HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 3 of 4 patients (Pt. #2, Pt. #3, and Pt. #5) clinical records reviewed, the Hospital failed to ensure that the patients were informed of the Patient Rights.

Findings include:

1. On 11/2/2022, the clinical record for Pt. #2 was reviewed. Pt. #2 underwent cataract extraction (eye surgery) on 11/2/2022. Pt. #2 was in the pre/post operative room #33. The clinical record did not indicate that Pt. #2 was informed of Patient Rights.

2. On 11/2/2022, the clinical record for Pt. #3 was reviewed. Pt. #3 underwent cataract extraction on 11/2/2022. Pt. #3 was in the pre/post operative room #34. The clinical record did not indicate that Pt. #2 was informed of Patient Rights.

3. On 11/2/2022, the clinical record for Pt. #5 was reviewed. Pt. #5 underwent cataract extraction on 11/2/2022. Pt. #5 was in the pre/post operative room #32. The clinical record did not indicate that Pt. #5 was informed of Patient Rights.

4. On 11/2/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" (effective 10/2020) was reviewed and required, "... II... B. Patients receiving health care services at (Name of the Hospital) shall be informed of these rights as well as their responsibilities through posted signs..."

5. On 11/2/2022 between 9:45 AM through 11:00 AM, an observational tour of the pre/post operative unit was conducted. During the tour, there were no posted signs regarding Patient Rights and Responsibilities in rooms #32, #33, and #34.

6. On 11/2/2022 at approximately 10:30 AM, interviews were conducted with #E #9 (Director of Surgery) and E #10 (RN Supervisor Pre/Post Surgery). Regarding informing patients of their rights and responsibilities,
E #9 and E #10 stated that signs are posted inside the patient rooms. E #9 stated that signs should be posted. E #9 and E #10 were also not able to provide documentation or proof that Pt. #2, Pt. #3, and Pt. #5 were informed of their rights.

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

Findings include:

1. On 11/2/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 underwent right cervical medial branch block (spinal injection to relieve pain) on 9/9/2022. E #6 (CRNA/certified registered nurse anesthesia) provided anesthesia services to Pt. #1 on 9/9/2022.

2. On 11/2/2022, the the Hospital's complaint and grievance log from 6/1/2022 through 10/31/2022 was reviewed. The log indicated, "... Post (operative) call made to (Pt. #1) on 9/13/2022 at (2:15 PM). At this time, (Pt. #1) stated that she was sexually assaulted at the Hospital on (9/9/2022)..."

3. On 11/3/2022, the Hospital's letter to the (Name of Anesthesia Group) on 9/15/2022 indicated, "... Due to a pending investigation related to a patient abuse and neglect allegation (at Name of the Hospital) requires that (E #6) be removed from the OR (operating room)..."

4. On 11/3/2022, the Hospital's policy titled, "Allegations of Patient Abuse by (Name of the Hospital) in the Hospital" (last revised on 8/2021) was reviewed and required, "... III... D. Notification to State Agencies within 24 hours... 2. Reports or allegations of possible Abuse... will generally be reported to... IDPH within 24 hours of receipt..."

5. On 11/2/2022 at approximately 3:00 PM, interview was conducted with E #1 (Director of Quality). E #1 stated that Pt. #1's allegation of sexual abuse was not reported to IDPH.


19843


B. Based on document review and interview, it was determined that for 1 of 1 Certified Registered Nurse Anesthesiologist (E #6), the Hospital failed to ensure, staff were not permitted to work during an alleged verbal sexual assault investigation, to ensure patients were free from all forms of abuse.

Findings include:

1. On 11/2/2022, the Hospital's policy titled, "Allegation of Patient Abuse by (Name of the Hospital) Personnel in the Hospital," revised 8/16/2021, was reviewed. The policy required, "...III Procedure... B. Immediate Response... a. Address Patient Safety and Care... Assure immediate protection of patient, including separating the patient from the alleged abuser..."

2. On 11/2/2022, Pt. #1's clinical record was reviewed. Pt. #1 arrived at the Hospital on 9/9/2022 for an out-patient pain relief procedure performed in the Operating Room (OR). Pt. #1's surgical consent dated and signed by Pt. #1 on 9/9/2022, included, "Right Cervical 3, 4, 5, 6 Medical Branch Block".

- The Anesthesia Operative Report dated 9/9/2022, included, anesthesia began at 12:23 PM, procedure began at 12:24 PM, procedure ended at 12:38 PM, and Pt. #1 exited the OR at 12:41 PM.

- A "Post Anesthesia Care Note," dated 9/9/2022 at 12:44 PM, written by the CRNA (E #6) included, " ... Post assessment: no apparent anesthesia complications ... Complications: none. Cardiopulmonary status: stable. Report given to [recovery room] nurse."

- A recovery room nursing note (E #14) dated 9/9/2022 at 1:06 PM, included, "Patient received from OR in distress, waking up, confused stating that she cannot breathe. Patient saturating at 100% on room air. Patient reoriented with no signs of learning. Anesthesia at bedside assessing." Another recovery room nursing note at 1:31 PM, included, "... Patient is alert and oriented at this time. Vital signs stable... Patient discharged home via car."

3. On 11/2/2022, Pt. #1's Complaint/Grievance dated 9/9/2022, was reviewed. Pt. #1's Complaint/ Grievance included, "This patient came to ... [the Hospital] on 9/9/2022, for an outpatient procedure at the Surgery Center. When getting prepared for procedure, she had a panic attack when she began thinking of how she will not know what is happening to her when she is under anesthesia. She claims that the male staff member (CRNA) [E #6] spoke to her very inappropriately as he was trying to address her panic attack. She claims he said, 'Look, you can breath, calm down or else we will call security and have you restrained', and 'Wow, this will make a juicy story later.' She shared that she was absolutely disgusted by the CRNA's inappropriate response. The Patient claims that no other staff members stepped in to defend her when he was behaving inappropriately ..."

- An update to the Complaint/Grievance dated 9/13/2022, included, "Post-op call made to patient on 9/13/2022 at approximately 2:15 PM. At this time patient stated that she was sexually assaulted at the Hospital on Friday [9/9/2022]. She stated, 'One of your creepy OR nurses [E #6] said he was going to tie me down. He turned me on my side and said he was going to bound me to the bed. Then he asked me what my safe word was.'..."

4. The OR Anesthesia CRNA work schedule from 9/9/2022 through 9/26/2022 was reviewed. The work schedule included E #6 working 8 surgical cases on 9/14/2022 between 10:19 AM and 2:53 PM, the day after the Complaint/Grievance update was received.

5. On 11/3/2022 at approximately 1:25 PM, an interview was conducted with the Director of Surgical, Women, and Infant Services (E #7). E #7 stated that E #6 was taken off duty by (Name of Anesthesia Agency), the Contracted Agency that employed E #6. E #7 stated that she was not sure why E #6 was not suspended at the time (9/13/2022 at approximately 2:15 PM) the complaint was updated to alleged verbal sexual assault.