HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to immediately suspend an accused staff member following a sexual abuse allegation to protect patients during the investigation of allegation of abuse.(See A-145)

Based on document review and interview, it was determined that for 1 of 1 (Pt #3) clinical record reviewed for sexual abuse allegation, the hospital failed to remove the accused staff member from patient care immediately following allegations of abuse to protect patients during an investigation of alleged sexual abuse.

Findings include:

1. On 11/1/2023, the Hospital's "2023 Orientation Reference Guide" (dated 2023) were reviewed and indicated, ... "Free from All Forms of Abuse & Harassment - Components of effective protections -prevent ...screen ...identify ...train ...protect: during investigation of any allegation of abuse or neglect or harassment, the patient must be protected. Investigate: investigations should be timely, thorough, and objective ...Report: all events are reported and analyzed, and the appropriate corrective, remedial or disciplinary action has been taken in accordance with local, state or federal law."

2. On 11/1/2023, the Hospital's policy "Discipline and Termination of Employment" (dated 7/2022) was reviewed and indicated, "Suspensions - Investigative Suspensions -An investigative suspension may be necessary based on the circumstances ..."

3. On 11/1/2023, the Hospital Bylaws (dated 7/2022) was reviewed and indicated: "Routine Corrective Action - Criteria for Initiation - Whenever activities, omissions, or professional conduct of a Practitioner with clinical privileges are detrimental to patient safety, to the delivery of quality of patient care, are disruptive, undermine a culture of safety or interfere with Hospital operations ...corrective action against such Practitioner may be initiated ..."

4. On 11/1/2023, Pt #3's clinical record (dated 10/24/2023 thru 10/27/2023) was reviewed and indicated:
-Pt #3's ED documentation dated 10/24/2023 noted "Pt #3 presents to ED with complaint of left shoulder, chest, flank pain after 1 week ago from moving something. Pt #3 complains of 10 out of 10 sharp pain ... Medication administration -Dilaudid (pain medication) 0.5 mg, IV push and Valium (sedative medication) 10 mg oral ..." Pt #3 admitted to 2nd floor Medical/Surgical unit under the care of Hospitalist (MD #1).

-MD #1's history & physical dated 10/24/2023 noted, "Pt #3 developed multiple bouts of sharp shooting pain to the posterior aspect of the neck radiating to the left shoulder and causing significant amount of discomfort ...Pt #3 will be admitted for further evaluation and treatment with neurological consult ..."

-Discharge Documentation dated 10/27/2023 at 3:15 PM noted, "Admission diagnosis - Severe shooting neck pain. Discharge Diagnoses -Severe shooting neck due to cervical radiculopathy (a disease of the root of the nerve) improved ...Disposition - Discharge the patient home. Discharge instructions - Follow up with Neurosurgery in 1 month. Hospital course -Pt #3 came with severe multiple bouts of sharp shooting pain of the left posterior and lateral neck. Due to the severity of the symptoms, we admitted Pt #3 to Med/Surg floor, started her on IV Dilaudid and IV Ativan (antianxiety medication). We obtained Neurology consult followed by CT C-spine myelogram (diagnostic imaging test), CT left shoulder with contrast, which basically showed some degenerative changes of the C-spine per Neurosurgery. Pt #3's neurological exam was grossly unremarkable. No neurological intervention at this time ...Pt #3 will be discharged home with appropriate follow-up by Neurosurgery with some improvement of her symptoms ..."

-Pt #3's record did not include any documentation of Pt #3 reporting any allegations of abuse to staff.

