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.

AURORA CHICAGO LAKESHORE HOSPITAL 4840 N MARINE DR CHICAGO, IL 60640 Nov. 21, 2018
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 2 (Pt. #7 and Pt. #10) clinical records reviewed for alleged abuse, the Hospital failed to ensure the reporting of abuse to IDPH (Illinois Department of Public Health) as required.

Findings include:

1. The Illinois State Licensure requirements include, "...Section 250.260 Patients' Rights section c) Patient Protection from Abuse 5) Upon receiving a report under subsection (c) (3), the hospital shall submit the report to the Department..."

2. On 11/13/18 at approximately 2:00 PM, the Hospital Transfer Log was reviewed. The transfer log indicated that on 9/11/18, Pt. #7 was transferred to another hospital (Hospital B) for evaluation of sexual assault allegation.

3. On 11/14/18 at approximately 9:30 AM, Pt #7's clinical record was reviewed. Pt #7 was a 7 year old female admitted on [DATE] with diagnoses of disruptive mood dysregulation disorder (DMDD), homicidal ideation, and asthma. Pt #7's clinical record included the records from Hospital B, where Pt #7 was transferred for evaluation of sexual assault allegations. Hospital B's Pediatric History and Physical, dated 9/11/18 at 5:38 PM indicated, " ...Pt #7 is in an inpatient psych (psychiatric) facility (Hospital A) ... Pt #7 is accompanied by a staff member ...Pt #7 stated that on 9/8/18, (Pt #12) sticked his (Pt. #12's) finger in my (Pt. #7's) private area ... (Pt #7) stated (Pt #12) tried to drag her (Pt. #7) into his (Pt. #12's) room. (Pt #7) then stated that he (Pt #12) pulled her (Pt. #7) into his (Pt. #12's) room, and (Pt. #12) kicked her (Pt. #7) in the stomach ... After initial assessment, (Pt #7) told the nurse a Mental Health Worker (E #2) touched her (Pt. #7's) private area and 'put his finger in my butt.' (Pt #7) does not remember exactly when this happened, maybe a week ago ..."

4. On 11/14/18 at 12:30 PM, the Hospital's Occurrence Report Logs from January 2018 to November 2018 were reviewed. The Occurrence Report Logs included an allegation of abuse regarding Pt. #10. Pt #10 was a [AGE] year old female, admitted on [DATE] with diagnoses of disruptive mood dysregulation disorder, bipolar disorder, and homicidal ideation. Pt #10's occurrence report, dated 8/27/18, indicated " ...Around 7:30 PM, (Pt #10) reported that the Mental Health Worker (E#2) closed the door while on 1:1 (direct, continuous observation) with (Pt #10), and pulled (Pt #10) on to his (E #2's) lap. (Pt #10) stated that she (Pt. #10) pulled away and he (E #2) then touched her (Pt. #10) breast ..."

5. On 11/16/18 at approximately 12:15 PM, the Hospital's policy titled, "Abuse, Neglect and Exploitation Reporting, Investigation and Response" (reviewed 8/18) was reviewed and included, " ... D. Investigation ... b. The Director of Risk Management shall report allegations of abuse, neglect or exploitation to the Illinois Department of Public Health Services..."

6. On 11/14/18 at approximately 1:00 PM, an interview was conducted with E #5 (Director of Performance Improvement and Risk Management). E #5 stated that she (E #5) did not report the sexual abuse allegations regarding Pt #7 and Pt #10 to the Illinois Department of Public Health.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review an interview, it was determined that the Hospital failed to send a patient to the Hospital immediately following an allegation of sexual abuse. As a result, the Condition of Patient Rights 42 CFR 482.13 was not in compliance. This potentially places all current and future patients at serious risk for harm and safety due to no quality program in place to implement measures to address patients demonstrating inappropriate sexual behavior.

