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.

INGALLS MEMORIAL HOSPITAL 1 INGALLS DRIVE HARVEY, IL 60426 April 2, 2019
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for1 of 4 (Pt. #1) patient records reviewed for abuse allegations, the Hospital failed to ensure that a patient assessment was conducted after an allegation of sexual abuse.

Findings include:

1. On 4/1/19, the Hospital's policy titled, "Abuse; Treatment of Victims of Sexual Assault" (reviewed by the Hospital 1/2017) was reviewed. The policy included, "Any actual or suspected sexual assault that is the result of staff conduct should be immediately communicated...The Hospital will investigate and take appropriate action regarding all allegations, observations, and suspected cases...Treatment: A. Medical examination: Appropriate medical examinations and laboratory tests shall be performed and shall include, but not limited to the following: 1. General physical examination..."

2. On 4/1/19, Pt. #1's medical record was reviewed. Pt. #1 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of DKA (Diabetic Ketoacidosis - serious diabetes complication where the body produces excess blood acids) and was on an insulin (medication for high blood sugar) drip (continuous medication through intravenous line). Pt. #1's medical record lacked documentation of a physical examination after an allegation of sexual abuse was reported on 3/21/19.

3. On 4/1/19, the investigation summary for the event dated 3/20/19 for Pt. #1 was reviewed. The summary included, "RPS [Risk Management and Patient Safety] received [a] report that an [AGE] year-old female admitted to [Hospital] ICU [Intensive Care Unit] on 3/20/19 for DKA, alleged she was sexually assaulted by a male nurse [E #1] on the evening shift of 3/20/19. The patient [Pt. #1] reported the alleged assault at approximately 12:00 PM on 3/21/19 to ICU nursing leadership. Per the patients [Pt. #1] report, between the hours of 00:00 - 02:00 [12:00 AM - 2:00 AM] on several occasions, RN [Registered Nurse/E #1] grabbed her right hand and was pressing it into his genitals. At approximately 0:200 [2:00 AM], he [E #1] placed his [E #1] hand under her [Pt. #1] gown and put his [E #1] fingers in her [Pt. #1] vagina."

4. On 4/1/19 at 11:32 AM, an interview was conducted with the Assistant Patient Care Manager of ICU (E #3). E #3 stated that she was told about Pt. #1's allegation of sexual abuse by the RN (E #4) who was caring for Pt. #1 on 3/21/19 during the day shift. E #3 stated that she (E #3) interviewed Pt. #1 with the Security Officer (E #5) present. E #3 stated that Pt. #1 stated that at around 10:00 PM on 3/20/19, E #1 grabbed her [Pt. #1] arm to start an IV (intravenous line) and his [E #1] testicles were against her [Pt. #1] fingers. E #3 stated that Pt. #1 stated that she [Pt. #1] pulled her arm away and E #1 grabbed her [Pt. #1] arm and placed her [Pt. #1] fingers back on his testicles and stated that he [E #1] needed to start an IV. E #3 stated that Pt. #1 stated that at around 12:00 AM, on 3/21/19, E #1 touched her [Pt. #1] neck and lifted her [Pt. #1] gown and touched her vagina. E #3 stated that Pt. #1 refused offers by security to press charges. E #3 stated that she did not notify Pt. #1's Physician (MD #1) immediately but called him a few days later.

5. On 4/1/19 at 2:45 PM, an interview with Pt. #1's Physician (MD #1) was conducted. MD#1 stated that he was informed of Pt. #1's allegation of sexual abuse 3 - 5 days ago (March 27, 2019 - March 29, 2019). MD #1 stated that he did not perform an assessment on Pt. #1 following the sexual abuse allegation.

6. On 4/2/19 at approximately 11:23 AM, an interview with the Assistant Director of Clinical Effectiveness (E#9) was conducted. E #9 stated that a physical assessment of Pt. #1 was not conducted because Pt. #1 did not report any signs or symptoms of physical assault. E #9 stated that in the future the patients should be offered an assessment.

B. Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patient records reviewed for abuse allegation investigations, the Hospital failed to conduct a thorough investigation.

Findings include:

1. On 4/1/19, the Hospital's policy titled, "Abuse; Treatment of Victims of Sexual Assault" (reviewed by the Hospital 1/2017) was reviewed. The policy included, "Any actual or suspected sexual assault that is the result of staff conduct should be immediately communicated...The Hospital will investigate and take appropriate action regarding all allegations, observations, and suspected cases."

2. On 4/1/19, Pt. #1's medical record was reviewed. Pt. #1 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of DKA (Diabetic Ketoacidosis - serious diabetes complication where the body produces excess blood acids) and was on an insulin (medication for high blood sugar) drip (continuous medication through intravenous line).

