HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition for Coverage 42 CFR 485.614, Patient Rights.

Findings include:

1. The Hospital failed to remove a physician (E#8) from patient care after an allegation of abuse; and failed to follow their policy to fully investigate the allegations of abuse beyond an internal review; and failed to ensure the staff physician (E #8) received further education/training prior to returning to patient care. (C-2525)

2. The Hospital failed to ensure Emeregency Departmenty (ED) staff were competent in restraint application. (C-2561)

Based on document review and interview, it was determined for 4 of 4 (Pt #1, Pt #11, Pt #12, and Pt #13) ED (Emergency Department) patients reviewed, the Hospital failed to remove a physician (E #8) from patient care after an allegation of abuse and failed to follow their policy to fully investigate the allegations of abuse beyond an internal review. This has the potential to affect all patients in the Emergency Department.

Findings include:


1. A review of the Reporting of Patient & Resident Abuse & Neglect Policy and Procedure (dated 7/29/24) on 6-10-25 noted, "Procedure 1. No administrator, agent, or employee of a hospital or a member of its medical staff may abuse a patient in the hospital a). Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this subsection (c) ...2. b). Upon receiving a report under this subsection (c), the hospital shall promptly conduct an internal review to ensure the alleged victims safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital's administrator and shall include, but are not limited to, removing the suspected violators from further patient contact during the hospitals internal review. b. I. All internal hospital reviews shall be conducted by a designated hospital employee or agent who is qualified to detect abuse and is not involved in the alleged victim' s treatment. All internal review findings shall be documented and filed according to hospital procedures and shall be made available to the Department upon request. 5. a. The Department shall investigate each report of patient abuse made under this subsection (c) according to the procedures of the Department, except that a report of abuse which indicates that a patient ' s life or safety is in imminent danger shall be investigated within 24 hours after such report. Under no circumstances may a hospital's internal review of an allegation of abuse replace an investigation of the allegation by the Department."

2. Pt #1's medical record was reviewed throughout the survey. Pt #1 arrived to the ED via Ambulance on 4/6/2025 at 9:23 PM for alcohol intoxication and suicidal ideation. The ED Adult Psychiatric History of Present Illness documented by E #8 and dated 4/6/2025 21:26 (9:26 PM) stated, "Patient (Pt#1) is brought in by ambulance for evaluation with suicide attempt by overdose of pills. EMS (Emergency Medical Services) states that the patient drank very heavily... also apparently took several different pills. Patient (Pt #1) states (they) took these pills a couple of hours ago. There were multiple open bottles of pills and some supplements as well. It is unclear as to how many pills that (they) took. We are still trying to get ...that information. Patient (Pt #1) states ...just does not want to be around anymore." The ED Treatment record indicated: " ...4/6/2025 22:44 (10:44 PM) ER Patient Care Note by E #10: Significant other at bedside, pt yelling and threatening to leave. Pt denies wanting to kill (themselves). Significant other states this all started due to an argument (Pt #1) had with oldest child ...4/6/2025 22:51 (10:51 PM) ...County Officer is on the way to sit with patient. Pt (Pt#1) is being aggressive towards staff ...4/6/2025 23:49 (11:39 PM) Restraints on 2300 (11:00 PM), Geodon (medication given for mental health disorders, can calm agitation in patients) given IM (intramuscular) 2330 (11:30 PM)... 4/6/2025 23:51 (11:51 PM) ... 2230 (10:30 PM) Pt started to get agitated and was trying to leave, 911 was called. 911 showed up at 2300 (11:00 PM) when restraints went on. (E #8) put hands on patient to restrain and got (Pt #1's) throat. Significant other trying to stop (E #8) from restraining pt's throat, law enforcement stepped in. Pt (Pt#1) thrashing about and screaming, trying to get out of restraints. 2 (two) cops from (city police department) and 2 cops from county present ...4/7/2025 06:12 (AM) ...at 0330 (3:00 AM) Pt (Pt#1) woke up from sleep. Pt (Pt#1) woke up cooperative and sore. Pt (Pt#1) requested restraints come off. (E #8) called from sleep room. (E #8) came into room and agreed for restraints to come off. Pt (Pt#1) no longer wishes to harm self ..." E #8 note indicated, " ...Pt (Pt#1) is very upset ...believes that (E #8) choked (Pt #1) ...wanted to call the police so that I can be arrested ... Time 0433 (4:33 AM) I have not been back in room since the police have arrived..."


