HospitalInspections.org

A. Based on document review and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #6) clinical records reviewed for allegation of abuse, the Hospital failed to report the allegation of abuse in accordance with the IDPH (Illinois Department of Public Health) regulations, to ensure patient was free from all forms of abuse or harassment.

Findings include:

1. On 5/12/2021, the Hospital's policy titled, "Adult/Child Abuse Neglect" (revised on 5/2017) was reviewed and included, " ... Definition ... Adult abuse is deliberate, intentional physical injury of another person or the fear of such violence regardless of the relationship of the individuals ... " The policy did not include reporting of allegation of abuse to IDPH.

2. Per TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIESPART 250 HOSPITAL LICENSING REQUIREMENTS ... Section 250.260 Patients' Rights ... c) Patient Protection from Abuse ... 3) 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)... 5) Upon receiving a report under subsection (c)(3), the hospital shall submit the report to the Department within 24 hours after obtaining such report..."

3. On 5/12/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was seen at the Hospital's outpatient clinic on 2/24/2021 for a 3-month follow-up visit and ongoing problem list of anxiety, chronic pain, and complex regional pain syndrome. Pt. #1 was seen at the clinic by MD #1 (Resident Physician).

4. On 5/12/2021, the clinical record of Pt. #6 was reviewed. Pt. #6's most recent visit with MD #1 was 10/20/2020 for post-partum clinic appointment.

5. On 5/12/2021, an email from MD #6 (Attending Physician), dated 3/10/2021 was reviewed and included, "(To MD #2/Attending Physician/Director, Physician Residency Program), I am writing to inform you of a serious accusation that was made today about (MD #1)... (Pt. #6) ... came to me extremely anxious and in tears ... (Pt. #6) stated that around the time of her birthday last December until recently, she felt pressured and entered into a physical relationship with (MD #1). (Pt. #6) states she knew it was wrong but was worried if she did not acquiesce to him, that she would be made to feel guilty about the care and assistance he (MD #1) had provided ..."

6. On 5/12/2021 between 10:30 AM and 3:00 PM, interviews were conducted with E #1 (Chief Legal Officer) and E #5 (Chief Nursing Officer). E #1 stated that on 5/11/2021, she heard from MD #3 (Attending Physician/Assistant Director of Physician Residency Program) that Pt. #1 reported an allegation of inappropriate touching by MD #1. Regarding Pt. #6, E #1 stated that the nature of the accusation against MD #1 was about abuse of power, "like an emotional abuse." As of 5/13/2021, the allegations of abuse for Pt #1 and Pt. #6 has not been reported to IDPH. E #5 said that allegations of abuse are not reported to IDPH.

7. On 5/13/2021 at approximately 9:35 AM, a telephone interview was conducted with MD #6. MD #6 stated that based on the 3/10/2021 email, the accusation against MD #1 was "kind of an abusive power" over Pt. #6. MD #6 stated that Pt. #6 was very emotional and tearful at the time and that there was a suspicion of an emotional abuse. MD #6 said, "It sounded like (MD #1) was pressuring (Pt. #6) to continue with the relationship. I knew what I was hearing was wrong and I had to report it."

B. Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #6) clinical record reviewed for allegation of abuse, the Hospital failed to notify the police, as required, to ensure patient was free from all forms of abuse or harassment.

Findings include:

1. On 5/12/2021, the Hospital's policy titled, "Adult/Child Abuse Neglect" (revised on 5/2017) was reviewed and included, " ... Definition ... Adult abuse is deliberate, intentional physical injury of another person or the fear of such violence regardless of the relationship of the individuals ... G. Intervention ...2. If violence is identified and acknowledged, notify ... the police department ... with victims consent ... Appendix A - Adult ... Patient identifies self as abused? Yes, obtain consent to notify police ..."

2. On 5/12/2021, the clinical record of Pt. #6 was reviewed. Pt. #6's most recent visit with MD #1 was 10/20/2020 for post-partum clinic appointment.

3. On 5/12/2021, an email dated 3/10/2021 was reviewed and included, "To (Name of MD #2/Attending Physician/Director, Physician Residency Program), I am writing to inform you of a serious accusation that was made today about (MD #1)... (Pt. #6) ... came to me extremely anxious and in tears ... (Pt. #6) stated that around the time of her birthday last December until recently, she felt pressured and entered into a physical relationship with (MD #1). (Pt. #6) states she knew it was wrong but was worried if she did not acquiesce to him, that she would be made to feel guilty about the care and assistance he (MD #1) had provided ..."

4. On 5/12/2021 between 10:30 AM and 3:00 PM, interviews were conducted with E #1 (Chief Legal Officer). E #1 stated that the nature of the accusation against MD #1 was about abuse of power, "like an emotional abuse." As of 5/13/2021, E #1 could not provide documentation that the Hospital offered or obtained Pt. #6's consent to call the police regarding the allegation of abuse.