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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 ensure patients were free from all forms of abuse by failing to follow the process for the reporting and investigation of an allegation of abuse. See A-145.

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #10 and Pt. #11) grievances reviewed, the hospital failed to provide the required written response for resolving grievances.

Findings include:

1. On 10/15/2024, the hospital's policy titled, "Patient Complaints and Grievances" (2/2023) was reviewed and included, "... V. Procedure... F. Written Response to Grievance. 1. Grievances are responded to in writing using the (Name of the Hospital's) Grievance Response Letter Template... 3. The Complaint Coordinator sends the complainant a written response to the grievance that includes the following elements: a. Steps taken on behalf of the patient to investigate the grievance. b. The hospital's decision/results of the investigation. c. Date of completion. d. Name of Hospital's contact person..."

2. On 10/15/2024, the hospital's grievance log was reviewed. The log included the following:

- On 7/15/2024, Pt. #10 filed a grievance to the hospital regarding seeing a primary care physician and making Pt. #10 feel that, "(Pt. #10) is a problem." There was no written response provided to Pt. #10 regarding resolution of the grievance.

- On 8/27/2024, Pt. #11 filed a grievance to the hospital regarding dissatisfaction of the service received from the hospital, e.g., tests completed were unnecessary and felt being experimented on. There was no written response provided to Pt. #11 regarding resolution of the grievance.

3. On 10/15/2024 at approximately 3:00 PM, findings were discussed with MD #1 (Chief Medical Officer). MD #1 could not provide the written responses to Pt. #10 and Pt. #11. MD #1 added that response letters should have been provided to both patients by the patient advocate.

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed, the hospital failed to ensure the patient's power of attorney (POA) was informed of the patient's change in health status after a patient (Pt. #1) sustained a fall and on a later date sustained unexplained bruising.

Findings include:

1. The hospital's policy titled, "Patient Rights and Responsibilities" (revised 01/2024) was reviewed and included, " ... 4. The patient (or the patient's legal representative) has the following rights: ... Information and Communication ... his/her representative has the right to make informed decisions regarding care ... informed of his/her health status, diagnosis and prognosis; being involved in the care planning and treatment; and being able to request or refuse treatment ..."

2. On 10/10/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the hospital's emergency department (ED) on 08/15/24 via ambulance from nursing home for evaluation for agitation and discharged back to the nursing home on 08/29/24. The clinical record included the following:

-Power of Attorney (POA) for Health Care, dated 01/01/23, signed by (Pt. #1) and witness, and (name of POA/daughter).

-History & Physical dated 08/15/24 at 10:00 PM, "Chief Complaint: Psych [psychiatric] Evaluation ... No medical concerns, all labs are WNL (within normal limits), vital signs stable (heart rate/HR 81 bpm (beats per minute), and blood pressure 138/91 mmHg (millimeter of mercury) [reference range [HR 60-80 bmp and BP 90/60mmHg to 140/90 mmHg], patient is admitted to psych with medicine on consult as patients is unable to ambulate.

-Physician Progress Note (Nurse Practitioner -NP/E #6) dated 08/20/24 at 10:06 AM, "(Pt. #1) with sitter at bedside ... noted with a bump on the head, per staff (Pt. #1) had a fall overnight due to constantly trying to get out of bed ... continues to be restless ... received Haldol (anti-psychotic) 2mg (milligrams) IM (intramuscularly) as well as Ativan (anti-anxiety) 1mg IM yesterday due to restlessness and constantly trying to get out of bed ...V/S (vital signs) from flow sheet 8/20/24 at 7:15 AM, Blood Pressure 134/87, Pulse (HR) 102 ..."

-Physician Progress Note (Internal Medicine/MD #1) dated 08/25/24 at 9:30 AM, "Called by house supervisor ... with a request for IM (Internal Medicine) to assess (Pt. #1) as supposedly has bruises all over ... (Pt. #1) was examined at bedside ... has a large bruise to right upper anterior chest/shoulder as well as a bruise over left anterior submental region on jaw. These bruises are consistent with injuries. Informed Supervisor who was at bedside to ensure bedrails are padded ... does have bruising over arms but this is also consistent with healing stages of ecchymosis (bruise) from IV (intravenous) insertions and blood draws ... No active concerns. Please pad bed rails and consider constant sitter if is prone to injuries ..."

The Physician Progress notes, and the clinical record did not include documentation that (Pt. #1's) POA was contacted or attempted to be contacted to inform of (Pt. #1's) fall or unexplained bruising.

