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.

THOREK MEMORIAL HOSPITAL 850 W IRVING PARK RD CHICAGO, IL 60613 Feb. 10, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 3 of 3 open clinical records (Pts. #5 -7) reviewed on the psychiatric unit, the Hospital failed to ensure advanced directive information was provided to and reviewed with the patient and/or his/her representative.

Findings include:

1. On 2/10/16 at 11:30 AM, Hospital policy #AD-59, titled, "Advanced Directives", revised 6/2013, was reviewed. The policy required, "3. If an adult individual is incapacitated at the time of admission or at the start of care and is unable to received information as a result of the incapacitating condition or articulate whether or not he or she has executed an Advance Directive, then the hospital may give Advance Directive information to the individual's family or surrogate in the same manner that it would issue other materials about policies and procedures to the family of the incapacitated individual or to a surrogate or other concerned person..."

2. On 2/10/16 at 10:00 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a [AGE] year old male, admitted on [DATE], with a diagnosis of suicidal ideation (SI). An advance directive form was included in Pt. #5's clinical record, but it had not been completed. Pt. #5's clinical record failed to document if Pt. #5 had an advanced directive or if advance directive information had been provided to Pt. #5 or his representative.

3. On 2/10/16 at 10:05 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a [AGE] year old male, admitted on [DATE], with a diagnosis of SI. An advance directive form was included in Pt. #6's clinical record, but it had not been completed. Pt. #6's clinical record failed to document if Pt. #6 had an advanced directive or if advance directive information had been provided to Pt. #6 or his representative.

4. On 2/10/16 at 10:10 AM, the clinical record of Pt. #7 was reviewed. Pt. #7 was a [AGE] year old male, admitted on [DATE], with diagnoses of SI and depression. An advance directive form was not included in Pt. #7's clinical record. Pt. 7's clinical record failed to document if Pt. #7 had an advanced directive or if advance directive information had been provided to Pt. #7 or his representative.

5. On 2/10/16 at 10:55 AM, an interview was conducted with the Chief Nursing Officer/ Manager of the Psychiatric Unit (E #1). E #1 stated the staff should complete the advance directive forms.
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, for 1 of 1 Patient (Pt. #1), who alleged to have been sexually abused, the Hospital failed to ensure an investigation and appropriate action took place for a known alleged sexual assault.

Findings include:

1. On 2/8/16 at 2:40 PM, Hospital policy #AMH - 303, titled, "Reporting of Suspected Patient Abuse", revised 11/2013, was reviewed. The policy required, "Policy: It is the policy of... [the] Hospital and its Mental Health Department that any suspected abuse will be reported to the appropriate agency or governing body... Definitions:... Assault: A violent, verbal, or sexual attack... Procedure: 1. Staff member identifying suspected abuse notifies Director of Psychiatric Nursing or Nursing Supervisor on off hours of operation of the suspicion..."

2. On 2/10/16 at 12:35 PM, Hospital policy #S-1, titled, "Sexual Assault", revised 9/2013, was reviewed. The policy required, "III Procedure: 1. Chicago police or Law Enforcement Officials in the jurisdiction the incident occurred are to be notified of all alleged sexual assaults... Evidence collection: In all instances of alleged sexual assault, the Illinois State Police Sexual Assault Evidence Collection Kit is to be used for the appropriate collection of evidence..."

3. On 2/8/16 at 10:30 AM, Pt. #1's record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with a diagnosis of bipolar disorder. A progress note dated 12/4/15 at 5:03 PM, by a Mental Health Specialist (MHS) (E #3), included, "...Patient does continue to claim he was sexually assaulted a few nights ago, claiming he told a night MHS [E #4], but was afraid to tell anyone else because he was fearful that he would have to stay in the Hospital longer..." There was no other documentation in Pt. #1's clinical record of alleged sexual assault.

4. On 2/8/16 at 2:50 PM, an interview was conducted with E #3. E #3 stated he did not believe Pt. #1 had been sexually assaulted for several reasons: Pt. #1 was always attention seeking; there were ongoing safety rounds every 15 minutes; and Pt. #1's roommate had been an inpatient 7 or 8 times with no report of sexual impropriety. E #3 stated he discussed Pt. #1's accusation with the other staff, including a Registered Nurse, but did not inform the Unit Manager (E #1).

5. On 2/8/16 at 2:25 PM, an interview was conducted the Pt. #1's Social Worker (E #2). E #2 stated she saw Pt. #1 every day on the unit and Pt. #1 never informed her of a sexual abuse allegation. E #2 was in communication with the Case Manager (Z #1) at Pt. #1's out-patient psychiatric program regarding school. Z #1 was not a Hospital employee.

6. On 2/9/16 at 9:45 AM, a phone interview was conducted with Z #1. Z #1 stated she visited Pt. #1 in the hospital on [DATE] (Thursday) and Pt. #1 told Z #1 "he had been raped by his roommate". Z #1 stated she informed a male staff member, probably a Mental Health Counselor, of the sexual assault allegation. Z #1 stated she also called the Social Worker (E #2) the next day (12/4/15) and told E #2 of Pt. #1's allegation. Z #1 stated E #2 told Z #1 no reports of the incident had been made, but E #2 would look into it. Z #1 stated she called E #2 on 12/8/15 to check on the investigation, but Pt. #1 had been discharged and an investigation had not been initiated.

7. On 2/9/16 at 10:30 AM, an interview was conducted with the Chief Nursing Officer/ 3 East (Psychiatric Unit) Manager (E #1). E #1 stated there were no incident reports or complaints filed on the 3 East Unit in December 2015 or January 2016. E #1 stated she was not aware of an allegation of sexual abuse to Pt. #1.

8. On 2/9/16 at 12:20 PM, an interview was conducted with the Psychiatric Medical Director (MD #1). MD #1 stated Pt. #1 was delusional and threatened to "blow up the unit". MD #1 did not recall a sexual abuse allegation from Pt. #1 or the staff. MD #1 stated a sexual abuse allegation requires an investigation and rape kit be completed. MD #1 stated he was upset he had not been informed of the allegation "in the system". MD #1 stated he would have "acted on it", if he had known.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, it was determined the Hospital failed to ensure each patient's rights were protected, potentially placing the 23 patients on the Psychiatric Unit at risk for sexual assault.

As a result, it was determined, the Condition of Participation 42 CFR 482.13, Patient Rights, was not met.


Findings include:

1. The Hospital failed to ensure an investigation and appropriate action took place for a known alleged sexual assault (A-145).