The immediate jeopardy began on 1/1/18 for the Hospital's failure to ensure the reporting of abuse allegations to IDPH, failure to ensure that a patient was sent to the Hospital's emergency room immediately following the allegation of sexual assault and failure to ensure that patients were free from physical abuse and harm. An immediate jeopardy was identified and announced on 11/19/18 at 10:35 AM at a meeting with the Chief Executive Officer and Director of Performance Improvement/Risk Management.

Findings include:


1. The Hospital failed to ensure the patients were free from sexual abuse. See deficiencies at A 145 -A.

2. The Hospital failed to ensure the patient was sent to the Hospital's Emergency Department immediately following the allegation of sexual assault. See deficiency at A 145 - B.

3. The Hospital failed to ensure the patients were free from physical abuse and harm. See deficiencies at A 145 -C.
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 for 13 of 13 (Pt #6, 7, 8, 10, 13, 16, 17, 19, 20, 21, 22, 23 and 39) clinical records reviewed for alleged inappropriate sexual behavior, the Hospital failed to ensure the patients were free from sexual abuse.

Findings include:

1. On 11/19/18 at approximately 11:10 AM the Hospital presented a document entitled, "Rights While in a Mental Health Facility in Illinois," that was revised 03/23/2006. The Document included, "...The Right to Adequate and Humane Care. People with disabilities who are recipients of mental health services have the right to be free from abuse and neglect."

2. The clinical record of Pt #6 was reviewed on 11/16/18 at approximately 11:00 AM. Pt #6 was an [AGE] year old female who was admitted on [DATE] with a diagnosis of disruptive mood dysregulation disorder (DMDD). Pt #6's clinical record contained documentation dated 6/19/18, that included, "Patient allegedly asked two female peers to have sex with her...Patient allegedly touched another female peer's buttocks and patted another peer's genital area during a group." A complete investigation was not conducted to determine if substantiated or not.

3. The clinical record of Pt #7 was reviewed on 11/14/18 at approximately 9:30 AM. Pt #7 was a 7 year old female admitted on [DATE] with diagnoses of disruptive mood dysregulation disorder, homicidal ideation, and asthma. Pt #7's clinical record included the records from Hospital B, where Pt #7 was transferred for evaluation of sexual assault allegations. Hospital B's Pediatric History and Physical, dated 9/11/18 at 5:38 PM indicated, " ...Pt #7 is in an inpatient psych (psychiatric) facility (Hospital A) ... Pt #7 is accompanied by a staff member ...Pt #7 stated that on 9/8/18, (Pt #12) sticked his (Pt. #12's) finger in my (Pt. #7's) private area ... (Pt #7) stated (Pt #12) tried to drag her (Pt. #7) into his (Pt. #12's) room. (Pt #7) then stated that he (Pt #12) pulled her (Pt. #7) into his (Pt. #12's) room, and (Pt. #12) kicked her (Pt. #7) in the stomach ... After initial assessment, (Pt #7) told nurse a staff member (E #2) touched her (Pt. #7's) private area and 'put his finger in my butt.' (Pt #7) does not remember exactly when this happened, maybe a week ago ..." A complete investigation was not conducted to determine if substantiated or not.

4. The clinical record of Pt #8 was reviewed on 11/16/18. Pt #8 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of DMDD. Pt #8's clinical record contained documentation dated 6/19/18 that included, "Patient reported to staff that a female peer (unnamed on occurrence report) touched her buttocks and made her feel uncomfortable. The incident occurred and was reported on 6/15/18." A complete investigation was not conducted to determine if the allegation was substantiated or not.

5. The clinical record of Pt #10 was reviewed on 11/16/18. Pt #10 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of DMDD. Documentation dated 8/27/18 included, "Pt reported that (E #2), while on over the weekend of 8/25 - 8/26, closed patient bedroom door and placed her arm on his lap. Patient then pulled away in which he then touched her breast. Patient stated that (E # 2) has a 'big stick' while on 1:1 with her." A complete investigation was not conducted to determine if the allegation was substantiated or not.

