The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ROCKFORD MEMORIAL HOSPITAL 2400 NORTH ROCKTON AVENUE ROCKFORD, IL 61103 March 16, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of Hospital policies, clinical records, Complaint Log (Riskmaster), and staff interviews, it was determined that the Hospital failed to ensure Pt #1's allegation of inappropriate sexual behavior by Hospital staff, was investigated. This potentially affected all patients on the census as of 3/14/12. The cumulative effect of these systemic practices resulted in the Hospital's inability to protect and maintain patients' rights; therefore the Condition of Patients Rights was not met.

Findings include:

1. In 1 of 1 (Pt #1) clinical record reviewed with a documented patient allegation of inappropriate sexual behavior, the Hospital failed to ensure the allegation was investigated. See A 145.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on review of Hospital policy, clinical records, and staff interview,it was determined that for 1 of 3 (Pt #1) clinical records reviewed of patients on suicide precautions, the Hospital failed to ensure patient behavior was documented every 15 minutes as required to help ensure patient safety.

Findings include:

1. Hospital policy entitled, "Management of Patients at Risk For Suicide," effective 2/2011, reviewed on 3/13/12 at approximately 9:30 AM required, "..V. Procedure. C. Suicide Safety Plan. 1. A sitter should remain within line of site of the patient at all time, observing the patient continuously and documenting behavior every 15 minutes."

2. The clinical record of Pt #1 was reviewed on 3/12/12 at approximately 9:30 AM. Pt #1 was a [AGE] year old male admitted on [DATE] with diagnoses of Drug Overdose and Suicide Attempt. The clinical record of Pt #1 contained a physician's order dated 3/2/12 at 5:10 PM that required Pt #1 was to be admitted to the Telemetry Unit with Suicide Precautions and a 1:1 sitter. Clinical documentation included that Pt #1 was on suicide precautions with a 1:1 sitter from 3/2/12 until 3/5/12, at which time Pt #1 was transferred to an inpatient psychiatric facility. However, the clinical record lacked documentation of patient behavior every 15 minutes on the following dates:
-3/2/12 - 8:15 PM to 12:40 AM on 3/3/12,
-3/3/12 - 9:30 AM to 10:00 AM; 11:16 AM to 11:47 AM; 1:01 PM to 2:01 PM; and from 2:17 PM to 3:00 PM;
-3/5/12 - 2:15 AM to 3:15 AM and 4:15 AM to 7:15 AM.

3. The findings were verified by the E-4 Clinical Educator during an interview on 3/13/12 at approximately 1:28 PM.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on review of Hospital policy, clinical records, Hospital complaint reports (Riskmaster), staff interview, Hospital internal e-mail review, and personnel file review, it was determined that for 1 of 1 (Pt #1) clinical record reviewed with a documented patient allegation of inappropriate sexual behavior, the Hospital failed to ensure the allegation was investigated.

Findings include:

1. Hospital policy entitled, "RMH Patient Grievance Process," effective 12/2011, reviewed on 3/13/12 at approximately 9:30 AM required, "III. Definitions:..B. Complaint: An expression of concern or dissatisfaction, whether verbal or written, provided by the patient...regarding quality of care or service... Grievance: 2. Involves abuse, neglect or patient harm ... IV. Accountability: IV. Each individual has the responsibility to see that any concern brought to their attention is received, reviewed, and where possible resolved in a timely manner."

Hospital policy entitled, "Code of Conduct," effective date 12/31/07, reviewed on 3/14/12 at approximately 3:00 PM required, "...Use of cellular phones or other communication devices should be limited to non-work time and used in non-working areas... In general, employees should not carry personal phones or other communication devices with them while performing their job duties."

2. The clinical record of Pt #1 was reviewed on 3/13/12 at approximately 10:00 AM. Pt #1 was a [AGE] year old male admitted on [DATE] with diagnoses of Drug Overdose and Suicide Attempt. Pt #1's clinical record contained documentation dated 3/2/12 at approximately 8:15 PM that included,"patient woke up, yelling, accusing staff of being inappropriate towards him..."