3. An interview was conducted with the Nurse Practitioner (E #6) on 10/15/24 at 1:10 PM. E #6 stated that E #6 saw Pt. #1 daily. E #6 stated that Pt. #1 had was assigned a sitter during the patient's admision it was started in the ED and continued throughout (Pt. #1's) admission for safety. E #6 stated that the first notice of bruises was on the 8/20/24. The staff reported that the bruise resulted from a fall on the previous shift. E #6 stated that a few days later on Monday (8/26/24) after the weekend E #6 asked staff about the new bruising, but no one knew what was going on or how (Pt. #1) got the bruises, E #6 was told that (Pt. #1) was restless over the weekend and tried getting out of bed. E #6 stated that (Pt. #1's) medication was adjusted. E #6 stated that E #6 spoke to POA before the fall, does not recall any other conversations.

Based on document review, observation, and interview, it was determined that for 4 of 4 (Pt #1-Pt #4) clinical records reviewed for monitoring, the hospital failed to ensure that fall preventive measures were in place and hourly rounding was documented, as required for patients at high fall risk.

Findings include:

1. The hospital's policy titled, "Fall Risk Assessment & Prevention Program" (dated 2/23), was reviewed, and required, " ...The Fall Prevention Program has been developed to minimize patient falls and potential injuries from a fall ...In addition to universal fall interventions implemented, any patients with Morse scale equal to or higher than 45 (high risk) should be given the following interventions ... Maintain within arm's reach during high risk activities... Activate bed/chair alarm appropriately ..."

2. The RN (Registered Nurse) and Certified Nurse Assistant Skills Validation Packet (orientation competency checklist) indicates that patient hourly rounds are required part of documentation.

3. The clinical record of Pt. #1 was reviewed. (Pt. #1's) Morse Fall Risk Scores were reviewed and on 08/18-08/19/24 the Morse Fall Score was 50 (high risk), on 08/24/24 score was 60 (high risk), and on 08/28/24 the score was 75 (high). The Hourly Rounding Flowsheets dated 08/16/24 to 08/29/24 were reviewed and indicated that the hourly round was not conducted on the following dates as ordered by the Physician on 08/16/24:
-08/18/24 from 6:56 PM to 08/19/24 at 12:11 AM (5 hours and 7 minutes).
-08/19/24 at 2:02 AM to 04:03 AM (2 hours 1 minute) - 06:08 AM, 2:00 PM (1 hour 52 minutes) to 4:00 PM. 6:00 PM (2 hours) to 8:00 PM (2 hours).
-08/24/24 at 11:01 PM to 08/25/24 at 1:07 AM (2 hours and 6 minutes), and 08/25/24 at 1:07 AM to 7:45 AM (7 hours and 38 minutes).
-08/28/24 at 8:07 PM to 10:09 PM (1 hour 58 minutes) to 08/29/24 at 12:02 AM (2 hours and 7 minutes) to 2:04 AM (2 hours 2 minutes) to 4:01 AM (2 hours 3 minutes) to 7:00 AM (2 hours and 59 minutes).

4. The clinical records of Pt #2, Pt #3, Pt #4, were reviewed. The patients' Morse Fall Risk scores were reviewed. Pt #2's fall risk score was 70 (high risk). Pt #3's and Pt #4's fall risk score was 45 (high risk).

5. On 10/10/2024 at 9:55 AM, an observational tour of the 7N/7S Medical/Surgical Telemetry unit was conducted. During the tour, Pt #2, Pt #3, and Pt #4, rooms were checked for fall preventive measures in place including bed alarms. The three patients who are high fall risk, did not have bed alarms set.
- Following the observation, the clinical records were reviewed for the required hourly rounding and the records including the following:
Pt #2's last hourly rounding was documented on 10/10/2024 at 2:56 AM (lacking rounds from 4:00 AM-10:00 AM).
Pt #3's last hourly rounding was documented on 10/9/2024 at 5:46 PM (lacking rounds from 6:00 PM-10/10/2024 at 10:00 AM).

6. On 10/10/2024 at 11:05 AM, an interview was conducted with the 7N Charge Nurse (E #2). E #2 stated that the RNs and CNAs rotate charting on hourly rounds and that they should be documented in the computer. E #2 confirmed that Pt #2, Pt #3, and Pt #4's bed alarms were not set while the patients were laying in the bed. E #2 stated that fall prevention measures include bed alarms, yellow socks, yellow non-skid socks, and chair alarms.

