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ADVOCATE CONDELL MEDICAL CENTER 801 S MILWAUKEE AVE LIBERTYVILLE, IL 60048 Dec. 31, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for allegation of abuse, the hospital failed to ensure the documentation of an investigation and reporting of abuse allegations in accordance with hospital policy.

Findings include:

1. The hospital policy entitled, "Detection and Reporting of Hospital Patient Abuse" (revised 3/21/12) required, "Abuse means any physical or mental injury or sexual abuse intentionally inflicted by a hospital associate, agent, or medical staff member on a patient of the hospital and does not include any hospital, medical, or health care, or other personal care services done in good faith in the interest of the patient according to established medical and clinical standards of care...Upon receiving a report of suspected abuse Risk Management will notify the hospital designated Regulatory position and Compliance position as needed, who shall submit the formal report to the (IDPH) Department within 24 hours of obtaining such report. In the event the hospital receives multiple reports involving a single alleged instance of abuse, the hospital shall submit one report to the (IDPH) Department...Reports of alleged abuse must be generated and submitted to the IDPH within 24 hours whether or not the investigation is complete...The opportunity to file a criminal complaint to local law enforcement will be offered and Public Safety will facilitate this process...All internal review findings must be documented and filed according to hospital procedures and shall be made available to the (IDPH) Department on request...Nothing relieves a hospital administrator, associate, agent, or medical staff member from contacting appropriate law enforcement authorities as required by law..."

2. The clinical record for Pt #1 was reviewed on /23/13 at approximately 11:30 am. Pt #1 was a [AGE] year old male who presented to the Hospital ' s ED on 9/5/13 at 12:43 pm with a complaint of altered mental status. Pt #1 was triaged at 12:43 pm and the triage RN ' s (E #1 ' s) note included, " ...confusion, chronic in nature. Pt noted tremors and unable to complete comprehensible sentences in Triage. Pt was dropped off by spouse who left. States " I was clubbed on the head in August and I have problems". Known history of ETOH [alcohol] abuse. Denies new trauma. " At 6:12 pm, the ED RN's note indicated that Pt #1 became agitated after asking for pain medication. Pt #1 pulled his monitor leads off and got dressed. At 6:24 pm, Pt #1 walked with his cane out of the ED in spite of multiple staff members trying to stop him. A code gray was called and public safety officers (PSOs - E #5, E #7, and E #8) responded. Pt #1 was brought back into the ED by ED staff and E #5, E #6, and E #7 on a cart. Restraints were ordered by the ED APN (E #2) and PSOs assisted in application of restraints.

Pt #1 was admitted to the hospital's telemetry unit on 9/5/13 at 9:35 pm with diagnoses of altered mental status and suspected TIA or CVA. The telemetry unit nurse's (E #4 ' s) note dated and timed 9/6/13 at 8:09 pm included, " Notified [MD #1] regarding bruising and swelling of left shoulder and upper arm. Pt is also complaining of bilateral knee pain which appears to be swollen as well. Pt informed RN that he was "roughed up by 7 security guards here yesterday" . E #4 did not report this allegation of abuse.

On 9/7/13 x-rays were ordered by MD #2 and completed of Pt #1 ' s left humerus, left clavicle, left elbow, left wrist, and bilateral knees. The clinical indication documented for these x-rays was pain, bruising, and assault. All of these x-ray results showed no acute fractures or dislocation.

The telemetry unit nurse's (E #3's) note dated and timed 9/9/13 at 10:26 am included, " Called patient representative [E #21], regarding the patient wants to talk about the incident at ER. She will come once the patient ' s wife is here."