6. The clinical record of Pt #13 was reviewed on 11/16/18. Pt #13 was [AGE] year old female who was admitted on [DATE], with a diagnosis of major depressive disorder. Pt #13's clinical record contained a "Suspected Abuse/Neglect Reporting Form" dated 6/20/18 that included, "Patient reports her peer (unnamed) asked her to have sex with her in their room the evening of 6/4/18. Reported this on 6/15/18. A complete investigation was not conducted to determine if the allegation was substantiated or not.

7. The clinical record of Pt #16 was reviewed on 11/16/18. Pt #16 was a [AGE] year old transgender who was admitted on [DATE] with a diagnosis of DMDD. The Hospital Occurrence Report dated 8/29/18 included, "Pt states he had sex with another patient, refused to state other patients names or give a specific time frame..." On 9/4/18, documentation from the Hospital Occurrence Report included, "(Pt #16) was swinging and fighting two patients back...the girls pulled her shirt off." Pt #16 was moved to boys unit for programming. A complete investigation was not conducted to determine if the allegation was substantiated or not.

8. The clinical record of Pt #39 was reviewed on 11/16/18. Pt #39 was a [AGE] year old male who was admitted on [DATE], with a diagnosis of major depressive disorder. On 9/5/18, documentation included, "Patient came out of his room and reported to staff his roommate touched him twice (putting his hands around his waste and touching him on his butt." A complete investigation was not conducted to determine if the allegation was substantiated or not.

9. On 11/14/18 at approximately 3:00 PM, the Hospital Occurrence report was reviewed and indicated "(Pt #17), a 12 year old) alleged on 12/8/17, (Pt #18) touched his genitals and butt." The Occurrence Report noted that 5 other patients (Pt #19, Pt #20, Pt #21, Pt #22 and Pt #23) reported to staff that (Pt #18) touched them all inappropriately. (Pt #19) stated [He touched all of us on the ass in the day room]. (Pt #20) stated that (Pt #18) asked him to be his boyfriend. "Pt #21" stated that "Pt #18" tried to touch his penis in the day room. (Pt #22) stated that (Pt #18) asked him to go by the fridge in the day room to suck his d****. (Pt #23) stated that when (Pt #18) was his roommate, he was almost 100% sure that (Pt #18) did something to him in his sleep." The Risk Management section indicated "Spoke with JDC (juvenile detention center) reported incident. Follow up plan - (Pt #18) was already discharged , could not follow up with alleged perpetrator. All incidents occurred while staff were present in room, but according to patients, it was done quietly when staff went to fridge. No video review due to camera outage." There was no other investigation noted for these incidents.

10. The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the above alleged incidents, and any measurable actions put into place, to prevent further allegations.

11. On 11/15/18 at approximately 9:30 AM, an interview was conducted with E #5. E #5 stated that E #2 was not suspended after Pt #10's sexual assault allegation, because the allegation had not been substantiated. E #5 stated that E #2 was moved to the Adult Hospital (Marine Building), during the investigation. E #5 stated that E #2 received "boundary" training on 8/2/18. E #5 stated the E #2 was suspended after the sexual assault allegation from Pt #7 dated 9/8/18. E #5 stated the E # 2 is currently suspended and remains suspended because both investigations remain open with DCFS.



B. Based on document review and interview, it was determined for 1 of 1 patient (Pt #1) reviewed, with untimely follow-up care post allegations of sexual assault, the Hospital failed to ensure the patient was sent to the Hospital's Emergency Department immediately following notification of sexual assault.

Findings include:

1. On 11/13/18 at approximately 10:00 AM, the Hospital's policy entitled "Abuse, Neglect and Exploitation Reporting, Investigation and Response" was reviewed and indicated "....Upon becoming aware of an allegation and depending on the nature of the allegation, the supervisory staff on site shall take immediate action to ensure the safety of the patient..."