Based on document review and interview it was determined that for 1 of 1 clinical record (Pt. #1) with an allegation of abuse, the hospital failed to follow the process for the reporting and investigation of an allegation of abuse. This could potentially affect all current and future patients at the hospital who report an allegation of abuse.

Findings include:

1. On 10/10/24 the hospital's policy titled, "Reporting of Abuse/Neglect Allegations" (revised 12/2023) was reviewed and required, "Definitions: IDPH (Illinois Department of Public Health) ... V. Procedure: A. Allegations of Abuse ... 1. Any personnel who have reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report ... 3. Upon receiving a report, the hospital shall promptly conduct an internal review to ensure the alleged victim's safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital's administrator and shall include, but are not limited to, removing suspected violators from further patient contact during the hospital's internal review ... B. 1. All internal hospital reviews shall be conducted by a designated hospital employee or agent who is qualified to detect abuse and is not involved in the alleged victim's treatment ... to determine if the allegation is substantiated or unsubstantiated ... All internal review findings shall be documented ... shall be made available to the Department upon request ..."

2. On 10/10/24, the hospital provided a "Safety Event" report and included, "Date Received: 08/25/24, Date of Event: 08/25/24 ... Location: 7N/Telemetry ... Significance: 5 - Event patient temporary harm ... LPN (licensed practical nurse/E #7) entered the room and noted that (Pt. #1) had multiple bruises on left and right upper arms and a large bruise on left jaw. According to staff that worked yesterday (Pt. #1) did not have any of these bruises. No report was given from night shift RN (registered nurse). Only SBAR (Situation, Background, Assessment, & Recommendation) hand off to writer by charge nurse ... Dr. made aware ... (Pt. #1) with new bruises and scratches to arms and face after night shift on Saturday (08/24/24). Written statements from sitters determined occurred on Saturday night. Patient restless and agitated, scratching and hitting self throughout night. (Pt. #1) was medicated ... bruising not noted on the night shift, but documented on Sunday AM by staff ... Discussion in huddle regarding documentation on bruising and scratching and any events that have occurred..."

3. On 10/10/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the hospital's emergency department (ED) on 08/15/24 via ambulance from nursing home for psychhiatric evaluation for agitation and discharged back to the nursing home on 08/29/24. The clinical record included the following:

-ED History & Physical dated 08/15/24 at 7:20 PM, "(Pt. #1) ... past medial history including dementia, Alzheimer's, alert and oriented x1 (to person) at baseline, generalized anxiety presenting to the ED via EMS (emergency medical services) for agitation ... Skin: Warm, dry, grossly intact, no obvious rashes ..." Admission to general medical floor."

-Nurse Progress Note, dated 08/19/24 at 4:12 PM, "High-risk Skin Assessment ... (Pt. #1) with complex medical history ... dementia/Alzheimer's, restlessness, unsteady gait, lack of coordination, cognitive communication deficit ... being seen for high-risk skin assessment - no alterations in skin integrity related to pressure or moisture.

-Physician Progress Note (Internal Medicine/MD #2) dated 08/25/24 at 9:30 AM, "Called by house supervisor ... with a request for IM (Internal Medicine) to assess (Pt. #1) as supposedly has bruises all over ... Reviewed the chart, not on any antiplatelets or anticoagulants. Current meds (medication) unlikely to predispose to bleeding ... (Pt. #1) was examined at bedside ... has a large bruise to right upper anterior chest/shoulder as well as a bruise over left anterior submental region on jaw. These bruises are consistent with injuries. Informed Supervisor who was at bedside to ensure bedrails are padded ... does have bruising over arms but this is also consistent with healing stages of ecchymosis (bruise) from IV (intravenous) insertions and blood draws ... No active concerns. Please pad bed rails and consider constant sitter if is prone to injuries ... Wound care nurse consult placed due to multiple abrasions over arms."

4. The "Time-Sheets" for E #8 (Registered Nurse) and E #9 (Sitter) from 08/24/24 to 10/15/24, were reviewed. The timesheets indicated that E #8 and E #9 continued to work at the hospital through 9/21/24. On 9/25/24, E #8 and E #9 were suspended due to unsatisfactory work performance. As of 10/16/2024, remain on suspension.