5. On 11/1/2023, the Hospital's investigation report (dated 10/30/2023 thru 11/1/2023) indicated:
"-10/30/2023 at 2:30 PM - Received patient complaint alleging sexual misconduct by a staff member during hospitalization. Event occurred on 2W on the 27th of October prior to discharge.
-Event was reported to an outpatient scheduler when Pt #3 called to schedule an outpatient MRI [on 10/30/2023]. Pt #3 informed the scheduler that she was awakened with a thumb in her mouth and two (2) fingers in her vagina by a tall brown man with short dark hair on the day of discharge. The scheduler informed the caller she would report and someone will be calling her.
-10/30/2023 at 4:00 PM - E #3 placed call to the patient to discuss the event. Spoke with patient approximately thirty (30) minutes. Pt #3 told E #3 the following, I was violated twice. The first time was on Wednesday (10/25) when I awoke with a man's hand down in my panties and his fingers in my vagina. I asked [What are you doing?] He responded "no worries."
-Pt #3 described the alleged perpetrator as being tall dark skinned (not African American) male with short dark hair, box hair style.
-Pt #3 stated Pt #3 saw him three (3) times while in the Hospital and he wore nice suits each time.
-Pt #3 stated there were no witnesses but a nurse came into my room with discharge papers while he was still in my room on day of discharge.
-Pt #3 stated that when Pt #3 got home, Pt #3 googled the name of the doctor who gave Pt #3 discharge medications and the picture on line looked like the man who violated me. Pt #3 spelled MD #1's name.
-10/30/2023 at 4:30 PM - E #3 called the number to report sexual abuse in IL per Google search 877-236-7703.
-Notified CEO (E #7) of allegation.
-10/31/2023 - E #3 received call from the IL Dept of Human Rights, caller stated that the report made on 10/30 needed to be made somewhere else that they did not handle sexual abuse cases only sexual harassment and discrimination ...11:15 AM - IDPH surveyor provided an email dph.hospitalreports.illinois.gov to submit a summary of the event on letterhead paper ...
-Notified chief of medical staff and medical director of the hospitalist of allegation
-10/31/2023 - Physician interview - Discussed the allegation with Pt #3. Explained to MD #1 that based on the seriousness of the allegation, we would not be able to let MD #1 continue to see patients until an investigation was completed and a decision was made as to whether allegation was substantiated or not. MD#1 denied any touching of Pt #3 except in the neck and shoulder area ...Interviews were conducted E#5 (Registered Nurse on 2nd floor) and E #6 (Patient Advocate). Each interview (E #5 and E #6) noted that staff members did not receive any complaints of abuse from Pt #3 or witness any abuse.

6. On 11/1/2023, the Hospital's suspension letter to MD #1, dated 10/30/2023 (per interview with E #3/Chief Quality Officer, date letter drafted), was reviewed and indicated, "A complaint has been submitted to the Quality Department which alleges sexual misconduct toward a female patient under your care. Because of seriousness of the accusation, we will be suspending you until the investigation is concluded and the determination made whether the allegation is substantiated or not substantiated."