3. The security incident report completed by [E #5] dated 9/5/13 at 7:05 pm included the following:
On the above date and time, while on an unrelated patient watch, I Public Safety Officer [E #5], did hear a CODE GREY being paged on the overhead public address system.
I immediately responded to the location, and upon arrival at the E.R. overflow parking lot, I did see a group of Emergency Department Medical Staff trying to talk a patient, into returning to the E.R. for immediate Medical Treatment.
I issued a verbal command for the patient to stop and listen to the Medical Staff. Patient was non compliant. [E #2] the Patients Nurse [E #6] was trying to stand in front of the patient in order to stop the patient from leaving and to convince him to return to the E.R.
[E #2] and Emergency Dept ...Charge Nurse [E #17], stated to me that patient ...may have had a stroke and is in a mental altered state, and that the patient cannot leave in his Medical condition.
As the unfolding incident needed appropriate, effective and an immediate response, using a soft open hand technique, I then took hold of the patients wrist and arm, however the patient was actively aggressive and resisted by trying to pull away from me, I then used an shoulder arm pin restraint in order to detain the patient, establish control quickly, and keep him from leaving.
At this time Lead Officer [E #7] arrived, I then unrestrained patient from the shoulder pin restraint as I felt I had incorrect arm placement, and allowed the Medical Staff to try and talk patient into voluntarily going back to the E.R. room #8. I then along with [E #7], walked along the side walk with the patient and Medical Staff, onto the corner of Lot-1.
Nurse Practitioners, [E #2 and E #18] were still talking/trying to get patient ...to return voluntarily to the E.R. , However patient was verbal non compliant, patient was making threatening verbal statements and continued to walk north on Stewart Street. At this point I [E #5], along with [E #7] physically took control of patient ...wrists and arms stopping his forward movement.
[E #7] then instructed [E #8] to go and retrieve a wheelchair, so that we could sit patient and return him to the E.R... When wheelchair arrived, and patient was asked to sit in the wheelchair, patient exhibited defensive resistance, then active aggression; patient struck me in the foot with his cane and made attempts to strike me in the groin area. PSO Officers, using soft empty hand techniques and upper body strength placed patient into the wheelchair.
When the attempt to turn the wheelchair and go back to the E.R. was made, patient grabbed onto the wheelchair wheels and refused to release them, so that the wheelchair could not be moved.
[E #7] then instructed Medical Staff to get an Emergency Dept ...Cart, and bring it out so that patient could then be transferred to it. When the E.R. cart arrived and an attempt was made to transfer the patient, the patient again exhibited active aggressive behavior and then allowed himself to slide off of the wheelchair and onto the side walk. As the patient was dead weight, I along with [E #7] and [E #8] had to physically lift patient off the side walk and onto the cart.
Patient ...was then wheeled into the emergency room ; cart Number eight (8), and [E #2] then issued orders for patient to be placed into four point hard restraints. After patient restrained, Public Safety Officers then cleared.

4. On 12/24/13 at approximately 1:16 pm, E #20 presented the surveyor with documentation of a complaint received by the hospital from Pt #1 which included the following:
9/9/13 1804 by [E #21] - I received a call from this patient who wanted me to come and speak with he and his wife. I went to visit with the patient with his wife present. He stated that he came in through the ED on Thursday about noon. His wife was with him. She left to go home and gather some things for him as medication list and went to work for a while. She then returned and left again because patient was waiting for inpatient bed. Patient states that he began having spasms in his back and legs and called for help. He states that the PCT came into the room and stated "what do you want me to do about that" to which he relied "I shouldn ' t have to know about that, you should know what to do". At that time he decided he wanted to leave and started taking off his gown and anything else he was attached to. The nurse came into his room and told him "you can't leave". He decided he was still going to leave and walked out the door and across the street. He states that several security guards came and tried to make him stop and he continued to walk away. He states the next thing he knows is that someone grabbed him from behind around the neck and another under his arm. He states they were very rough with him and had him on the ground. He states that someone "bit him on his legs" and he showed me multiple sores on his arms, back, hands and legs. He says they gave him some kind of shot and brought him back into the hospital where he was placed in locked restraints with metal on them and put in a "special room". He states he was told he could not leave and he asked to see that paperwork several times, but never did see that in writing. I asked the wife if she had anything to say. She stated that she also gave consent for him to have a sedative. She stated she was told it took seven people to subdue him. She also feels that his stay has been extended because of the injuries that have occurred and that he has had a significant amount of undue pain.
The patent states he is surprised that no one has checked on his bruises since he has been in his room or even in the ED. I assured him that they are documented in his chart. He also stated that he has spoken with his lawyer.

9/11/13 1540 by [E #21]
Pt was discharged yesterday. Initial letter was sent out today.

