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.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #1) clinical records reviewed related to abuse, the Hospital failed to follow the process for reporting and investigating allegation of an abuse, to ensure patient was free from abuse or harassment.

Findings include:

1. On 8/11/2020 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital with a diagnosis of unspecified psychosis (severe mental disorder). E #10's (Registered Nurse) progress note dated 7/13/2020, included, "... (Pt. #1) ... overheard telling daughter on phone she (Pt. #1) was being abused..." The clinical record did not indicate that the program manager or nurse manager was notified of Pt. #1's allegation of an abuse.

2. On 8/12/2020 at approximately 9:00 AM, the Hospital's policy titled, "Patient Abuse or Neglect" (reviewed by the Hospital on 9/2018) included, " ... It is clearly understood by all staff that abuse and/or neglect of ... patients cannot and will not be tolerated... 1. Reporting guidelines and protocols will be followed for all patient abuse/neglect situations ...Refer to (the Hospital's) Abuse Prevention Program..."

3. On 8/12/2020 at approximately 9:30 AM, the Hospital's policy titled, "Abuse Prevention Program" (revised 1/2017) included, " ... IV ... Employees are required to immediately report any occurrences of potential mistreatment they ... hear about ... to their department manager ... The hospital staff is responsible for writing an incident report ... VI ... In addition to completing an incident report, the department manager will initiate an intense investigation ... VII ... 1 ... When an allegation of mistreatment has been reported, the Department of Public Health (IDPH) is notified immediately ... Within 24 hours after the occurrence report ..."

4. On 8/11/20 at approximately 3:00 PM, the Registered Nurse (E #10) was interviewed. E #10 stated that she should have reported to her manager Pt.#1 allegation of abuse.

5. On 8/12/2020 at approximately 11:15 AM, findings were discussed with E #4 (Unit Manager, Geriatric Behavioral Health Unit). E #4 said that the allegation should have been reported by E #10, an incident report should have been written, and a follow-up investigation should have happened. E #4 added that the allegation should have also been reported to the Illinois Department of Public Health, within 24 hours, when the allegation was reported to staff. E #4 could not provide documentation that Pt. #1's allegation of abuse was reported and investigated, as required.