7. On 11/1/2023 at 9:00 AM, an interview was conducted with the Chief Quality Officer (E #3). E #3 stated that a complaint regarding Pt #3 came on 10/30/2023 at 9:30 AM. E #3 stated that the complaint came through the Hospital Registration for outpatient testing. E #3 stated that Pt #1 was scheduling an outpatient MRI on 10/30/2023 via telephone. Pt #3 told the Hospital scheduler that on the day of discharge (10/27/2023), Pt #3 had been violated. E #3 stated that Pt #3 told the scheduler that the man who violated Pt #3 was brown in color (not African American). E #3 stated that Pt #3 told the scheduler that while Pt #3 was in the Hospital, the man put his finger in her mouth and private area. E #3 stated that the scheduler told Pt #3 that the scheduler would report this incident to her supervisor immediately. E #3 stated that E #3 found out about this incident from the CFO on 10/30/2023 at 2:30 PM. E #3 stated that she (E #3) called Pt #3 at 3:30 PM on 10/30/2023. E #3 stated that Pt #3 told E #3 that a tall, dark skin male (not African American) woke Pt #3 up the day of discharge with his thumb in her mouth and 2 fingers in her vagina. E #3 stated that Pt #3 told her that the man violated Pt #3 one other time. E #3 stated that E #3 asked Pt #3 how she responded. E #3 stated that Pt #3 asked the man what he was doing. E #3 stated that Pt #3 stated that Pt #3 did not mention this to anyone while Pt #3 was in the hospital. E #3 stated that E #3 reported the incident to the State on 10/30/2023. E #3 stated that she thought that MD #1 was not the Hospitalist on duty the week of the 30th, so would not be in the hospital seeing patients. E #3 found out on 10/31/2023 that MD #1 was on duty on 10/31/2023 and had already done rounds on patients that morning. E #3 stated that she talked to MD #1 on 10/31/2023 around 10:00 AM. E #3 stated that MD #1 was verbally told that he could not work or be at the hospital until investigation was complete on 10/31/2023, but a letter of suspension was not provided or sent to MD #1 at that time. E #3 stated that MD #1 should have been suspended immediately. E #3 stated MD #1 told her that he did not sexually abuse Pt #3. E #3 stated that MD #1 stated, "You're kidding me." E #3 stated that she had drafted the suspension letter for MD #1 on 10/30/2023; spoke to MD #1 on 10/31/2023; and would be mailing the suspension letter today (11/1/2023).
On 11/2/2023 at 2:20 PM, an additional interview was conducted with E #3. E #3 stated that she asked the administrative assistant to mail the letter on 11/1/2023, but the administrative assistant did not mail it on 11/1/2023. E #3 mailed the suspension letter this morning 11/2/2023 to MD #1.
On 11/6/2023 at 9:00 AM, E #3 stated that the investigation was over, and the findings were unsubstantiated. E #3 stated that MD #1 was not back at work yet.

8. On 11/1/2023 at 2:30 PM, an interview was conducted with MD #1. MD #1 stated that MD #1 admitted Pt #3 to a medical/surgical unit for pain control and imaging. MD #1 stated that Pt #3 had severe pain on left side of neck and shoulder. MD #1 stated that imaging was done, and the imaging noted that there was no serious damage to neck or shoulders. MD #1 stated that Pt #3's pain improved. MD #1 stated that he did the discharge instructions for Pt #3. MD #1 stated that Pt #3 wanted MD #1 to be her primary doctor. MD #1 stated that he explained to Pt #3 that he was a Hospitalist and does not follow patients after discharge. MD #1 stated that his relationship was "purely professional." MD #1 stated that Pt #3 was awake and alert and oriented each time he saw Pt #3 and stated that he does patient rounds around 2:00 PM each day. MD #1 stated that he did not put his finger in Pt #3's mouth and did not place his fingers in Pt #3's vagina. MD #1 stated that he was verbally informed yesterday by the Chief Quality Officer (E #3) that he was suspended until the investigation was completed. MD #1 stated that MD #1 had already made rounds on patients yesterday on 10/31/2023 prior to being informed that he was suspended. MD #1 stated that he has worked at the Hospital for 20 years and has received abuse training.

9. On 11/1/2023 at 3:00 PM, an interview was conducted with the CEO (E #7). E #7 stated that E #7 was informed about the sexual abuse allegation against MD #1 on 10/30/2023. E #7 stated that MD #1 was suspended on 10/31/2023. E #7 stated that MD #1 did rounds in the Hospital on 10/31/2023 prior to notification of his suspension due to a scheduling oversight. E #7 stated that MD #1 should have been suspended immediately following the notification of the allegation of sexual abuse. E #7 stated that not suspending MD #1 immediately was a hospital error.

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services.

Findings include:

1. The hospital failed to ensure incidents of elopement of behavioral health patients from the Emergency Department (ED) were reviewed to analyze the effectiveness and/or need for revision of policies/procedures. (See A-1104 A)

2. The hospital failed to ensure processes were in place and evaluated for the monitoring of patients in the ED waiting room, during an extended wait time. (see A-1104 B)

A. Based on document review and interview, it was determined that for 3 of 3 (Pt. #4, Pt. #6 and Pt. #7) behavioral health patients presenting to the ED who eloped, the hospital failed to ensure incidents of elopement of behavioral health patients from the Emergency Department (ED) were reviewed to analyze the effectiveness and/or need for revision of policies and procedures.

