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 Dec. 2, 2019
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 for 1 of 1 clinical record reviewed (Pt. #1), the Hospital failed to ensure that the patient was free from alleged sexual abuse. This potentially placed 16 patients on the 2B Behavioral Health Unit at risk for serious harm.

1. On 11/25/19, the Hospital's policy titled, "Patient Rights and Responsibilities," (approved 4/12/18) was reviewed. The policy required, "Personal Safety: The patient has the right to expect personal safety insofar as the Hospital practices and the environment are concerned. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, exploitation and corporal punishment."

2. On 11/26/19, the Hospital's policy titled, "Homicide Aggression Precautions," (approved 3/22/18), was reviewed. The policy required, "Procedure: 1. The Physician may order Homicide/ Aggression precautions as a level of intensity deemed appropriate based on assessment of aggressive behavior risk. A. Homicide / Aggression Precautions: One to One Observation: The individual is considered actively homicidal or behaving in a violent manner. A dedicated staff member is assigned to remain within arms reach of the patient at all times ..."

3. The Ingalls Security Report, #19-610, dated 11/17/19 at 9:30 PM, included the Harvey Police Report #1911 H 1449. The report included, "Narrative: On 11/17/19 at 7:45 PM, R/O (Reporting Officer) was dispatched to the Wyman Gordon [Behavioral Health Units] 2B wing for a Sexual Assault complaint. R/O was joined by HPD (Harvey Police Department) Officer ... to conduct field interviews of what had occurred. R/O and Officer ... were informed by Wyman nursing supervisor [E #6] that the alleged victim [Pt #1] ... was sexually assaulted by [Pt. #2] ... the alleged offender. R/O was informed by supervisor [E #6] ... that the victim told her that the offender had touched the breast and used his fingers to penetrate her vagina; this was also reported to Behavioral Tech [Technician/E #5]. R/O, Officer [HPD], House Manager and Supervisor [E#6] spoke to victim of what occurred. The victim could not give a full detail account of what occurred in her own words. R/O and Officer [HPD] asked questions of what happened and where she was touched. The victim pointed to her breast, lower pelvic area and her buttocks. The Victim did state when asked if she told the offender to stop. She replied yes. The victim did not state to R/O and Officer [HPD] that the offender penetrated her vaginally. That concluded the interview with the victim. The victim was removed from the unit where the alleged assault took place for safety reasons..."

4. On 11/25/19, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on [DATE] with a diagnosis of schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate action and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).

- Pt. #1's Emergency Department Provider note dated 11/12/19 at 12:13 PM, included a history of present illness including, "Primary complaint ... Suicidal Ideation ... with a history of bipolar disorder [a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs], schizophrenia, and borderline retardation [a person with below average intelligence], arrived to the ER [emergency room ] accompanied by mother for psych [psychiatric] evaluation. Patient stated she has SI [suicidal ideation] with plan of killing herself by overdosing on pills. Patient states that she hears voices commanding her to kill herself.

- Pt. #1's Psychiatric Evaluation dated 11/13/19 at 1:55 PM, included, "III. Chief Complaint/ Reason for Admission ... Bipolar disorder. IV. History of Present Illness: A. Onset of psychiatric symptoms/ Circumstances leading to current admission ... reported that she cannot sleep at home, has been hearing voices and seeing [a] blonde hair, blue-eyes person that was telling her to kill herself. She is [had] planned to overdose on pills ... Insight and judgment was [were] poor. Memory was fair ... XI ... Diagnosis: Schizoaffective disorder, bipolar type ..."

- Pt. #1's physician's order dated 11/12/19 at 4:10 PM, included, "Suicide Precautions: (Mild) 15 minute checks. Staff make visual contact with patient and confirms the patient is safe and in no physical distress at frequent and random interval not to exceed 15 minutes apart. Whenever possible, verbally interact with patient to assess safety and well-being."

- Pt. #1's nursing note dated 11/17/19 at 6:40 PM, included, "At approximately 6:40 PM, this writer [nursing supervisor, E #6] received a call from the charge nurse on 2B that [the] patient [Pt. #1] had told one of the BHTs [Behavioral Health Technicians, E #5] that a male patient touched her inappropriately. This writer spoke to the patient and was told by the patient that 'she was sitting watching TV [television], minding her own business and a male patient sat next to her and put his fingers under her gown touching her private area and her breast... [The] Patient then complained that she felt burning in the vaginal area and wanted to be seen by a doctor..."

5. On 11/25/19, Pt. #2's clinical record was reviewed. Pt. #2 was admitted from the medical floor to Unit 2B (the same psychiatric unit as Pt. #1) on 11/12/19 at 7:13 PM, with the diagnosis of psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality].