2. On 11/13/18 at approximately 10:30 AM, the Hospital's policy entitled "Sexually Acting Out Behavior" was reviewed and indicated "... A patient believed to be a victim of alleged or actual coerced sexual behavior will be taken to a hospital of the attending Physician's choice or the family's choice, as soon as possible..."

3. The clinical record of Pt #7 was reviewed on 11/12/18. Pt #7's was a 7 year old female who was admitted on [DATE], with a diagnosis of disruptive mood dysregulation disorder (DMDD). Pt #7's clinical record contained documentation dated 9/8/18, that included, "...(Pt #12) stuck a finger in my private area..." A physician's order dated 9/11/18 included, "Transfer to ER at Hospital B for evaluation of reported sexual assault."

ER (emergency room ) documentation included, "...(Pt #7) told nurse a staff member (E #2) touched her private area and 'put his finger in my butt.' "(Pt #7) does not remember exactly when this happened, maybe a week ago. (Pt #7) stated she was taken to the Hospital for evaluation. DCFS updated with this information. Contacted by police regarding case. Police officer stated to nurse that report was made today. ER (emergency room ) Social Worker involved..."

4. On 11/14/18 at approximately 1:00 PM, an interview was conducted with the Director of Risk Management/Performance Improvement (E #5). E #5 stated that she came to work on 9/10/18 and reviewed incident reports. E #5 stated that she reviewed Pt #7's sexual assault allegation regarding Pt #12. E #5 stated that she then followed up with the Chief Nursing Officer (E #1). E #5 stated that Pt #7 was sent to the Hospital for evaluation of the sexual assault allegation on 9/11/18 but should have been sent to the Hospital immediately following the incident and she is not sure what happened. E #5 stated that the nurses have received training since the incident regarding the importance of immediately sending patients to the Hospital following a sexual assault allegation.






C. Based on document review and interview, it was determined that for 5 of 5 (Pt #1, 3, 9, 49, and 58) clinical records reviewed for alleged physical abuse, the Hospital failed to ensure the patients were free from physical abuse and harm.

Findings include:

1. On 11/19/18 at approximately 11:10 AM the Hospital presented a document entitled, "Rights While in a Mental Health Facility in Illinois," that was revised 03/23/2006. The Document included, "...The Right to Adequate and Humane Care. People with disabilities who are recipients of mental health services have the right to be free from abuse and neglect."

2. The clinical record of Pt #1 was reviewed on 11/15/2018. Pt #1 was a [AGE] year old male who was admitted on [DATE] with a diagnosis of disruptive mood dysregulation disorder (DMDD). Pt #1's clinical record contained documentation dated 4/28/18 that included, "Pt. accused the staff member of chocking him..." There was no evidence of sufficient investigation to unsubstantiate the allegation.

3. The clinical record of Pt #3 was reviewed on 11/15/18. Pt #3 was a [AGE] year old female who was admitted on [DATE], with a diagnosis of bipolar disorder, manic. Pt #3's clinical record contained documentation dated 3/26/18, that included, "I'm tired of being in this Hospital and getting punched by staff like her." There was no documentation that this incident was investigated to unsubstantiate this incident.

4. The clinical record of Pt #9 was reviewed on 11/16/18. Pt #9 was an [AGE] year old female who was admitted on [DATE], with a diagnosis of DMDD. Documentation dated 6/17/18 included, "...in dayroom and got into a verbal altercation...(peer) grabbed the shirt and hair and hit her in the lip. (Pt #9) had a bloody lip..." There was no evidence of sufficient investigation to unsubstantiate the allegation.

5. The clinical record of Pt #49 was reviewed on 11/16/18. Pt #49 was an [AGE] year old male who was admitted on [DATE] with a diagnosis of DMDD. Nursing documentation dated 6/13/18 included, "Patient was attacked by another peer for no reason. Ice pack was given but declined." There was no evidence of sufficient investigation to unsubstantiate the allegation.