3. Review of Email written on 4/7/25 at 8:26 AM by ED RN (E #10 - no longer employed at facility, staff resigned day of the event) revealed, " ...this e-mail is in regard to the 3:00 AM assault on an intoxicated patient. Patient (Pt#1) woke from Geodon slumber and calmly asked if the restraints could be taken off. Patient (Pt#1) was in pain and in need of oral care and an assessment. Significant other was present at the bedside and was advocating ... 3:00 AM ... (Reference to E #8) arrived in the room shortly after and spoke to the patient (Pt#1) and agreed they were calm enough to have restraints taken off. Restraints were taken off roughly around 3:15 AM. (E #8) left the room. We got the patient (Pt#1) a washcloth for (reference to Pt #1) face and some water. Patient (Pt #1) asked if refeerence to Pt #1 could leave and was wanting to sign out AMA (against medical advice). Doctor (E #8) appeared and sat bedside to explain the process of leaving and it was during that time that the patient (Pt#1) started to remember that (reference to E #8) had previously choked patient (reference to Pt #1) and started to panic and asked (reference to E #8) to leave ...didn't feel safe. Patient (Pt #1) asked (reference to E #8) a couple of times to leave, and (reference to E #8) refused. Doctor (E #8) and patient (Pt #1)started to argue over the earlier abuse. Patient (Pt#1)was tearful and scared. (Pt #1) went to sit up and (reference to E #8) lunged at the patient's face and throat, which caused patient (Pt #1) to defend (reference to Pt #1), they started to wrestle and the significant other put themselves on top of patient (Pt #1) to protect them from (reference to E #8.) At this time, the police showed up and the reference to (E #8) left the room. Myself, family member, and (reference to E #9) were left in shock and noticed bruising over the right eye. Patient (Pt #1)was crying and asking the police to arrest (referencet to E #8) for the assault. Significant other was asking to speak with the Police Department ... We quickly called our nursing manager and left a message..."

4. A phone interview with E #10 was conducted on 5/23/2025 at approximately 9:40 AM. E #10 confirmed taking care of Pt #1 and confirmed the patient (Pt #1) came in agitated and was yelling and screaming, wanting to leave. The doctor (E #8) wanted the patient restrained and E #9 and the doctor (E #8) were helping E #10 to place 4-point restraints. E #10 states " ...I don't even feel like the first time (reference to Pt #1) should have been restrained. I think that the doctor (E #8) just didn't want to deal with (reference to Pt #1) and wanted to go back to the sleep ...(reference to Pt #1) wasn't being combative or spitting or any of that stuff ...(reference to Pt #1) wanted to go home and he ordered restraints and that is when (reference to Pt #1) started getting agitated and combative ...as soon as we touched (reference to Pt #1) it was on like Donkey Kong ...(reference to Pt #1) started fighting ... the doctor (E #8) was initially holding the patient's (Pt#1) chest down and then out of the blue next thing we know (reference to E#8) like on (reference to Pt #1)'s throat choking (Pt #1) and ....even the Police Sergeant said 'whoa, whoa' to get the doctor (E #8) to let go of (reference to Pt#1) ..."

5. An interview was conducted with E #9 on 5/23/2025 at approximately 10:14 AM. E #9 which revealed E #9 did confirm taking care of Pt #1 and recalls the incident during that visit. E #9 stated " ...(refernece to Pt #1) was very aggressive, verbal when they got there and we have to put them in restraints ...yes, (reference to Pt #1) was hitting ...we had 4 (four) police officers at the bedside and they can't do a whole lot with (reference to Pt #1) they can't put their hands on (them) right ...so that's why we had to put (them) in restraints ...(reference to Pt #1) ...was hitting, kicking, scratching ... E #9 confirmed at the time of the incident it was very traumatic to witness because E #9 had little experience with agitated patients but after thinking about the incident and speaking with other staff, E #9 did confirm they felt the incident was handled correctly and the patient was not harmed. E #9 did confirm taking the Essentials of Aggression Management course.

6. An interview was conducted with ED Manager (E #5) on 6/10/25 at approximately 1:00 PM. E #5 stated, "The local police came to my house regarding the event with (Pt #1) and (E #8). I got up and went in to the ED early that morning. I did not remove the physician (E #8) from working. I did not call the ED Medical Director. The CNO (Chief Nursing Officer - E#3) called, I believe." When asked if any re-education or training has been provided, E #5 stated, "No we have not. Our monthly staff meeting is scheduled for June 19th and that is when we will discuss the concerns."