Findings include:

1. The ED quality meeting minutes for 2023 were reviewed on 11/2/2023. The quality indicators reported each quarter with a plan included barcoding of medication and left without being seen statistics. The other indicators tracked for data only included left against medical advice, eloped, door to doctor wait times, admit wait times and EMS calls. However, the data had not been analyzed for trends or effectiveness of ED policies and procedures.

2. The ED elopement log from May 2023 to present was reviewed on 11/1/2023. Three patients with a behavioral health diagnosis were identified on the log (Pt. #4, Pt. #6, and Pt. #7), and these records were reviewed.

3. On 11/1/2023, the ED record for Pt #4 was reviewed and included:
-The Triage note, dated 6/30/2023 at 12:32 AM, included, "Pt brought by EMS (emergency medical services) with a manic episode. On arrival pt is uncooperative."
-The ED Nurse Practitioner ' s note, dated 6/30/2023 at 12:21 AM, included, "[Pt] with a history of bipolar, depression, presents to the emergency department with aggressive behavior towards her mother. Patient brought in by EMS, accompanied by her significant other ... Upon arrival to ED patient was verbally aggressive and threatening towards staff and security. Patient was yelling at myself, and was not forthcoming with history. Patient requiring chemical and physical restraints due to threatening behavior. Patient denies suicidal and homicidal ideations."
Nurses notes included:
-6/30/2023 at 9:10 AM, "Called SASS [Screening, Assessment Support Services - provides assessment of children and adolescent mental health patients] to inquire about follow up with pt regarding when an evaluator would be coming to ED since pt is refusing to speak to them over the phone ..."
-6/30/2023 at 10:01 AM, " ... SASS present in ED now. Petition and Certificate filled out."
-6/30/2023 at 1:45 PM, "Pt accepted at Riveredge Hospital in Forest Park, accepted by [psychiatrist ' s name]."
-6/30/2023 at 2:50 PM, "Pt updated by Provider that she is being transferred to [behavioral health hospital in another suburb]. Pt became very upset and yelling that she does not want to go to [behavioral health hospital in another suburb] and that she wants to go to [different behavioral health hospital]. Pt then threatened the sitter, saying she was going to punch her in the face when she tried to stop her from eloping. Security and PA [physician ' s assistant] attempted to stop pt but she ran out onto [Name of road next to hospital]. Pt obtained a red sweatshirt from somebody in the waiting room. Security called [local] PD."

4. On 11/1/2023, the clinical record for Pt. #6 was reviewed. Pt. #6 was brought by an ambulance to the hospital's ED on 6/17/2023 at 3:55 PM, and the record included the following:
- The triage nurses note, dated 6/17/2023 at 4:39 PM included, "Chief Complaint: [Nursing Home] would like a psychiatric evaluation for erratic behavior." Sitter placed at bedside.
- The ED physician note, dated 6/17/2023 at 9:01 PM included, "Discharge patient [back to nursing home].
- The discharge information included, "Disposition: eloped". No other information was included, i.e. witnessed, when.

5. On 11/1/2023, the clinical record for Pt #7 was reviewed. Pt #7 was brought by police to the hospital ' s ED on 6/8/2023 at 11:43PM, and the record included the following:
-The Triage Nurse ' s note, dated 6/8/2023 at 11:53 PM, included, "Chief Complaint: Patient pulled over by police and told police he tried to kill himself by hanging."
-The CSSRS (Columbia Suicide Severity Rating Scale), completed on 6/9/2023 at 1:15 AM, indicated, "Level of Suicide Risk: High risk."
Nurse ' s notes included:
-6/9/2023 at 1:55 AM, "Pt was on the phone and saw both doors to the lobby open and ran through the open door out the main ED entrance. He ran through the parking lot east on Glen Flora and got in a vehicle and drove away."
-6/9/2023 at 1:58 AM, "PD [police department] was contacted and asked to try [to] locate [Pt #7]. The PD checked the pt address ... and was unable to locate the pt."
-6/9/2023 at 2:20 AM, "Pt has not been located [by PD]"
The ED record included that Pt #7 ' s elopement was witnessed, however, did not include any documentation of attempts to prevent the patient from eloping by the sitter; sitter reporting that Pt #7 had left the patient room; or notification to security to assist is preventing the patient from eloping.