6. The clinical record of Pt #58 was reviewed on 11/16/18. Pt #58 was a [AGE] year old female who was admitted on [DATE], with a diagnosis of DMDD. Nursing documentation dated 1/21/18, included, "Patient was involved in a physical altercation with a peer and after staff separated the fight, staff noticed that patient was bleeding from the nose. Ice was placed ..." The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the alleged incident, and any measurable actions put into place, to prevent further allegations. There was no evidence of sufficient investigation to substantiate or unsubstantiate the allegation.

7. During an interview on 11/19/18 at approximately 10:10 AM, the Director of Risk Management (E #5) stated, the patients are expected to be free from any form of abuse and free from injury. The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the alleged incident, and any measurable actions put into place, to prevent further allegations. There was no evidence of sufficient investigation to unsubstantiate the allegation.

8. The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the alleged incident, and any measurable actions put into place, to prevent further allegations.

9. On 11/21/18 at approximately 9:15 AM, an interview was conducted with E #5. E #5 stated that the allegation investigations consist of video review and interviewing patients. E #5 stated that the video camera has been "down" on and off for quite awhile. E #5 stated that if an allegation is between 2 patients, it becomes a matter of "he said, she said." E #5 stated that an allegation is substantiated if the Hospital can say 100% that the allegation did happen. E #5 stated that an allegation is unsubstantiated if there is not enough evidence.
VIOLATION: QAPI Tag No: A0263
Based on document review and interview, it was determined, that the Hospital failed to implement and maintain a Quality Improvement Program including monitoring, tracking, implementing and evaluating corrective actions, for all adverse outcomes and incidents. As a result, the Condition of Participation for Quality Improvement Performance Improvement, 42 CFR 482.21 was not in compliance. This potentially affects all current and future Behavioral Unit Patients.

Findings include:

1. The Hospital failed to ensure allegations of inappropriate sexual behavior and physical assault were tracked and trended for improvement. See deficiencies at A 273.

2. The Hospital failed to ensure, the quality improvement plan included sexually acting out (SAO) or physical abuse incidences. See deficiencies at A 283.

3. The Hospital failed to ensure the Performance Improvement Program included measurable indicators. See deficiencies at A 286.

4. The Hospital's Governing Body failed to ensure the Performance Improvement Plan included all potential adverse events. See deficiencies at A 308.

The Immediate Jeopardy began on 1/1/18 for the Hospital's failure to develop a thorough and comprehensive Quality Improvement Plan, including high risk, high volume issues, thus placing all psychiatric patients at serious potential risk for harm.

An Immediate Jeopardy was identified on 11/19/18 and announced on 11/19/18 at 10:35 AM, during a meeting with the Chief Executive Officer, Chief Nursing Officer and the Director of Performance Improvement/Risk Management/Quality Improvement. The Immediate Jeopardy was not removed by the survey exit date of 11/20/18.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and interview, it was determined that the Hospital failed to ensure actions of inappropriate sexual behavior and physical assault on patients were tracked and trended through the Hospital's Performance Improvement Program. This potentially affects a census of 34 children and adolescents as of 11/14/18.

Findings include:

1. The Hospital's Incident Log for January 2018 through October 2018 was reviewed on 11/13/18 at approximately 11:00 AM. The log included 60 allegations inappropriate sexual behavior and 70 allegations of physical assault on patients in the Children's Pavilion.

2. The Hospital's Performance Improvement Plan (reviewed 9/17), included, "...III. A...The program consists of these focus components: performance improvement, patient safety, quality assessment/improvement and quality control activities...These indicators are objective, measurable, based on current knowledge...and are structured to produce statistically valid, data driven performance measures of care provided...B...1. The monitoring, assessment and evaluation of the patient care...may include but not limited to...b. Adverse events...e. Safety management..."

