HospitalInspections.org

Based on document review, video review, and interview, it was determined that the hospital failed to comply with the Condition for Coverage 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure that patient observational rounds included visualizing the patient's face at least every 15 minutes to ensure patient safety. (A-144).

2. The hospital failed to ensure that patients were free from all forms of abuse by failing to follow the process for allegations of abuse. (A-145).

Based on document review, video review and interview, it was determined that for 6 of 6 patients (Pt. #1, Pt. #7, Pt. #8, Pt. #9, Pt. #10 and Pt. #11) on the behavioral health unit, the hospital failed to ensure that the observational rounds were conducted every 15 minutes, as required.

Findings include:

1. On 9/19/2024, the hospital's policy titled, "Monitoring of Patients on High Risk Precautions" (dated 3/2022) was reviewed and required, "Purpose - to ensure the safety of all patients and staff on the adult mental health unit...These high risk precautions include: 1:1, Suicide (SP), Homicide (HP), Assault (AP)....Patients are placed on every 15 minute observation..."

2. On 9/19/2024, a video footage review of the 5 South Behavioral Health Unit (dated 9/8/2024) from 7:00 PM until 11:00 PM was conducted with the IT Director (E #10). Pt. #1, Pt. #7, Pt. #8, Pt. #9, Pt. #10 and Pt. #11's rooms were viewed in the video footage review. The video footage noted that E #1 (Mental Health Technician) walked down the hall at 8:39 PM, 9:48 PM, 9:54 PM, 10:07 PM and 10:10 PM but E #1 did not look into any rooms for patient locations. E #1 was seen in the video footage walking in the hallway past each room. E #1 did not open any patient room doors to see if the patients were safe.

3. On 9/19/2024, the following clinical records were reviewed:
- Pt. #1 was admitted to the hospital on 09/07/2024 with a diagnosis of depression, suicidal ideation, and post-traumatic stress disorder. Pt. #1 was on every 15 minute monitoring for SP.
-Pt. #7 was admitted to the hospital on 8/26/2024 with a diagnosis of homicidal behavior. Pt. #7 was on every 15 minute monitoring for HP.
-Pt. #8 was admitted to the hospital on 9/2/2024 with a diagnosis of major depressive disorder. Pt. #8 was on every 15 minute monitoring for SP and AP.
-Pt. #9 was admitted to the hospital on 9/1/2024 with a diagnosis of bipolar disorder. Pt. #9 was on every 15 minute monitoring for SP and AP.
-Pt. #10 was admitted to the hospital on 9/3/2024 with a diagnosis of aggression. Pt. #10 was on every 15 minute monitoring for AP.
-Pt. #11 was admitted to the hospital on 9/4/2024 with a diagnosis of hallucinations and aggressive behavior. Pt. #11 was on every 15 minute monitoring for AP.

4. On 9/19/2024 at 1:00 PM, an interview was conducted with the Director of Quality (E #9). E #9 stated that rounding on each patient on the behavioral health unit should have occurred every 15 minutes. E #9 stated that the every 15 minute patient rounds are to locate and ensure each patient's safety.

Based on document review and interview it was determined that for 1 of 1 clinical record (Pt. #1) with an allegation of sexual abuse was reviewed, the Hospital failed to ensure patients were free from all forms of abuse by failing to follow the process for 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. The hospital's policy titled, "Response to Abuse and Neglect Allegations" (revised 01/2023), was reviewed and included, "All patients have the right to be free from all forms of abuse and neglect and protected if abuse and neglect is suspected to have occurred on hospital premises ... All staff are required to report immediately ... any received report of alleged abuse to their immediate supervisor ... complete an incident report ... After receiving an allegation of abuse ... an internal investigation is initiated ... with collaboration with other departments deemed as necessary ... b. review of patient's medical record ... c. Review of alleged employee ... d. interviews with other patients as appropriate ... other staff members from other department/location... Review of video surveillance ... Protection: ... The organization shall provide appropriate medical attention based on assessment of patient ..."

2. On 09/19/2024, the Hospital's policy regarding sexual abuse was requested, the Director of Quality (E #9 ) stated that the Hospital did not have a policy/procedure for sexual abuse.

3. On 09/18/2024, the clinical record of Pt. #1 was reviewed. Pt. #1 was a direct voluntary admission to the hospital on 09/07/2024 with a diagnosis of depression, suicidal ideation, and post-traumatic stress disorder. Pt. #1 was discharged to home on 09/13/2024. The clinical record included the following:

-Nursing Progress note (entered by Nurse Supervisor/E #4) dated 09/10/24 at 11:16 PM, included, "At 5:00 PM, CPD (Chicago Police Department) came to inquire about (Pt. #1). They said they received a call from next of kin of (Pt. #1) and alleges that (Pt. #1) got sexually assaulted last night (09/09/24) at (name of outside Hospital) ... after the CPD was told that (Pt. #1) has been admitted (this hospital) since 09/07/24, they decided to leave ..."

