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.

CHICAGO BEHAVIORAL HOSPITAL 555 WILSON LANE DES PLAINES, IL Aug. 2, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, it was determined that the Hospital failed to ensure patients' rights were protected. This has the potential to affect all current and future patients with sexual abuse allegations at risk for harm. 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 the grievance process was followed, as required (A-0118).

2. The Hospital failed to ensure allegations for sexual abuse were thoroughly investigated, to ensure patients are free from abuse (A-0145).

An Immediate Jeopardy (IJ) began on 10/15/17 for the Hospital's failure to thoroughly investigate Pt. #1's sexual abuse allegations by an employee (E#16), thus potentially placing all psychiatric patients with sexual assault allegations at risk for serious harm.

The IJ was identified and announced on 8/2/18 at 3:20 PM, during a meeting with the Chief Executive Officer, Senior Vice President of Clinical Services, and the Director of Performance Improvement and Risk Management. The IJ was not removed by the survey exit date of 8/2/18.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that the Hospital failed to follow the grievance process for 2 of 4 allegations (Pt. #1) for sexual abuse, as required.

Findings include:

1. On 7/31/18 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of schizoaffective disorder, depressive type. On 5/23/18, the daily nursing progress notes of E #6 (Registered Nurse/RN-Pt. #1's RN on 5/23/18).1` indicated, "Thought Process: Continues to say outloud that she was sexually approached by male staff the last time I (Pt. #1) was here." However, a follow-up investigation regarding Pt. #1's allegation was not available.

2. On 7/31/18 at approximately 10:45 AM, the Grievance and Complaint Log from 2/2018 to 7/29/2018 was reviewed. The log did not include Pt. #1's allegation of sexual abuse.

3. An incident report dated 10/15/17, for Pt. #1's hospitalized from [DATE] to 10/16/17 due to unspecified schizophrenia, was received from the hospital on [DATE]. The incident report written by the Nursing Supervisor (E #13) indicated, "Godmother of (Pt. #1) called this writer (E #13) stating that her daughter was here and had recently accused someone of raping her(.) (B)ut godmother states she later found that to be untrue. She continued the conversation stating there was a staff member here(,) her daughter had been intimately involved. She said her daughter (Pt. #1) had been here before and wanted to come back here. Her mother stated once previously while out at her home the staff she called (E #16) (a bald, black man in his 50's with the same birthday as [Pt. #1]) had called (Pt. #1's) cell phone at 3 AM. When mother asked why was he calling her patient (Pt. #1) state(d) "he was just checking on me." Mother also said patient said they (Pt. #1 and staff) had had consensual sexual intercourse two times previously. She says that (Pt. #1) also was given (a) phone by the person who allowed her to text and call her mother. Per patient's mother he was standing next to her and he told her she only had five minutes. When mom asked who that was, patient told mother that was him. I [E #13] told mother I would investigate this further and go and talk to her. I [E #13] went and spoke to patient and she denied stating they had sex. She (Pt. #1) said, this man was checking in on her at night, but she felt ok because someone else would come right in after him and check on her. She also said she could not remember his name. She said she didn't want to be bothered with him and just wanted to go home. I [E #13] asked her to describe the person and she said he was tall, bald, black and big but not fat."

4. On 7/31/18 at approximately 11:00 AM, the Hospital's policy titled, "Grievances and the Patient Advocate" (effective 11/2014) was reviewed and indicated, "Policy: (The Hospital) will provide an effective mechanism for handling patient... grievances as an important part of providing quality care and services to our patients... Procedure... 2. It is the responsibility of each staff member to respond promptly to any concern or grievance voices by patients... 3. When a patient voices a complaint, the patient may be encouraged to discuss the complaint with their physician or unit nursing staff. The staff nurse supervisor may be involved... 4. An issue becomes a grievance if it involves an allegation of abuse... 5... the facility staff should listen to the patient's grievance, consider the circumstances and context of the issue, assure the patient that their concerns will be investigated... 6. The Risk Manager should be made aware of all serious patient complaints..."

5. On 7/31/18 at approximately 11:30 AM, the Hospital's policy titled, "Patient Abuse and Neglect" (effective 11/2014) was reviewed and included, "...1. All allegations of patient abuse or neglect will be thoroughly investigated... Definitions: Class 1 Abuse... B. Any sexual assault or sexual exploitation involving an employee..."

6. On 8/1/18 at approximately 10:30 AM, the Hospital's document titled, "Position Description, Staff Nurse" (October 2017) was reviewed and included, "... Performance... 3. Act as the patient's advocate and assure that patient rights are upheld... 7. Follow facility, departmental and personnel policies and procedures."

7. On 8/1/18 at approximately 9:52 AM, an interview was conducted with E #6 (Registered Nurse/RN-Pt. #1's RN on 5/23/18). E #6 admitted to writing the documentation for Pt. #1 in the nursing progress notes on 5/23/18. E #6 stated, "I took it as something that happened in the past and that had already been investigated the last time she (Pt. #1) was here... In hindsight, I should have gotten details... reported to the nursing supervisor... made an incident report." When asked how she (E #6) would know if the allegation happened in the past, E #6 said, "I would not know unless I went ahead and do the (follow-up) report."