3. The Hospital's Riskmaster reports dated 9/11 to present were reviewed 3/13/12 at approximately 10:45 AM. The reports failed to include documentation of Pt #1's complaint allegation of inappropriate behavior by Hospital staff towards him.

4. The Survey Readiness Manager stated during an interview on 3/13/12 at approximately 10:55 AM that any accusation of inappropriate behavior should have an incident report completed and there were no reports on file regarding Pt #1.

5. The Manager of the E-4 Telemetry Unit (E #4) presented an internal E-mail dated 3/2/12 at 9:56 PM that was reviewed on 3/13/12 at approximately 1:55 PM. The E-mail included: "There was an incident in room e 411 on 3/2/12... E #1 was sitting in the chair next to the window... had periodically been using his cell phone when I was in the room... The patient started yelling at me that E #1 was taking pictures of his 'butt'... The patient rolled over in an attempt to show the nursing staff. Patient asked nursing staff to 'smell his butt' so we would know what happened... I asked if I should do a Riskmaster and was told no, that she had let the nursing office know about the situation and they were taking care of it."

6. The Manager of E-4 was interviewed on 3/13/12 at approximately 1:55 PM. During the interview the Manager stated, "I became aware of the incident on Monday (3/5/12) following the incident. There is not a Riskmaster report filed for the incident only the E-mail from the nurse... I did not follow up with E #1 or the Nursing Office. I did not complete a Riskmaster report as required. I only spoke with the patient and did not follow through with and investigate."

7. The above findings were verified by the Vice President of Quality and Performance Measurement during an interview on 3/13/12 at approximately 2:00 PM.

8. The Manager of the Float Pool (E #6) was interviewed on 3/13/12 at approximately 2:11 PM. E #6 stated, "I was not aware of the incident that occurred with E #1. He (E #1) had been in the float pool for 5 years and the only incidents were in 2010 with texting on his cell phone while working." E #6 was again interviewed on 3/14/12 at approximately 2:30 PM. E #6 stated, " I follow the Hospital policy on cell phone use. I don't give anyone permission to use cell phones. In fact I have written him (E #1) up for this. They can use cell phones in a non nursing area while at lunch and on break."

9. The Certified Nursing Assistant (E #1) sitting with for Pt #1 on 3/2/12 at the time of Pt #1's allegation was interviewed on 3/13/12 at approximately 3:45 PM. E #1 stated, "I was with him from 3:00 PM until approximately 8 to 9:00 PM. He was sleeping, woke up and scampered to the head of his bed then started yelling nurse, nurse, nurse. Nurse (E #8) and her orientee (E #7) were his nurses. I have a cell phone with E-Reader App. and I was reading, which I okayed with the nurse...I did not take pictures or touch the patient. "

10. The personnel file of E #1 was reviewed on 3/14/12 at approximately 9:45 AM. The
file contained written counseling dated 1/10/10 regarding "proper use of personnel cell phone" and 10/1/10 written disciplinary action for "failure to demonstrate appropriate use of personnel cell phone." The file did not contain any disciplinary action regarding Pt #1.

11. On 3/16/12 at approximately 9:00 AM, the Hospital presented an Employee Suspension Notice date 3/13/12 addressed to E #1 and presented an inservice from E-4 Telemetry regarding Pt #1. On 3/16/12 at approximately 10:30 AM, the Hospital presented the schedule for E #1 dated from 3/4/12 to 3/12/12. The schedule included that E #1 worked 3/5/12 as a sitter, 3/6/12 as a sitter, 3/7/12 as a sitter, 3/10/12 as a sitter, and 3/11/12 as a floor CNA. The Chief Nursing Officer (E #10) was interviewed on 3/16/12 at approximately 10:35 AM. The E #10 stated, " No one knew if cell phones were used while sitting. E #1 was not monitored for cell phone usage from 3/5/12 to 3/11/12, because we were unaware of the incident. " The Hospital failed to removed E#1 from service pending investigation, until the date of the survey, 3/13/12 (11 days after the allegation of inappropriate behavior toward a patient).

