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 1 (Pt. #1) psychiatric patient with allegation of sexual abuse, the Hospital failed to follow the process for reporting and conducting an investigation for allegation of abuse.

Findings include:

1. On 1/14/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on [DATE] with diagnoses of schizoaffective disorder and suicidal ideation. The clinical record included:

- The ED physician's progress note dated 1/7/2021 at 12:06 AM included, " ... (Pt. #1) presents ... (for) psychiatric evaluation (suicidal ideation) ... General appearance: Well-appearing male, no acute distress ... Alert and oriented ... Assessment and Plan ... Discussed with (MD #1/Psychiatrist) ... Recommends admission for suicidal ideations ... Accepting Psychiatrist: (MD #1) ..."

- E #1's progress note on 1/7/2021 at 1:10 AM included, "(Pt. #1) making accusations that this RN (E #1) is sexually offending him. (Pt. #1)..."

- MD #1's progress note on 1/7/2021 at 1:40 AM included, " ...(Pt. #1)... seen by me (MD #1) for a psychiatric evaluation via video at the emergency room at (Name of the Hospital). (Pt. #1) states that he has been feeling very depressed and suicidal ... Mental status examination: (Pt. #1) is awake, alert... stated that the male nurse who came to his room in the emergency room molested him sexually and (Pt. #1) wants this thing to be written in the chart ...(Pt. #1's) knows the name of the current president and memory for recent and remote events grossly intact ..."

- The "Constant Observation Monitoring Log" indicated that Pt. #1 was on 1:1 (1 patient to 1 staff) monitoring while in the ED on 1/7/2021 from 12:00 MN through 4:45 AM. The monitoring log indicated that E #1 provided the constant monitoring for Pt. #1 from 12:00 MN to 12:30 AM.

- E #2's (ED RN) progress note dated 1/7/2021 at 4:51 AM included, "... (Pt. #1) to go to floor (Behavioral Health Unit/BHU) with crisis worker and security with belongings secured in bags."

- E #9's (BHU RN) progress note on 1/7/2021 at 6:48 AM included, "(Pt. #1) arrived from ER ... Patient was irritated and stated that male RN who assisted him remove his sock was sexually assaulting him ... Also accused ER male nurse of sexual assault ..."

- The physician's discharge summary on 1/12/2021 included, "Admission Diagnoses: Schizoaffective disorder, depressive type ... Indication for Admission: suicidal thoughts. Hospital Course: Patient admitted after expressing suicidal thoughts with plans of jumping in front of a train ... By the time of discharge, (Pt. #1) had no suicidal thoughts, plans or intentions."

2. On 1/14/2021, the Hospital's policy titled, "Allegation of Patient Abuse in Hospitals" (effective 10/31/2016) was reviewed and included, "Purpose: It is the policy of (Name of the Hospital) to respond consistently and timely to allegations of ... sexual abuse of patients ... Reporting 1. An Associate or Health Care Provider who ... receives an allegation of Abuse ... must inform the Charge Nurse immediately. The Charge Nurse must notify the Nurse Manager ... 2. The Nurse Manager or House Manager will immediately notify: a. Risk Management; b. Administrator On-Call; c. Quality Lead ... B. Immediate Response: 1. When an associate or Health Care Provider has reasonable cause to believe that a patient has been subjected to abuse by any person ... the following steps will be immediately taken: a. Assure immediate protection of patient, including separating the patient from the alleged abuser ... C. Investigation: 1 ... the Quality Department will initiate an investigation with the assistance of the Department Manager and/or Unit Director ... The patient and any possible witnesses will be interviewed ...D ... submit a written report of the alleged Abuse to the Illinois Department of Public Health within 24 hours ... E. Documentation ... 2. Any associate or Health Care Provider who reasonably believes that a patient Abuse has occurred will complete a variance report."

3. On 1/14/2021 at approximately 11:30 AM, E #11 (Director, Systems Quality) confirmed that there were no variant report (incident report) or investigation regarding Pt. #1's allegation of sexual abuse.

4. On 1/14/2021 at approximately 2:05 PM, an interview was conducted with E #1 (ED RN). E#1 stated that Pt. #1 was accusing him (E #1) of "sexually offending" him (Pt. #1). E #1 said, " I took care of (Pt. #1) until I finished my shift then gave report to the incoming nurse." E #1 stated that he did not report to the charge nurse because the ED intake coordinator and the ED physician heard the allegation.

5. On 1/14/2021 at approximately 3:35 PM, a telephone interview was conducted with MD #1 (Psychiatrist). Regarding Pt. #1's allegation of sexual abuse, MD #1 said that based on his judgement, the allegation of sexual abuse did not happen. MD #1 said that the allegation was unlikely to happen because there was a lot of traffic in the ER. Regarding his responsibility for reporting allegation of abuse, MD #1 said, " It is not my responsibility to report and investigate if that happened. I cannot report (allegation of abuse) if a patient is psychotic. I was not there."

6. On 1/15/2021 at approximately 9:18 AM, a telephone interview was conducted with E #9 (BHU RN). E #9 stated that she (E #9) did not report the allegation because of patient's history of making inappropriate comments. E #9 stated that it was only after talking with the BHU Manager on 1/14/2021 that she (E #9) knew that an allegation of sexual abuse is to be reported.

7. On 1/15/2021 at approximately 9:34 AM, a telephone interview was conducted with E #10 (BHU Mental Health Counselor). E #10 stated that Pt. #1 made multiple allegations of sexual abuse against the ED RN. E #10 said that the ED RN (E #1) was Pt. #1's nurse for about 3-4 hours even when Pt. #1 made multiple allegations of sexual abuse.

8. On 1/15/2021 at approximately 9:11 AM, an interview was conducted with MD #2 (Chief Medical Officer). MD #2 stated that whether a patient has paranoid delusion, an allegation of sexual abuse should be reported so a proper investigation can occur. MD #2 stated that the Hospital started an investigation yesterday (1/14/2021) after E #11 (Director, Systems Quality) stated that an investigation has not been conducted for Pt. #1. MD #2 added that Hospital physicians and staff are responsible for reporting allegation of abuse, and that Pt. #1's allegation should have been reported and investigated.