3. The Hospital's Clinical Risk Management Report, was reviewed on 11/15/18 at approximately 10:00 AM. The Report included monitoring of Assaultive Episode with and without injury. The Report failed to include the monitoring of inappropriate sexual behavior.

4. The Hospital's Performance Improvement Meeting minutes dated January 2018 to September 2018 were reviewed on 11/15/18 at approximately 10:15 AM. The minutes did not include any corrective action that was initiated and evaluated to reduce assaults and did not include monitoring and/or measures to decrease inappropriate sexual activity.

5. The Risk Manager (E #5) was interviewed on 11/15/18 at approximately 1:00 PM. E #5 stated that the incidents are monitored but not included in the Performance Improvement minutes. E #5 stated that the incident reports go to the nursing supervisor the same day of the occurrence. E #5 stated that the incident reports are discussed at a morning meeting and given to E #5. E #5 stated that there is no documentation regarding the incidents in the Quality Improvement Meetings for 2018.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review and interview, it was determined that the Hospital failed to ensure, the quality improvement program included sexually acting out (SAO) or physical abuse incidents. This potentially affects all current an future admissions to the Hospital.

Findings include:

1. The log of incidents from 1/1/18 through 11/13/18 was reviewed on 11/15/18. The log included approximately 60 allegations of SAO and 70 allegations physical abuse incidents.

2. The Hospital's Quality Improvement Meetings minutes for 1/1/18 through 9/27/18, were reviewed. The minutes did not include any investigation or data collected related to SAO or physical abuse allegation incidents.

3. The Hospital's Clinical Risk Management Report, which listed the performance improvement (PI) activities did not include SAO prevalence.

4. On 11/15/18 at approximately 1:45 PM the Director of Quality Improvement and Risk Management (E #5), was interviewed. E #5 stated that an SAO mitigation plan was developed and implemented in December of 2017. E #5 stated that SAO is listed in the Hospitals Clinical Risk Management Report, under "other", which E #5 stated, "other includes any incidents related to patient belongings and SAO. E #5 stated "We discuss it in the Quality improvement meetings that meet monthly. " E #5 reviewed the Quality Improvement Meeting minutes during the interview, however E #5 could not find the discussion on the allegations of SAO and abuse in the meeting minutes.

5. At 2:30 PM on 11/15/18 E #5 returned to the conference room and stated, "I concede, SAO and abuse allegation incidents were not discussed in the Hospital's Performance Improvement Meetings. We discussed them in the corporate meetings."
VIOLATION: PATIENT SAFETY Tag No: A0286
**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 the Performance Improvement Program included measurable indicators. This affects all current and future patients in the Hospital.

Findings include:

1. The Hospital's Incident Log for January 2018 through October 2018 was reviewed on 11/13/18 at approximately 11:00 AM. The log included 60 potential inappropriate sexual behavior and 70 physical assault patients in the Children's Pavilion.

2. The Hospital's Performance Improvement Plan (reviewed 9/17), included, "...III. A...The program consists of these focus components: performance improvement, patient safety, quality assessment/improvement and quality control activities...These indicators are objective, measurable, based on current knowledge...and are structured to produce statistically valid, data driven performance measures of care provided..."

3. The Hospital's Performance Improvement Meeting minutes dated January 2018 to September 2018 were reviewed on 11/15/18 at approximately 10:15 AM. The minutes did not include tracking of inappropriate sexual behavior and did not include any measurable indicators, to identify a reduction in inappropriate sexual behavior and physical assault on patients.

4. The Hospital's Occurrence Report dated 9/9/18, indicated, "Pt #7 stated/reported Pt #12 (male, [AGE]), while passing by Pt #12's room, Pt #7 went to Pt #12's room and tell him to shut up and Pt #12 pulled her pants down and stick his finger in her vagina and Pt #7 did not report as she was scared. This incident happened yesterday 9/8/18 in the afternoon, mentioned about 8 PM but [I am not sure]. The incident report listed that following under 'Identify Cause, Identify Corrective Action:' MD #1 notified and left a message, case worker notified and left message, Abuse Hotline notified, incident form filled out. The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the alleged incident, and any measurable actions put into place, to prevent further incidents. There was no evidence of sufficient investigation to unsubstantiate the allegations.

