HospitalInspections.org

Based on document review, and interview, it was determined that the Hospital failed to protect and promote each patient's rights. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients were free from abuse by failing to complete a thorough investigation and offer an evidence collection kit, prior to allowing staff accused of sexual abuse to return to work and provide direct patient care. A 145 A.

The immediate jeopardy began on 2/8/2022, due to the Hospital's failure to fully investigate an allegation of sexual abuse and offer an evidence collection kit prior to allowing the accused staff to return to work and provide direct patient care.

The IJ was identified on 3/30/2022 and announced on 3/30/2022 at 2:00 PM, during a meeting with the Chief Medical Officer, General Counsel, 2 Assistant Vice Presidents, Director of Quality Outcomes and Accreditation, and was not removed by the survey exit date of 3/31/2022.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #8) reviewed of psychiatric patients, the Hospital failed to ensure the patient received care in a safe setting by failing to ensure observations were completed as ordered.

Findings include:

1. On 3/30/2022, the Hospital policy titled, "Precaution Status and Observation Levels," revised 6/24/2022, was reviewed. The policy required, "High Risk Level - Suicide: An individual who is actively endorsing self-harm or who has made an attempt to harm him or herself while on the unit... One to one observation requires the staff member to be no further away than arms-length from the individual at all times unless the individual poses immediate risk to the staff member to which case the 1:1 is full body length..."

2. On 3/29/2022, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted on 3/17/2022 with a diagnosis of suicide ideation. The Emergency Department records on 3/17/2022 indicated that Pt. #8 had ingested screws and was under police custody. A history and physical on 3/17/2022 at 7:35 AM, included, a chest X-ray and KUB (ultrasound) "shows ingested screw projects over the left upper quadrant (LUQ). GI [gastrointestinal] evaluated patient in the ER and planning for possible EGD [esophagogastroduodenoscopy] for removal of foreign body." Physician orders on 3/17/2022 at 7:35 AM, included, "provide Sitter" (a staff member to maintain watch and monitor the patient).
- Physician progress notes included:

- On 3/19/2022 at 9:20 AM, Pt. #8 was told the screws had been removed and he was going back to jail where he could be treated by the jail psychiatrist. Pt. #8 told the physician, in the presence of the Sitter, "Don't worry, I know what to do" and "10 minutes later I got a call that he [Pt. #8] had swallowed a screw again."

- On 3/21/2022 at 3:06 PM, included, "swallowed 2 more screws 3/21/2022? KUB from 3/20/2022 showed screws in the RUQ and LUQ. No abdominal pain."

- On 3/22/2022 at 10:39 AM, included, screws present in Pt. #8's abdomen, "X-ray abdomen 3/22/2022, multiple right abdominal metallic screws projecting in the region of the ascending colon, unchanged from prior exam. No evidence of obstruction."

- Nursing Notes documented that a sitter was present with Pt. #8 on 3/17/2022 at 5:02 PM, 3/18/2022 at 6:55 PM, 3/18/2022 at 9:40 PM, 3/21/2022 at 9:02 AM, 3/22/2022 at 8:06 PM, and 3/23/2022 at 2:40 PM. Pt #8's record lacked documentation that a sitter was present on 3/19/2022 and 3/20/2022, as ordered.

3. On 3/30/2022 at 1:30 PM, an interview was conducted with an Assistant Vice President (E #4). E #4 stated that Pt. #8 came to the Hospital from Cook County Jail and was admitted to the Telemetry Unit with a police guard and sitter. The police guard stayed closer to the patient than the sitter, as Pt. #8 was cursing and swearing at staff. E #4 stated that sitters do not document in the medical record.

A. Based on document review and interview, it was determined that for 2 of 2 clinical records(Pt. #1 and Pt. #2) reviewed for abuse allegations, the Hospital failed to ensure patients were free from abuse. This included failure to complete a thorough investigation and offer an evidence collection kit, prior to allowing the accused staff to return to work and provide direct patient care.

Findings include:

1. On 3/28/2022, the Hospital's policy titled, "Abuse Reporting: External and Internal Events" (reviewed by the Hospital 11/25/2021) was reviewed. The policy included, "...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation...Procedure for reporting internal event: A. When suspected patient abuse and/or neglect is reported, the Program director and Nurse Manager shall immediately report the situation to the Hospital Liaison, Hospital policy and state law requirements will be followed for investigation, additional reporting, and documentation....D. The Program director shall immediately suspend any Hospital employee involved in the incident from all future patient care until the incident has been investigated and resolved."

2. On 3/28/2022, the Hospital's policy titled, "Treatment of Sexual Assault" (revised by the Hospital June 5, 2019) was reviewed. The policy required, " ...Procedure ...11. The consenting patient is to be examined by the ED provider ...12. The medical examination shall include but not be limited to the following; a. general physical examination, appropriate blood tests, stains and cultures for sexually transmitted disease (cultures for these tests to be collected from vagina, cervix ...anus and/or oropharynx as indicated by the nature of the alleged assault) ...Evidential Materials ...2. With the survivor's consent, the Evidence Collection Kit shall be completed if the survivor presents himself/herself within seven days after sexual assault."