5. An interview was conducted with the Director of Nursing (DON/E #1) on 10/10/24 at 2:58 PM. E #1 stated that E#1 did get a call about some bruising and scratches on (Pt. #1) on 08/29/24 by nursing home staff. (Pt. #1) had just been discharged back to the SNF (Skilled Nursing Facility). The SNF's DON called and told E #1 they had a concern about abuse to (Pt. #1). E #1 stated that when E #1 had received the call, there had been an investigation already started about a hospital staff reporting bruising on (Pt. #1), however the hospital did not view this incident on 08/25/24 as abuse and did not investigate it as abuse. E #1 stated that a Midas event (electronic safety event reporting system) was entered prior to this call, by the nurse (E #7) on the day shift of 8/25/24. E #1 stated that the hospital was gathering more information to be able to investigate what happened. E #1 stated that he did a chart audit, staff interviews, however from their internal investigation their results came back inconclusive and did not suspect abuse. E #1 stated that there has not been any further investigation that E #1 is aware of. E #1 stated that after the call on 08/29/24 from the SNF, E #1 did not report this call as an allegation of abuse to Risk Manager, or administrators, and did not report to IDPH (Illinois Department of Public Health).

6. An interview was conducted with the Vice President of Safety (E #5) on 10/10/24 at 3:20 PM. E #5 stated that their investigation conducted for 08/25/24, was inconclusive, the hospital has the names of staff (E #8 and E #9) involved in the care of (Pt. #1) on the prior evening of 08/25/24. Staff were interviewed and they all stated that they did not see anything happen to (Pt. #1). Some of the staff stated that (Pt. #1) was scratching self. On one occasion (08/25/24), the medical team saw the patient and recommended that they pad the rails. E#5 stated that the hospital has not identified that there was any type of abuse, so the hospital has not done anything further. E #5 stated that in early October, the hospital hired a third party (name of law firm) to help them with their investigation. E #5 stated that the two staff identified as working on the shift that they suspect were providing care when the incident occurred have been suspended as of 09/25/24. E #5 stated that this incident was not reported to IDPH (Illinois Department of Public Health). Additionally, E #5 stated that the hospital does not have any documentation to show what has been done about this incident, E #5 stated that the investigation is still ongoing as of 10/10/24.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #8) clinical records reviewed regarding use of restraints, the hospital failed to ensure that a physician's order for the application of violent restraints was obtained, as required.

Findings include:

1. On 10/15/2024, the hospital's policy titled, "Restraint and Seclusion" (2/2024) was reviewed and included, "... Obtaining physician's order for... behavioral restraints... See Table 1... Order time limit... Behavioral Restraints. Age: Age 18 and older - four (4) hours... Order renewal... Within the required timeframe..."

2. On 10/15/2024, the clinical record for Pt. #8 was reviewed. On 7/20/2024, Pt. #8 was admitted with a diagnosis of paranoid behavior. On 7/22/2024 at 3:15 PM, a physician's order was made to place Pt. #8 in violent restraints for four hours (order expired at 7:15 PM). Pt. #8's restraints continued until 8:20 PM, however, a physician's order was not obtained, as required, when the restraints order expired at 7:15 PM.

3. On 10/15/2024 at approximately 10:30 AM, findings were discussed with E #1 (Director of Nursing). E #1 stated that a physician's order should have been obtained at 7:15 PM and not 8:20 PM.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #8) clinical records reviewed regarding use of violent restraints, the hospital failed to complete the required face-to-face assessment within one hour after the initiation of restraints.

Findings include:

1. On 10/15/2024, the hospital's policy titled, "Restraint and Seclusion" (2/2024) was reviewed and included, "... Face-to-Face Evaluation for Violent or Self-Destructive Behavior. 1. Patients placed in restraint... for violent or self-destructive behavior, a face-to-face evaluation is performed between the LIP (licensed independent practitioner), qualified RN... The purpose... is to determine if the use of these measures is justified... 2. The LIP conducting the face-to-face evaluation... must include an assessment of the following issues and must be documented the findings in the medical record: a. The patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition..."

2. On 10/15/2024, the clinical record for Pt. #8 was reviewed. On 7/20/2024, Pt. #8 was admitted with a diagnosis of paranoid behavior. On 7/22/2024 at 11:15 AM, violent restraints were applied to Pt. #8. The clinical record lacked the required face-to-face evaluation within one hour of placing the violent restraints..."

3. On 10/15/2024 at approximately 10:30 AM, findings were discussed with E #1 Director of Nursing). E #1 stated that the required face-to-face evaluation was not documented in the clinical record.