5. On 11/14/18 at 12:30 PM, Pt #10's Hospital Occurrence Report was reviewed. Pt #10 was a [AGE] year old female admitted [DATE], with the diagnoses: Disruptive mood dysregulation disorder, bipolar disorder and homicidal ideation. Pt #10's occurrence dated 8/27/18, indicated " ...Around 7:30 PM, 8/27/18, Pt #10 reported that the Mental Health Worker (E#2) closed the door while on 1:1 with Pt #10 and pulled Pt #10 on his lap. Pt #10 stated that she pulled away and he then touched her breast. Pt # 10 stated that, E #2 mentioned that he had [big d****] on a previous encounter, in the past to her. Identify Cause, Identify Corrective Actions - E #2 (Chief Nursing Officer) notified, E #5 (Director of Risk Management) notified, female staff to attend to Pt #10. DCFS staff came out and investigated and interviewed Pt #10 on 8/28/18. Staff moved to Marine Building during investigation. Staff denied allegation, no witnesses." The Hospital's Performance Improvement minutes dated 9/27/18, lacked documentation of the alleged incident, and any measurable actions put into place, to prevent further incidents. There was no evidence of a sufficient investigation or the implementation of a corrective action..

6. On 11/14/18 at 1:00 PM, the Pt #9's Suspected Abuse/Neglect Reporting Form was reviewed and indicated " ...Pt #9 alleged another female patient asked her to have sex. Reported to writer on 6/18/18. Pt #9 was an [AGE] year old female. Investigation to occur."The Hospital Occurrence Report dated 6/14/18 was reviewed on 11/14/18 at approximately 1:30 PM and indicated "According to (Pt #13, [AGE] year old female) and (Pt #9, Pt #6, [AGE] year old female) asked them both to have sex with her. Per (Pt #13, Pt #6) contact made." There was no documentation of what kind of contact. "(Pt #14, [AGE] year old female) and (Pt #15, [AGE] year old female) reported (Pt #6) touched them inappropriately. Identify Cause, Identify Corrective Actions - DCFS hotline report made, Investigation is underway, (Pt #6's) room was blocked with SAO precautions (sexual acting out, closer monitoring) Attending physician informed." There was no documentation regarding any preventive measures that the Hospital implemented to prevent further incidents. The Hospital's Performance Improvement Meeting Minutes dated 7/19/18 were reviewed. The Meeting Minutes did not have any documentation regarding the sexual assault allegations or investigation. There was no evidence of sufficient investigation or the implementation of corrective action.

7. On 11/14/18 at approximately 2:30 PM, Pt #24's, a [AGE] year old male, Hospital Occurrence Report dated 4/14/18, was reviewed and indicated " ...Pt knocked over soiled laundry basket and attempting to hit staff. MHW (Mental Health Worker) escorted (Pt #24) to his room. (Pt #24) continued to attack staff. Two(2) Mental Health Workers told (Pt #24) that they would break his arm, it was concluded that the statement, 'You could break your arm' as opposed to 'I'll break your arm' was made, however, it was not made in a threatening manner. It was found that the MHWs were using verbal de-escalation techniques, educating (Pt #24) on the possible risk of harm related to his continued aggressive behavior." The investigation found that Pt #24 was bruised during a physical hold, where he was stated to be non-cooperative and physically aggressive. The Hospital's Performance Improvement Meeting Minutes, dated 5/17/18, were reviewed and lacked documentation regarding the physical abuse allegation. There was no evidence of sufficient investigation or the implementation of corrective actions.