3. On 3/28/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 1/18/2022 to the telemetry unit with the diagnoses of COVID-19 and pneumonia. Pt. #1 was discharged home on 2/3/2022. The provider progress note dated 1/26/2022 at 11:57 AM, (by a Nurse Practitioner /E #9), lacked documentation of an assessment/examination related to the allegation of a sexual assault. Pt. #1's clinical record lacked documentation that an evidence collection kit was offered.

4. On 3/28/2022, the Hospital's incident report dated 1/26/2022, was reviewed and included the following:
-On 1/26/2022 at 10:30 AM, (by a Registered Nurse/E #2), "RN [Registered Nurse] was in pt [PT #1] room providing care. Before leaving, patient [Pt. #1] stated that she had a 'strange encounter with a male nurse [E #10].' The patient [Pt. #1] then began to tell RN that yesterday 1/25/2022, the patient [Pt. #1] had called on the call light for assistance with washing up. A 'large black male wearing gray scrubs' [E #10] came in and offered to help pt [Pt. #1] with washing up. He [E #10] stated that he was a nurse and that he would be able to help her. He [E #10] asked her if she felt comfortable with him giving her care since he was a man, and she replied yes, because she had known that it was his job to assist patients. After helping her [Pt. #1] wash up and completing assistance, the male had left the room. He returned to the room and offered to help her clean her back. Patient [Pt. #1] was lying on her side and she stated that she [he] touched her [Pt. #1] and put his [E #10] fingers in her, and she felt his junk was hard on her back. She had then told him to stop whatever he was doing. He then came to face her in the front with his private areas exposed. She again told him to stop what he was doing and he left the room. Patient [Pt. #1] visibly upset, crying while telling story...Event occurred yesterday 1/25/2022 in afternoon."

5. On 3/28/2022, the Hospital's investigation report related to Pt #1's allegations of sexual assault, dated 1/27/2022, was reviewed. The investigation included staff interviews and an interview with Pt. #1, but lacked documentation of an examination of Pt. #1 to assess for injury and collect evidence. The report also included an interview with the Patient Care Technician/PCT (E #10). In the investigation interview with E #10, E #10 stated that he was assigned as Pt. #1's PCT on 1/25/2022 but denied the allegation against him from Pt. #1. The report also included documentation that on 1/27/2022, the city police department detective reported to the Director of Risk Management and Legal Services (E #3), that the police had received another report from a second patient of similar allegations by a staff member matching the Patient Care Technician's (PCT/E #10's) description during that patient's hospitalization. The Hospital's investigation report indicated that the other incident occurred on the third floor (telemetry unit) of the Hospital. The city police department detective shared the other patient's (identified as Pt #2) information with the Hospital on 2/4/2022. However, the Hospital's investigation report did not include any investigation by the Hospital of Pt #2's similar allegations of abuse that were reported to the police.
-The Hospital's investigation report conclusion was that the Hospital was unable to corroborate the allegation made against E #10 by Pt. #1. The report also concluded that Pt. #1 "changed the story" when reporting to other staff members. Therefore, E #10 was allowed to return to work providing direct patient care on 2/8/2022.

6. On 3/28/2022, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 1/10/2022 to the intensive care unit and was transferred to the telemetry unit on 1/12/2022, with the diagnoses of COVID-19 and pneumonia. Pt. #2 left Against Medical Advice (AMA) on 1/18/2022. The nursing progress note, dated 1/18/2022 at 12:20 AM, (by a Registered Nurse/E #6), included, "Pt [Pt. #2] signed out against medical advice, writer attempted to educate pt about the risks of leaving AMA without success. Dr. [Pt. #2's Physician name] attempted to educate pt without success, pt left unit accompanied by transporter ..." Pt. #2's clinical record lacked documentation of an allegation of abuse while hospitalized. Staffing assignments included that E #10 was assigned to Pt. #2 on 1/18/2022.

7. On 3/28/2022 at 12:18 PM, an interview was conducted with the Director of Risk Management and Legal Services (E #3). E #3 stated that on 1/27/2022, the city police department detective reported that another patient made allegations similar to Pt. #1's allegation, involving an employee with the same description. E #3 stated that the city police department did not give details of the other patient's complaint. E #3 stated that the city police department did not provide the other patient's (Pt. #2) name until 2/4/2022 but did not release the details or nature of the complaint related to Pt. #2. E #3 stated that a full investigation was not conducted for Pt. #2 because the city police department did not release information about the content of the allegation. E #3 stated that Pt. #2 signed herself out of the Hospital against medical advice and did not file a grievance/complaint with the Hospital.

