrist restraints for 4 hours...face-to-face assessment completed...(signature of ER physician) ...place patient on mental health protocol for patients on medical unit...Precautions: Place patient in yellow gown ...assault precautions...elopement with close observation... (signed and dated 05/31/2022) by attending physician..."

3. On 07/14/2022 at approximately 12:00 PM, the Hospital's document titled, "Patient Relations Worksheet Grievance #22-102" was reviewed and writer Patient Advocate (E #2) included, "Date received: 06/01/2022 at 2:45 PM ... [name of Pt. #1's mother] ...c/o [complained of] Security Officer [name of security officer] [Security Officer/E #1] ...joking her son and pulling his hair out while restraining him ...this writer reviewed footage on 06/01/2022 at 3:04 PM, with [name of Director of Security Officers/E #11] and unable to (substantiate) the alleged incident ...this writer also went to patient's [Pt. #1's] room and examined his head ...patient have dread locks and this writer didn't [did not] notice any missing dread locks ...notified [name of Pt. 1's mother]." The documentation included statements, dated 06/01/2022 and 06/02/2022, from Security Officer (E #1) and Security Officer (E #2) indicating that E #1 and E #2 were holding Pt. #1's limbs and hands, and were not pulling Pt. #1's dread locks. The complaint was closed on 06/01/2022 (the same day the grievance was received by the Patient Advocate/E #2) although statements (including E #14's/ER Liaison) to unsubstantiated the complaint were not completed until 6/3/2022.

4. On 7/14/2022, an email from E #12 (Director of Nursing) on 6/1/2022 was reviewed and indicated that the Hospital received a complaint from Pt. #1's mother alleging that E #1 choked and pulled Pt. #1's hair on 5/30/2022.

5. On 7/14/2022, an email on 6/3/2022 from E #12 (Director of Nursing) to E #13 (Vice President of Organizational and Community Development) was reviewed. The email included, "Hello (E #13), Attached is the written statement from (E #14), for the incident that occurred... with (Pt. #1). (E #14) stated if she needs to give a verbal statement, (E #14) would be fine with coming in."

6. On 07/14/2022 at approximately 12:30 PM, the Hospital's document titled, "Time-Card Report - Security Officer/E #1" was reviewed and indicated E #1 working on 05/29/2022: 12:23 AM - 7:11 AM, 06/01/2022: 11:04 PM - 7:33 AM, and 06/02/2022: 11:03 PM - 2:27 PM and 06/03/2022: 11:07 PM - 7:36 AM ..." The timecard for Security Officer (E #1) did not indicate the staff being placed on suspension while the allegation of physical abuse was investigated.

7. On 07/14/2022 at 11:30 AM, the Patient Advocate (E #2) was interviewed. E #2 stated that the patient's mother called her (E #2) and reported regarding the Security Officer (E #1) pulling the dread locks while restraining the patient (Pt. #1) on 06/01/2022 at 2:45 PM. E #2 stated that she examined the patient (Pt. #1's) dread locks and did not find any dread locks being pulled out and the complaint was closed on 06/01/2022 at 3:04 PM. E #2 stated that she reported the incident to the Director of Security (E #11). E #2 stated that they both (E #2 and E #11) watched the video footage and was not able to see the staff applying the restraints or that staff pulled the patient's (Pt. #1's) hair and only the foot-end of the video was seen due to construction in the ER. (This was the only image that could be captured due to construction)

8. On 07/14/2022 at 1:00 PM, the Director of Security (E #11) was interviewed. E #11 stated that she watched the video along with the Patient Advocate (E #2) and did not consider it as an abuse. E #11 stated that she collected the statements from the involved Security Officers on 06/01/2022 and 06/02/2022. E #11 stated that she is not sure if the investigation for the allegation of abuse was closed. E #11 stated that she reported the incident to her supervisor and no employees were suspended during the investigation.

9. On 07/15/2022 at 9:15 AM, the Vice-President of Organizational and Community Development (E #13) was interviewed. E #13 stated that she received a phone call regarding the incident on Memorial Day (5/30/2022). E #13 stated that she requested the Director of Nursing (E #12) to obtain nurses statements to confirm what had happened. E #13 stated, "I cannot tell the exact date when the investigation was closed." E #13 stated that she does not consider it as a physical abuse. E #13 stated that it was not reported to the State Agency because it was not considered as an abuse. E #13 stated that she feels it was ok for the Security Officer (E #1) to return to work on 06/01/2022 since the patient (Pt. #1) was discharged and did not think about other patients in the hospital.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) record reviewed for an allegation of abuse, the Hospital failed to report the alleged physical abuse to the Illinois Department of Public Health, as required, to ensure patient is free from all forms of abuse.

Findings include:

1. On 07/14/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought in by the Chicago Fire Department (CFD) to the Hospital's emergency room (ER) on 05/30/2022 at 1:40 AM, with a chief complaint of psychiatric emergency.

2. On 07/14/2022 at approximately 12:00 PM, the Hospital's document titled, "Patient Relations Worksheet Grievance #22-102" was reviewed and writer Patient Advocate (E #2) included, "Date received: 06/01/2022 at 2:45 PM ... [name of Pt. #1's mother] ...c/o [complained of] Security Officer [name of security officer] [Security Officer/E #1] ...joking her son and pulling his hair out while restraining him ...this writer reviewed footage on 06/01/2022 at 3:04 PM, with [name of Director of Security Officers/E #11] and unable to the alleged incident ...this writer also went to patient's [Pt. #1's] room and examined his head ...patient have dread locks and this writer didn't [did not] notice any missing dread locks ...notified [name of Pt. 1's mother]."

3. On 7/14/2022, an email from E #12 (Director of Nursing) on 6/1/2022 was reviewed and indicated that the Hospital received a complaint from Pt. #1's mother alleging that E #1 choked and pulled Pt. #1's hair on 5/30/2022.

4. On 07/14/2022 at approximately 12:40 PM, the Hospital's policy titled, "Guidelines for Victims of Suspected Abuse" dated 11/19/2022 was reviewed and included, " ...abuse means any physical ...injury ...intentionally inflicted by a hospital employee ...and clinical standards of care ...Upon receiving a report of suspected abuse, the hospital shall submit the report to the Department within 24 hours after obtaining such report. The report will be filed on the State of Illinois Complaint Form and faxed or through the Healthcare Facilities and Program Unit ... and notifying appropriate authorities ..."

5. On 07/15/2022 at 9:15 AM, the Vice-President of Organizational and Community Development (E #13) was interviewed. E #13 stated that she received a phone call regarding the incident on Memorial Day (5/30/2022). E #13 stated that she does not consider it as a physical abuse. E #13 stated that it was not reported to the State Agency because it was not considered as an abuse.