8. Pt #17 was a [AGE] year old male, who reported being fondled by a [AGE] year old as well as 5 other patients reported the teen (the [AGE] year old male Pt #18), touched them inappropriately when employees were not looking. There was no evidence of sufficient investigation or the implementation of corrective actions.

On 11/14/18 at approximately 3:00 PM, the Hospital Occurrence report was reviewed and indicated "Pt (#17), a 12 year old) alleged on 12/8/17, (Pt #18) touched his genitals and butt." The Occurrence Report noted that 5 other patients (Pt #19, Pt #20, Pt #21, Pt #22 and Pt #23) reported to staff that (Pt #18) touched them all inappropriately. (Pt #19) stated [He touched all of us on the ass in the day room]. (Pt #20) stated that (Pt #18) asked him to be his boyfriend. (Pt #21) stated that (Pt #18) tried to touch his penis in the day room. (Pt #22) stated that (Pt #18) asked him to go by the fridge in the day room to suck his d****. (Pt #23) stated that when (Pt #18) was his roommate, he was almost 100% sure that (Pt #18) did something to him in his sleep." The Risk Management section indicated, "Spoke with JDC (juvenile detention center) reported incident. Follow up plan - (Pt #18) was already discharged , could not follow up with alleged perpetrator. All incidents occurred while staff were present in room, but according to patients, it was done quietly when staff went to fridge. No video review due to camera outage." There was no other investigation noted for these incidents. The Hospital's Performance Improvement Meeting Minutes, dated 2/18/2018, were reviewed and lacked documentation regarding the sexual abuse allegations. There is no documentation of quality measures or improvement processes that were implemented to prevent further incidents.

9. During the course of the investigation, 47 additional clinical records from the Child and Adolescent Pavilion for the months of September 2018, October 2018, and November 2018 were reviewed regarding inappropriate sexual activity, abuse with harm, and abuse without harm. The review included: 18 abuse occurrences with injury, 14 abuse occurrences without injury, and 15 occurrences of inappropriate sexual activity. The Performance Improvement minutes failed to include corrective action measures put into place, to prevent further allegations.

10. The Risk Manager (E #5) stated during an interview on 11/15/18 at approximately 1:00 PM, that inappropriate sexual behavior is monitored as adverse events, however they are not indicated. We have a SAO (sexual acting out) mitigation plan that was started in December 2017.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on document review and interview, it was determined that the Hospital's Governing Body failed to ensure the Performance Improvement Plan included all potential adverse events.

Findings include:

1. The Hospital's Incident Log for January 2018 through October 2018 was reviewed on 11/13/18 at approximately 11:00 AM. The log included 60 allegations of inappropriate sexual behavior and 70 allegations of physical assault on patients in the Children's Pavilion.

2. The Hospital's Performance Improvement Plan (reviewed 9/17), signed by the the Department Director, Chief Executive Officer, and Chief Medical Officer on 9/1/17, included, "...III. A...The program consists of these focus components: performance improvement, patient safety, quality assessment/improvement and quality control activities...These indicators are objective, measurable, based on current knowledge...and are structured to produce statistically valid, data driven performance measures of care provided...B...1. The monitoring, assessment and evaluation of the patient care...may include but not limited to...b. Adverse events...e. Safety management..."

3. The Hospital's Clinical Risk Management Report, was reviewed on 11/15/18 at approximately 10:00 AM. The Report included monitoring of Assaultive Episode with and without injury. The Report failed to include the monitoring of inappropriate sexual behavior.

4. The Hospital's Board of Trustees Meeting dated 10/17/17, included, "The Director of PI/RM/QI (Performance Improvement/Risk Management/Quality Improvement) presented the QAPI (quality assessment performance improvement) plan. Was approved by the Board."

5. The Risk Manager (E #5) stated that she signed the plan and then presented the plan to the Chief Executive Officer and Chief Medical Officer for signage, prior to presenting to the Board of Trustees for approval.