7. An interview was conducted with E #3 on 6/10/25 at 1:15 PM. E #3 was asked what the process is when there is an allegation of abuse, E #3 stated, "I'm not sure. I would have to look at the policy. I received a call from (E #5) and came into the ED around 4:00 AM. We did not remove (reference to E #8) from patient care until after (reference to E #8's) shift ended at 7:00 AM. (Reference to E #8) was on Administrative leave until May 1st. On May 1st (2025), there was a debriefing held with (E #8), (E #9), (E #5), ED Medical Director and myself. (E #8) returned to work on May 2nd. (E #8) did not receive any disciplinary action." When asked if any re-education or training has been provided, E #3 stated, "That would be (Reference to E #5)'s responsibility. I know they have a meeting in June that they are going to address the concerns."

8. A request was made for the Incident Investigation and/or Root Cause Analysis for this incident on 6/10/25 at approximatley 10:30 am to the E #2 and E#3. The facility was unable to provide or speak to an investigation being conducted. Only an internal review was conducted for the alleged incident. The internal review action items include: 1) New understanding that police can't assist unless arresting the patient, educate all staff (complete - staff and board members have been educated) 2. Additional staff training on restraints for all staff - will occur at June Staff meeting. 3.) Security for the ED after hours - Contract has been signed with tentative start date in June. Governing Body had not convened for their quarterly meeting at the time of this investigation. E #3 stated that it would be on the agenda for their next meeting but was unable to provide the exact date of the next quarterly meeting. E #8 is currently working in the hospitals ED. No disciplinary action was given to E #8, and the Hospital did not report E #8 to the State of Illinois Medical Board. There was a "debriefing"/ discussion on 5/1/25 between E #9, E #8, E #3, E #5, and ED Medical Director to discuss the events and to "ensure everyone was still able to work together." E #8 will be taking an 8 hour aggression management course in June but has not received any retraining / re-education before being allowed to return to work.

9. The ED log was reviewed for 4/6/25 thru 4/7/25. The log indicated 3 other pts would have received care from E #8 before being placed on Administrative Leave. The log indicated the following:
Pt #11 arrived on 4/6/25 at 8:46 PM with a complaint of abdominal pain. Pt #11 was discharged on 4/7 at 12:22 PM.
Pt #12 arrived on 4/6/25 at 7:33 PM with a complaint of headache. Pt #12 was discharged on 4/7 at 12:00 PM.
Pt #13 arrived on 4/7 at 4:54 AM with a complaint of flank pain. Pt #13 was admitted at 10:40 AM.
All 3 patients received care from E #8 after the allegation of abuse was reported.

Based on Document review and staff interview, it was determined the facility failed to ensure staff are competent in patient- centered, trauma informed competency- based training and education on the use of restraint and seclusion.

Findings include:

1. The policy titled "Patient Restraints and Seclusion Management" (approved on 4-11-25) was reviewed on 6-10-25. The policy noted "Policy 2. Restraint will be limited to those situations which improve the patient's safety. Restraint will not be used to punish or discipline the patient. 3. When restraints are necessary every effort will be made to use the least restrictive method to control the behavior and limit the time that restraints are applied."

2. The Emergency Department Course Narrative documented by E #8 was reviewed on 6-10-25. E #8's documentation notes, "Time 2323: ....attempted to get up several times and then starting swinging wildly at staff including myself. At that time we decided that we would place her in 4 point restraints... Even in restraints we are having difficulty keeping her down, she did keep slipping out of the restraints and flailing her arms and continuing to scream." There was no documentation found of lesser restrictive methods to control the behavior being implemented for the patient.

3. During an interview on 5/23/25 at approximately 9:40 AM, the ED RN (E #10) stated, "...I don't even feel like the first time (Pt #1) should have been restrained."

4. A review of the debriefing from 5/1/25 was conducted on 6-10-25 at approximately 1:35 pm and notes, "(E #9) requested additional restraint education be provided as they aren't used often. The ED manager (E #5) will be setting up additional training....."

5. An interview with ED manager (E #5) was conducted on 6-10-25 at approximately 11:15 am. E #5 was asked if any additional restraint education was provided immediately post incident and stated, "No, we have scheduled hands on training on June 19th."