-Nursing Progress note (entered by Nurse Manager/E #3) dated 09/12/24 at 2:48 PM, "(Pt. #3) requested to speak to (E #3) ... (E #3) spoke to (Pt. #1) in private room ... (Pt. #1) told me wants a police report, (Pt. #1) was physically assaulted, (E #3) informed (Pt. #1) I needed to have a witness (E #8) here to discuss an alleged physical assault ... (Pt. #1) said it happened on 5-South, late in evening, guessed around 8:00 PM. (Pt. #1) described (Mental Health Technician-MHT/E #1), (E #3) asked when did this happen, (Pt. #1) stated Monday or Tuesday (09/09/24 or 09/10/24). (E #3) reminded (Pt. #1) that we (E #3 and Pt. #1) talked on Tuesday Morning (09/10/24) about a similar situation. (E #3) reviewed my (E #3) notes and reminded (Pt. #1) stated (Pt. #1) described a similar individual but stated (E #1) was verbally inappropriate but nothing physical. (Pt. #1) stated 'Well if that is what I said then that is what it was.' (Pt. #1) then said it happened after (E #3 and Pt #1) talked on Tuesday ... (Pt. #1) then began to change (Pt. #1's) mind and say can't remember if it was Monday or Tuesday ... Reinforced with (Pt. #1) that (Pt. #1's) safety is what is important and (E #3) is here to listen ..." The clinical record did not include documentation that (Pt. #1) was offered to file a police report, or that a physician was notified of the allegation of sexual abuse. There was no documentation that (Pt. #1) received a medical exam or was offered a sexual assault kit. The record did not include a note by E #3 from 9/10/2024 as referenced in this note from 9/12/2024.

4. The Incident Log (09/01/24 - 09/18/24) was reviewed, there was no incident report for (Pt. #1) listed in the log.

5. An interview was conducted with the Nurse Manager (E #3) on 09/18/24 at 1:40 PM. E #3 stated that (Pt. #1) asked to speak to (E #3) in the hallway on 9/10/24, (Pt. #1) stated that there was a male employee who made (Pt. #1) feel uncomfortable. (E #1) was saying inappropriate comments to (Pt. #1) such as (MHT/E #1) wanted (Pt. #1) to be (E #1's) girlfriend, that (E #1) loves and misses (Pt. #1), this allegedly happened on the prior night 9/9/24 at around 9pm. E #3 stated that based on the description that (Pt. #1) provided and the staff on the schedule, E #3 was able to conclude who the alleged staff was. E #3 contacted the staffing department to contact the agency to ask them to not have (E #1) return to the hospital. E #3 stated that E #3 did not provide a reason for not putting (E #1) back on schedule, E #3 did not file an incident report since (Pt. #1) stated that (E #1) was only being verbally inappropriate, and there was no physical or sexual contact. E #1 stated that E #1 reviewed the video footage alone for 09/09/24 from 7:00 PM to 11:30 PM, (E #1) did not enter (Pt #1's) room during this time. E #1 did not interview any staff or other patients. E #3 stated that on 09/12/24, (Pt. #1) asked to speak with E #3 again, to report that (Pt. #1) was physically assaulted, (this conversation was witnessed by a social worker/E #8). (Pt. #1) said that the assault happened on 5-South late in the evening, (Pt. #1) again described (E #1), stated it happened after (E #3 and Pt. #1) spoke on Tuesday. (E #3) reminded (Pt. #1) that (E #3 and Pt. #1) spoke about a similar situation and described the same person (E #1). (Pt. #1) said if that is what I said happened, then that's what it was. (Pt. #1) then said it happened after we talked on Tuesday. E #3 stated there was no further investigation conducted, there was no incident report filed. E #3 offered (Pt. #1) to file a police report, however (Pt. #1) said that (Pt. #1) did not want to get anyone in trouble.

6. An interview was conducted with the Social Worker (E #8) on 09/19/24 at 11:50 AM. E #8 stated that on one occasion, E #8 was asked to be present while (Pt. #1) gave details to (E #3/Nurse Manager) about an allegation of abuse. E #8 stated that (Pt. #1) reported that a male had sexually assaulted (Pt. #1). (Pt. #1) told (E #3) that the assault happened after (Pt. #1) initially reported to (E #3) that (E #1) had been making inappropriate comments to (Pt. #1) and (Pt. #1) was afraid something worse was going to happen. E #8 did not recall if (E #3) offered (Pt. #1) to file a police report or to be examined for sexual assault. E #8 stated that E #8 was not involved in the investigation of this incident and is not aware of outcome.

7. An interview was conducted with the Chief Nursing Officer (CNO/E #13) on 09/23/24 at 11:20 AM. E #13 stated that the hospital does not have a policy that is specific for allegations of sexual abuse. The hospital follows their SASETA (Sexual Assault Survivors Treatment Act) plan. If a patient at hospital has been sexually assualted they are sent down to the hospital's emergency department.