12. On 3/16/12 at approximately 9:10 AM, the Survey Readiness Manager (E #9) was interviewed again. E #9 stated that, "for a grievance we try Service Recovery, if not able it is my responsibility to call or meet with the patient and/or family. Then we follow CMS requirements as outlined in policy. Neglect and Abuse is included in the Grievance Policy. If neglect or abuse, we get risk management, and all direct line management involved. We contact legal for a more coordinated investigation."

In spite of the Hospital's knowledge of an allegation of inappropriate behavior of E#1 toward Pt. #1, the Hospital failed to investigate the allegation until the surveyors arrived onsite.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on review of Hospital policy, clinical records, Hospital Security Report,and staff interview, it was determined that in 1 of 4 (Pt #1) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure the restraint device was only used to ensure the immediate physical safety of the patient and staff.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion for Management of the Violent and/or Self-Destructive Patient," effective 5/2011, reviewed on 3/13/12 at approximately 11:00 AM required "III. Introduction to Restraint Management: RMH recognizes the right of every patient to: A. Be free of restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience..."

2. The clinical record of Pt #1 was reviewed on 3/13/12 at approximately 10:00 AM. Pt #1 was a [AGE] year old male admitted on [DATE] with diagnoses of Drug Overdose and Suicide Attempt. Clinical documentation included that Pt #1 was on suicide precautions with a 1:1 sitter from 3/2/12 until 3/5/12, at which time Pt #1 was transferred to an inpatient psychiatric facility. Nursing documentation dated 3/3/12 at 5:07 AM included: "Foley placed at this time - pt placed in soft restraints for procedure due to unpredictability of patient behavior and to protect staff; pt tolerated well; security called to bedside for assistance also during Foley placement." The clinical record lacked documentation of immediate danger to patient the patient or others to justify restraint usage.

3. The Hospital's Security report dated 3/3/12 at 4:12 AM included; "Pt had been aggressive towards staff earlier in the day. At the time of Security arriving, Pt had been sedated and placed in 4 point restraints...stood by until procedure was over. It was completed without incident."

4. On 3/13/12 at approximately 1:40 AM the Registered Nurse (E #3) that applied the restraints to Pt #1 was interviewed by phone. E #3 stated that, "Pt #1 was not very responsive and hard to arouse, but when awakened he kept telling E #3 to leave him alone. The patient was very unpredictable and scary so I put restraints on (the patient) to protect myself while putting in the Foley. About an hour or so we released the restraints from the bed but left them on the patient. When the patient was able to follow commands they were removed."

5. The above findings were verified by the Survey Readiness Manager during an interview on 3/14/12 at approximately 2:30 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 4 (Pt #1) clinical records reviewed of patients with restraints, the Hospital failed to ensure physicians' orders were received to authorize restraint usage.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion for Management of the Violent and/or Self-Destructive Patient," effective 5/2011, reviewed on 3/13/12 at approximately 11:00 AM required "... Obtain an order for restraint: If the face to face evaluation is conducted...The order for restraint ...must be obtained at this time."

2. The clinical record of Pt #1 was reviewed on 3/13/12 at approximately 10:00 AM. Pt #1 was a [AGE] year old male admitted on [DATE] with diagnoses of Drug Overdose and Suicide Attempt. Clinical documentation included that Pt #1 was on suicide precautions with a 1:1 sitter from 3/2/12 until 3/5/12, at which time Pt #1 was transferred to an inpatient psychiatric facility. Nursing documentation dated 3/3/12 at 5:07 AM included: "Foley placed at this time - pt placed in soft restraints for procedure due to unpredictability of patient behavior and to protect staff; pt tolerated well; security called to bedside for assistance also during Foley placement." The clinical record lacked a physician's order for restraint usage.

3. On 3/13/12 at approximately 1:40 AM the Registered Nurse (E #3) that applied the restraints to Pt #1 was interviewed by phone. E #3 stated that, "Pt #1 was not very responsive and hard to arouse, but when awakened he kept telling E #3 to leave him alone... The patient was very unpredictable and scary so I put restraints on (the patient) to protect myself while putting in the Foley. About an hour or so we released the restraints from the bed but left them on the patient. When the patient was able to follow commands they were removed."

4. The above findings were verified by the Manager of E-4 and the Clinical Educator of E-4 during an interview on 3/13/12 at approximately 1:28 PM.