- Pt #2's "Integrated Assessment Behavioral Health" form dated 11/12/19 at 9:00 AM [PM], noted that Pt #2 "had a seizure and was placed on the medical floor... became increasingly psychotic [severe mental disorders that cause abnormal thinking and perceptions], aggressive and delusional... threatening to kill staff on med floor/security and not responding appropriately to questions asked. Pt #2 is uncooperative and difficult to redirect... making threatening gestures, yelling and cursing at staff, security had to be called several times due to Pt #2's threatening behaviors... Pt #2 is unpredictable. Pt #2's mental status exam dated 11/12/19 noted "Thought content - Delusions and Pt #2 [is a] danger to self or others."

- Pt. #2's physician's telephone orders dated 11/12/19 at 6:50 PM, included precautions for suicide precautions (SP) and assault precautions (AP) to include 15 minute checks. The physician's order failed to ensure Pt. #2 was placed on Homicide/Aggression Precautions, to include one to one observation (dedicated staff member assigned to remain within arms reach of the patient at all times), which may have prevented the incident.

- On 11/26/19 at 2:00 PM, an interview was conducted with Pts. #1 & 2's Psychiatrist (MD #1). MD #1 stated that when Pt. #2 was on the medicine unit Pt. #2 had trouble breathing when during a seizure which created "anxiety." Pt. #2 denied threatening staff. When Pt. #2 was transferred to 2B, he was calm and "good in the milieu [social environment]."

6. On 11/25/19 at 3:30 PM, an interview was conducted with E #6. E #6 stated the incident most likely occurred on 11/17/19 between 12:30 PM and 2:00 PM. (During an interview with E #5 on 11/26/19 at 3:30 PM, E #5 stated the incident happened after lunch, between 1:00 PM and 3:00 PM. The exact time of the incident could not be determined.) E #6 stated that there is "usually a staff member in the dayroom," although sometimes the staff is outside the dayroom watching through the windows. E #6 stated that vulnerable patients like [Pt. #1] are kept in line of sight [patient always visible to staff]. E #6 stated that Pt. #1 was vulnerable because she was "mentally retarded."

7. On 12/2/19 at 10:00 AM, an interview was conducted with a Behavioral Health Technician (E #2). E #2 stated that on 11/17/19, his assignment was to monitor the day room. E #2 stated that he was positioned at the door of the day room and could visualize everything. E #2 stated that he is 100% sure that nothing happened when he was monitoring the day room. E #2 stated that the lights always stay on in the day room. E #2 stated that the lights were on in the day room on 11/17/19. E #2 stated that Pt #2 was aggressive about his food on 11/17/19. E #2 stated that Pt #1 was preoccupied with the telephone on 11/17/19. E #2 stated that Pt #1 and Pt #2 were not in the day room when he was monitoring the day room. E #2 stated that he took lunch at 12:30 PM on 11/17/19. E #2 stated that he cannot remember who monitored the day room while he was on his lunch break. E #2 stated that he heard about the incident that happened with Pt #1 and Pt #2 some days ago from a coworker. E #2 stated that no one has interviewed him about that day.

8. Pt. #1's "patient location history" form indicates that Pt. #1 was transferred to another psychiatric unit (1N) on 11/17/19 at 7:51 PM. After security and police interviews, Pt. #1 was escorted to the Emergency Department at 10:07 PM. A sexual assault kit was completed. A nursing note on 11/18/19 at 1:14 AM, included, "Patient states that she does not feel safe returning to Wyman Gordon [Behavioral Health Units]." Pt. #1 was discharged home on 11/18/19 at 10:52 AM. The Psychiatrist's (MD #1) note dated 11/25/19, included a discharge plan for follow up psychiatric counseling and medication management.

9. On 11/26/19 at 2:00 PM, an interview was conducted with Pts. #1's & #2's Psychiatrist (MD #1). MD #1 stated that he was notified about the incident on Saturday [11/17/19] but does not remember what time. MD #1 discharged Pt. #1 on 11/18/19, because Pt. #1 was no longer thinking of suicide and her mother stated she could take care of her at home. MD #1 stated he was not involved in the investigation of the incident and added that "in hindsight" there "absolutely" should have been a root cause analysis (detailed investigation) of the incident. There was no Root Cause Analysis initiated at the time of the survey (The incident occurred 2 days prior to the start of the survey).
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation and interview, it was determined that the Hospital failed to protect a patient (Pt. #1) from alleged sexual abuse. This potentially placed 16 patients on the 2B Behavioral Health Unit at risk for serious harm.

As a result, it was determined that the Condition of Participation for Patient Rights, CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to protect and promote a patient's right to be free from alleged sexual abuse. See deficiency at A-145.

The immediate jeopardy began on 11/17/19, due to the Hospital's failure to protect a patient from alleged sexual abuse, by vaginal finger penetration and touching of the breasts and buttocks.

The IJ was identified on 11/27/19 and was announced on 11/27/19 at 12:30 PM, during a meeting with the Chief Medical Officer, Executive Director of Behavioral Health, Program Director of Behavioral Health, Executive Director of Patient Care Services, Assistant Director of Clinical Effectiveness, Manager of Regulatory Compliance. The IJ was not removed by the survey exit date of 12/2/19.