8. On 3/28/2022, E #10's employee work schedule (1/1/2022 - 3/12/2022) was reviewed. The schedule showed that E #10 worked on 1/12 - 1/14/20222, 1/17/2022, 1/18/2022, 1/20-1/22/2022, 1/24 -1/25/2022, 2/8/2022, 2/10 -2/11/2022, 2/14 -2/16/2022, 2/18 -2/20/2022, 2/22/2022, 2/23/2022, 2/25/2022, 2/28/2022, and 3/1/2022. E #10 was assigned to Pt. #2 on 1/18/2022. On 1/25/2022, E #10 was not assigned to provide care for Pt. #1, although during the Hospital's investigation interview E #10 stated that he was assigned to provide care for Pt. #1. Following the abuse allegation, E #10 did not work on 1/26/2022, was suspended on 1/27/2022 and returned to work 2/8/2022. E #10 provided direct patient care between 2/8/2022 - 3/1/2022 and was terminated on 3/2/2022 due to poor work performance.

9. On 3/30/3022 at 10:35 AM, an interview was conducted with the Director of Risk Management and Legal Services (E #3). E #3 stated that an investigation was conducted regarding Pt. #2's abuse allegation with the city police department. E #3 stated that she was present for all of the interviews conducted by the city police department, with Hospital staff. E # 3 stated that she will provide an affidavit of her presence during the interviews.

10. On 3/30/2022, the Hospital provided an affidavit letter of investigation re: Pt. #2, dated 3/30/3022 and signed by the Director of Risk Management and Legal Services (E #3). The letter included documentation that an investigation into Pt. #2's abuse allegation was conducted in conjunction with the city police department on February 10, 2022.

11. The Hospital could not provide documentation that a thorough investigation by the Hospital was conducted related to Pt. #2's allegation, prior to allowing E#10 to return to work on 2/8/2022 and provide direct patient care.

B. Based on document review and interview, it was determined that for 1 of 10 (Patient Care Technician/E #10) personnel files reviewed for abuse training, the Hospital failed to ensure patients right to be free from all forms of abuse by providing abuse training to all staff.

Findings include:

1. During the course of the survey the Hospital did not provide an abuse policy regarding employee training requirements.

2. On 3/29/2022, the Patient Care Technician job description (revised by the Hospital August 9, 2019) was reviewed. The job description required, "...Essential Functions...7. Maintains knowledge base and annual competencies."

3. On 3/29/2022 E #10's personnel file was reviewed. E #10 was hired as a Patient Care Technician for the 3 East telemetry unit on 10/25/2021. E #10's personnel file lacked documentation that E #10 received education/counseling related to abuse or abuse training. E #10 was terminated on 3/2/2022 for poor work performance.

4. On 3/28/2022, the Hospital's incident reports dated were reviewed. The incident reports that three (3) patients filed grievances against E #10 with allegations of sexual assault. The allegations were for care provided by E #10 on 1/18/2022, 1/25/2022, and January 2022 (specific date unknown).

5. On 3/28/2022 at 1:00 PM, an interview with the Interim Director of Human Resources (E#11). E #11 stated that the Hospital does not have documentation that E #10 had the required abuse training.

6. On 3/31/2022 at 9:19 AM, an interview was conducted with a Registered nurse (E #21). E #21 stated that abuse training is included in the annual compliance training.

Based on document review and interview, it was determined that for 3 of 3 employees (E #15 - #17), with religious exemptions to receiving the COVID-19 vaccine, the Hospital failed to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff not fully vaccinated for COVID-19.

Findings include:

1. On 3/29/2022, the Hospital policy titled, "COVID-19 Vaccination Policy," effective 9/1/2021, was reviewed. The policy required, "Special Instructions ... C. Vaccination Exempted Employed and Non-Employed HCWs [Health Care Workers]. The employee or non-employed HCW shall be required to wear a surgical or procedure mask in all patient care areas and will be subject to weekly COVID-19 testing ..."

2. On 2/28/2022, the "COVID-19 Vaccination Exemption Requests" were reviewed. There were
no medical exemption requests found. There were 3 employees (E #15 - 17) with religious exemptions. There was no documentation of weekly testing for E #15, E #16, and E #17.
- E #15 is a full time (1.0 FTE) Lead Pharmacy Technician,
- E #16 is a part time (0.8 FTE) Stationary Engineer in Plant Operations,
- E #17 is a part time (0.2 FTE) Stationary Engineer in Plant Operations,

3. During the interview with the Infection Control Manager (E #8) on 3/29/2022 at 9:05 AM, E #8 stated that E #16 and #17 were part time, spent most of their time in Plant Operations, and wore protective PPE (personal protective equipment) when in the Hospital. E #8 stated that there is no documentation of weekly COVID testing for any of the exempt employees.

4. On 3/31/2022 at 2:20 PM, an interview was conducted with the Director of Quality Assurance (E #1). E #1 stated that exempted non-vaccinated Hospital staff should have their weekly COVID testing tracked by their Managers.