9/14/13 10:51 am [E #21] - Complaint received from Pt #1
Read below. I will be talking to Channel 5 news next week.
Comments - ED dept is terrible. The floor nurses are wonderful. I have already contacted an attorney. S/t ' jumped by our security guards ' and beat up in the parking lot because I wanted to leave the hospital. I have the right to leave the hospital anytime. I pulled the IV out and walked out. I ' m not doing well. I was beat up and my wife was there. The RN rammed an IV into my neck and gave me Ativan. I have over 100 black and blue marks on body, broken patella, and ACL tear. One person had right leg, one left leg and pulled. A small woman bit my testicles where they were black and blue. "Killer choke hold". It ' s on the film. Chained me to the gurney. I need to have two surgeries (on my legs) during the next week because of your hospital. Know that this is not the last time you'll hear my name.

10/11/2013 0819 by Patient Representative Supervisor - Patient has retained legal counsel which precludes further direct contact with this patient. Follow up is being managed through other channels.


5. On 12/30/13 at approximately 10:15 am, an interview was conducted with the ED Director (E #10). E #10 stated that the manager of the telemetry unit had said something about Pt #1 ' s complaint. E #10 stated the patient representatives start the grievance process per hospital policy. E #10 stated that she did not recall her involvement in the investigation, and she did not recall interviewing the ED staff members involved in the incident. E #10 stated the day after the incident (9/6/13); it was on the report sheet of elopements. Pt #1 attempted elopement and was unstable from an altered mental status point of view. E #10 stated that she did not speak to the manager of public safety about this incident and did not recall if she spoke with Pt #1. E #10 stated, " I do remember reviewing the patient ' s record. The patient is well known to us. In my professional opinion, nursing care was appropriate. I think the patient stated he had been clubbed. I think his wife dropped him off. Staff knows the patient. He is here 8 or 9 times a year. " E #10 could provide no documentation of staff interviews or investigation of this abuse allegation. E #10 did not report the abuse allegations to IDPH.

6. On 12/30/13 at approximately 12:35 pm, an interview was conducted with the public safety manager (E #14). E #14 stated that the reports, videos, and follow up with PSOs are normally done for all code grays. E #14 stated that the reports are corroborated with the staff involved. E#14 stated that in September (could not recall date), he was contacted by risk management about a complaint received from Pt #1 related to this incident. Since E #14 had already investigated this incident, E #14 collected the videos and report of this event and gave them to risk management. However, E #14 could provide no documentation of interviews with the PSOs, review of the videos, or any investigation of this abuse allegation. E #14 stated that he did not speak with Pt #1 to offer for Pt #1 to file a criminal complaint to local law enforcement and facilitate this process if Pt #1 requested. E #14 did not report the abuse allegations to IDPH.

7. On 12/30/13 at approximately 2:02 pm, an interview was conducted over the telephone with the (now former) risk manager (E #15). E #15 stated she remembered getting the security report for Pt #1 ' s incident. Pt #1 tried to leave AMA. E #2 had determined that Pt #1 was not suitable to leave. Security said Pt #1was well known and there were several security reports where Pt #1 was agitated and hitting staff with his cane. E #15 stated that Pt #1 had requested pain medication, didn ' t want to wait for his wife, was hitting staff with his cane, and went outside. E #15 stated that it is up to the medical staff (E #2) to decide to let the patient go, call the police department or keep the patient in the hospital. It was E #2 ' s judgment call to physically restrain Pt #1 and bring him back to the ED. E #15 stated that she had interviewed ED staff involved and the record and video had been preserved. E #15 stated that E #14 had interviewed public safety staff. E #15 stated that she met with the ED director (E #10) to discuss Pt #1 ' s complaint. E #15 stated that substantiated reports of abuse are reported immediately to the corporate office who reports them to the appropriate agencies. E #15 stated this complaint was found unsubstantiated based on Pt #1 ' s past history and staff reports. E #15 did not speak with Pt #1. E #15 stated when the patient obtains legal counsel; the complaint/grievance is closed from risk management, and sent to the claims department. E #15 did not report the abuse allegations to IDPH.

8. On 12/31/13, the above findings were discussed with the Associate General Counsel (E #20). E #20 stated that per hospital policy the investigation should have been documented and the allegation of abuse should have been reported to IDPH.