HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (Pt. #2) patients reviewed for allegation of abuse, the Hospital failed to ensure that a thorough investigation for an allegation of abuse was conducted and reported to state agency as required.

Findings include:

1. On 1/12/21, the policy titled, "Reporting of Alleged Abuse and Neglect (revised 10/19/20) was reviewed and included, " ...Reporting ...A. All allegations of abuse/neglect ...shall be reported to ...IDPH (Illinois Department of Public Health) ...within 24 hours of the initial discovery of the incident of alleged abuse ... Any allegation of abuse by an employee ...Investigation will be led by the Director of Risk Management or designee ...F. i. The Director of Risk Management or designee will compile the investigative report. The investigative report shall contain a narrative summary of the investigation which shall include a. A timeline of the investigation, recommendation as to whether the findings of the investigation should be substantiated, unsubstantiated or unfounded; and b. Any actions taken by the agency as a result of the allegation."

2. On 01/12/2021 at approximately 9:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Medical/Surgical Unit on 01/01/2021 at 1:26 PM, with a diagnosis of dislodged supra-pubic catheter (urine catheter). The clinical record included:
- The Hospitalist's (MD #3) note, dated 01/02/2021 at 6:30 PM, documented, " ...security rough with him ...he (Pt. #2)was on floor ...his (Pt. #2) arm was twisted ...back of head struck by security ...patient [Pt. #2] called police ...filed a report ...alleging that he was assaulted by security ...reduced movement of left shoulder ...hematoma on the back of the head ...tender ...x-ray left shoulder and head CT [computerized tomography] ..."

3. On 01/12/2021, the Hospital's Security Event #39873, dated 01/02/2021, was reviewed. The writer Public Safety Officer (E #10) included, " ...On January 2nd 2021 at approximately 4:25 PM, a code gray was called ...PSO (E #1) and (two other PSOs) responded ... CPD [police department] arrived badge #1211 due to patient (Pt. #2) stated assaulted by staff members and security ...police filed non-criminal report ...Event #2100208366 ... RESOLUTION AND OUTCOMES: treated as a grievance."

4. On 01/12/2021, the Hospital's Grievance Case #1146 dated 01/04/2021 was reviewed. The writer Patient Experience Officer (PEO) (E #14) included, " ...On 01/04/2021 the Director (of the Medical Surgical Unit E #12) and the PEO follow-up visit to patient (Pt. #2's) room ...check on the patient and issue over the weekend with the staff and public safety officer ...patient contact police department and attorney ...(Pt. #2) was punched by staff and public safety in the back of the head ...he (Pt. #2) called police ...case elevated to the risk management department."

5. No abuse investigation available to review. The Hospital was unable to provide documentation that Pt. #2's alleged incident of abuse was reported to IDPH as required.

6. On 01/12/2021 at approximately 3:30 PM, Patient Experience Officer (E #14) was interviewed. E #14 stated that, he (Pt. #2) stated that he had called the police because the security guard had punched his head. E #14 stated that, whatever the patient (Pt. #2) said verbally to us we filed it under the grievance case. E #14 stated that, the case was notified to the Risk Manager (E #13).

7. On 01/12/2021 at approximately 3:30 PM, the Risk Manager (E #13) were interviewed. E #13 stated that the patient's allegation of abuse by security guard was not investigated. E #13 stated that, the allegation of abuse was not reported to IDPH.