8. On 8/1/18 at approximately 11:25 AM, an interview was conducted with E #2 (Director of Performance Improvement and Risk Management). E #2 stated that he (E #2) is normally made aware of any allegation of abuse. E #2 stated that he (E #2) was not made aware of Pt. #1's allegation in May 2018, so an investigation was not conducted. When shown E #6's documentation on 5/23/18, E #2 said, "As soon as they [staff] are told, they should report to the Nurse Supervisor... do a full investigation... that should have been reported."

9. On 8/1/18 at approximately 2:00 PM, when the incident report from 10/15/17 was presented, interviews were conducted with E #1 (Chief Executive Officer), E #2 (Director of Performance Improvement and Risk), and E #14 (Senior Vice President of Clinical Services). E #14 stated that the incident report filed by the Nursing Supervisor (E #13) on 10/15/17 was not fully investigated. E #14 added that normally, the report should have been forwarded to Risk Management. E #14 stated that the incident report was filed without proper investigation and that the Hospital's policy was not followed.
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 interview, it was determined that the Hospital failed to ensure allegations of sexual abuse were thoroughly investigated, to ensure patients are protected from abuse. This has the potential to affect an average daily census of 112 patients in the Hospital.

Findings include:

1. On 7/31/18 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of schizoaffective disorder, depressive type. On 5/23/18, the daily nursing progress notes of E #6 (Registered Nurse) indicated, "Thought Process: Continues to say outloud that she was sexually approached by male staff the last time I (Pt. #1) was here." However, a follow-up investigation regarding Pt. #1's allegation was not conducted by the Hospital.

2. An incident report dated 10/15/17 was received from the hospital on [DATE]. The incident report written by the Nursing Supervisor (E #13) indicated, "Godmother of (Pt. #1) called this writer (E #13) stating that her daughter was here and had recently accused someone of raping her(.) (B)ut godmother states she later found that to be untrue. She continued the conversation stating there was a staff member here(,) her daughter had been intimately involved. She said her daughter (Pt. #1) had been here before and wanted to come back here. Her mother stated once previously while out at her home the staff she called (E #16) (a bald, black man in his 50's with the same birthday as [Pt. #1]) had called (Pt. #1's) cell phone at 3 AM. When mother asked why was he calling her patient (Pt. #1) state(d) "he was just checking on me." Mother also said patient said they (Pt. #1 and staff) had had consensual sexual intercourse two times previously. She says that (Pt. #1) also was given (a) phone by the person who allowed her to text and call her mother. Per patient's mother he was standing next to her and he told her she only had five minutes. When mom asked who that was, patient told mother that was him. I [E #13] told mother I would investigate this further and go and talk to her. I [E #13] went and spoke to patient and she denied stating they had sex. She (Pt. #1) said, this man was checking in on her at night, but she felt ok because someone else would come right in after him and check on her. She also said she could not remember his name. She said she didn't want to be bothered with him and just wanted to go home. I [E #13] asked her to describe the person and she said he was tall, bald, black and big but not fat."

3. On 7/31/18 at approximately 11:00 AM, the Hospital's policy titled, "Grievances and the Patient Advocate" (effective 11/2014) was reviewed and required, "Policy: (The Hospital) will provide an effective mechanism for handling patient... grievances as an important part of providing quality care and services to our patients... Procedure... 2. It is the responsibility of each staff member to respond promptly to any concern or grievance voices by patients... 3. When a patient voices a complaint, the patient may be encouraged to discuss the complaint with their physician or unit nursing staff. The staff nurse supervisor may be involved... 4. An issue becomes a grievance if it involves an allegation of abuse... 5... the facility staff should listen to the patient's grievance, consider the circumstances and context of the issue, assure the patient that their concerns will be investigated... 6. The Risk Manager should be made aware of all serious patient complaints..."

4. On 7/31/18 at approximately 11:30 AM, the Hospital's policy titled, "Patient Abuse and Neglect" (effective 11/2014) was reviewed and included, "...1. All allegations of patient abuse or neglect will be thoroughly investigated... Definitions: Class 1 Abuse... B. Any sexual assault or sexual exploitation involving an employee..."

5. On 8/1/18 at approximately 9:52 AM, an interview was conducted with E #6. E #6 admitted to writing the documentation for Pt. #1 in nursing progress notes on 5/23/18. E #6 stated, "I took it as something that happened in the past, and that had already been investigated the last time she (Pt. #1) was here... In hindsight, I should have gotten details... reported to the nursing supervisor... made an incident report." When asked, how she (E #6) would know if the allegation happened in the past. E #6 said, "I would not know unless I went ahead and do the (follow-up) report."

6. On 8/1/18 at approximately 11:25 AM, an interview was conducted with E #2 (Director of Performance Improvement and Risk Management). E #2 stated that he (E #2) is normally made aware of any allegation of abuse. E #2 stated that he (E #2) was not made aware of Pt. #1's allegation in May 2018, so an investigation was not conducted. When shown E #6's documentation on 5/23/18, E #2 said, "As soon as they [staff] are told, they should report to the Nurse Supervisor... do a full investigation... that should have been reported."

7. On 8/1/18 at approximately 2:00 PM, when the incident report from 10/15/17 was presented, interviews were conducted with E #1 (Chief Executive Officer), E #2 (Director of Performance Improvement and Risk), and E #14 (Senior Vice President of Clinical Services). E #14 stated that the incident report filed by the Nursing Supervisor (E #13) on 10/15/17 was not fully investigated. E #14 added that normally, the report should have been forwarded to Risk Management. E #14 stated that the incident report was filed without proper investigation and that the Hospital's policy was not followed.