6. The Director of the ED (E#8) was interviewed on 11/2/2023 at 3:30 PM. E#8 stated that elopement data has been collected but has not been analyzed. The above cases have not been reviewed for the events that occurred or for process improvement. E #8 stated that there is no policy/procedure related to elopement available. E #8 stated, "Our Director of Security just started approximately 3 weeks ago. I have had one meeting with the Director of Security to look at what can be done with security coverage to assist the ED staff a little more." E#8 stated that other than the meeting with security, nothing has been done to evaluate/improve the process to prevent elopements.

7. The Chief Quality Officer (E#3) was interviewed on 11/2/2023 at 10:00 AM. E#3 stated that the number of patient elopements should be zero. Especially for psychiatric patients. E#3 stated, "The ED has not included elopements in their monitoring or action plans." E #3 stated that there has been no investigation or analysis of the behavioral health patients' elopements.

B. Based on document review and interview, it was determined that 1 of 1 patients (Pt. #1) waiting in the emergency department (ED) for an extended wait time, the hospital failed to ensure a process was in place for the monitoring of patients while in the waiting room between triage and admission to the ED.

Findings include:

1. The Hospital policy titled, "Assessment and Reassessment of the Patient in the ED (4/2021)" was reviewed on 10/31/2023 and required, "ED patients are reassessed at intervals based on patient condition, response to intervention, diagnostic testing results, any change in condition, and at least at the following intervals: a) upon triage/arrival, b) on admission to the ED ..." The policy did not include frequency of monitoring/assessment of patients while in the waiting room between triage and admission to the ED.

2. The clinical record of Pt. #1 was reviewed on 10/31/2023. Pt. #1 arrived at the ED on 9/12/2023 at 2:44 PM via ground ambulance. The triage note (E#2), dated 9/12/2023 at 2:55 PM included, "Chief complaint: Patient [Pt. #1] arrived via EMS [emergency medical services] for Foley catheter leaking for 2 days." Vital signs were blood pressure 110/69, temperature 98.1 degrees, pulse 70 and respirations 18 on room air. Repeat vital signs at 9:05 PM were blood pressure 104/69, pulse 76, respirations 20. The clinical record did not include monitoring in the waiting room from arrival time of 2:55 PM until 9:05 PM (6 hours/10 minutes later).

3. The ED quality meeting minutes for 2023 were reviewed on 11/2/2023. The quality indicators reported each quarter with a plan included barcoding of medication and left without being seen statistics. The other indicators tracked for data only included left against medical advice, eloped, door to doctor wait times, admit wait times and EMS calls. However, the data did not include monitoring of patients in the waiting room, and collected data had not been analyzed for trends or effectiveness of ED policies and procedures.

4. The ED staff huddle minutes dated September and October were reviewed on 11/2/2023 and included that the goal is to get patients into the ED within 30 minutes. "This might not always be possible, when there are longer wait times, we must monitor these patients for any change in status. Patients need to be kept current on wait times, so round frequently."

5. The charge nurse (E#1), who worked the night shift 7:00 PM - 7:00 AM on 9/12/2023, was interviewed on 11/1/2023 at 7:30 AM. E#1 was unaware of any policy related to required monitoring in the ED. E#1 stated, "I would think vital signs should be taken every 2 hours while waiting to ensure there has been no change in the patients' condition."

6. The Director of the ED (E#8) was interviewed on 11/1/2023 at approximately 1:45 PM. E#8 stated that a lot of work has been done to decrease wait times. E#8 stated that staff had been educated on faster ED throughput [the time from patient arrival to time of discharge]. Patients in the waiting room are to be rounded on to see if they need anything and let them know about wait times [not hard wired yet - no documentation]. E #8 stated that there is not a policy on rounding on patients in the waiting room.