3. On 4/1/19, the investigation summary for the event dated 3/20/19 for Pt. #1 was reviewed. The summary included, "RPS [Risk Management and Patient Safety] received [a] report that an [AGE] year-old female admitted to [Hospital] ICU [Intensive Care Unit] on 3/20/19 for DKA [Diabetic Ketoacidosis], alleged she was sexually assaulted by a male nurse [E #1] on the evening shift of 3/20/19. The patient [Pt. #1] reported that alleged assault at approximately 12:00 PM on 3/21/19 to ICU nursing leadership. Per the patients [Pt. #1] report, between the hours of 00:00 - 02:00 [12:00 AM - 2:00 AM] on several occasions, RN [Registered Nurse/E #1] grabbed her right hand and was pressing it into his genitals. At approximately 0:200 [2:00 AM], he [E #1] placed his [E #1] hand under her [Pt. #1] gown and put his [E #1] fingers in her [Pt. #1] vagina. Security was immediately notified to obtain a statement from the patient [Pt. #1]. The patient [Pt. #1] was offered the option to file a police report with [local police department] but refused. Human resources was notified of the alleged incident. The male RN [E #1] was on orientation as a new RN; therefore, [E #1's] preceptor [E #2] and [E #1] were asked to provide statements describing their interactions with the patient during the 7p - 7a shift on 3/20/19. Both RN's [E #1 and E #2] denied the allegations, reporting that RN [E #1] was never alone in the patient's [Pt. #1] room without the preceptor [E #2]. The nurse preceptor [E #2] reported that RN [E #1] was running around most of the night dealing with their other patient and spent most of the shift administering medications. The preceptor [E #2] reported that she did not witness any inappropriate behavior from RN [E #1]. According to RN's [E #1 and E #2] statements, there were multiple clinicians in the room the evening of 3/20/19 attempting to start a peripheral IV [intravenous line] on the patient [Pt. #1] ...[E #1] was suspended pending investigation of the alleged incident. A meeting with HR [human resources] and nursing leadership occurred on 3/26/19. It was determined there was not sufficient evidence to support the patient's allegation; therefore, the RN [E #1] returned to work."

4. On 4/1/19, in the presence of the Compliance Manager (E #6), a RN's (E #2/Preceptor) written statement was reviewed. The statement included the names of two RN's (E #7 and E #8) who entered Pt. #1's room on 3/20/19 - 3/21/19, during the night shift, to try to start Pt. #1's IV. The Hospital's investigation for Pt. #1's allegation of sexual abuse on 3/20/19, included written statements from E #1 and E #2. The Hospital's investigation did not include interviews with other nursing staff (E #7 and E #8) who were present or who provided care to Pt. #1 on 3/20/19 - 3/21/19.

5. On 4/1/19 at 10:54 AM, an interview with a Registered Nurse (RN/E #1) was conducted. E #1 stated that he took care of Pt. #1 on the night on 3/20/19 from 7:00 PM - 7:00 AM. E #1 stated that multiple nurses came into Pt. #1's room throughout the night to try to start her IV.

6. On 4/1/19 at 11:09 AM, an interview with a RN (E #2/preceptor) was conducted. E #2 stated that there were multiple staff in Pt. #1's room throughout the night. E #2 stated that Pt. #1 did not voice any concerns of sexual abuse, and E#1 did not state that he was uncomfortable providing care to Pt. #1. E #2 stated that she was not in Pt. #1's room each time E #1 went inside.

7. On 4/1/19 at 1:08 PM, an interview with a RN (E #4) was conducted. E #4 stated that Pt. #1 stated that the RN (E #1) lifted her gown and panties and put his (E #1) hand in her (Pt. #1) vagina. E #4 stated that Pt. #1 also stated that E #1 put her hand on his groin area when trying to start an IV. E #4 stated that she has not seen E #1 inappropriately touch a patient. E #4 stated that she reported the allegation to E #3 who told her [E#4] that she [E #4] did not need to write a statement since she [E #3] would be conducting the interview with security. E #4 stated that she did not provide a written statement and was not interviewed after Pt. #1 reported the allegation of sexual abuse.

8. On 4/1/19 at 2:14 PM, an interview with a Security Officer (E #5) was conducted. E #5 stated that he was called to the ICU to witness an interview with a patient [Pt. #1] who made an allegation of sexual abuse. E#5 stated that Pt. #1 mentioned that a nurse (E #1) was trying to start an IV and supposedly put her [Pt. #1] hand on his genitals. E #5 stated that Pt. #1 did not provide a nurse's name but simply said "the nurse."

9. On 4/2/19 at approximately 12:07 PM, an interview was conducted with the Compliance Manager (E #6). E #6 stated that E #7 and E #8 (RN's) were interviewed by the Assistant Patient Care Manager of ICU (E #3). E #6 stated that the interviews were not documented because E #7 and E #8 did not have any information to contribute to the investigation. E #6 stated that E #7 and E #8 refused to provide written statements.