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Based on document review and staff interview, it was determined that for 2 (Pt. #s 1 and 11) of 12 patients reviewed for patient's rights, the Hospital failed to ensure that patient care was provided in a setting that was safe and free of abuse. As a result, the Condition of Participation for Patient Rights 42 CFR 482.13, was not met.

Findings include:

1. The Hospital failed to ensure an effective process to address sexual acting out behaviors of patients was in place to ensure care is provided in a safe setting. See deficiency cited at A 144.

2. The Hospital failed to ensure that appropriate measures were taken to protect patients from abuse. See deficiency cited at A 145.

The immediate jeopardy (IJ) began on 8/16/15 with the sexual assault of Pt. #1 by Pt. #2. Pt. # 2 was on restraints for about an hour after the incident, however, Pt. #2 remained on the same unit as Pt. #1 until the following day when Pt. #2 was ordered 1:1 observation and transfer to a different unit. A similar case was also reviewed regarding the sexual assault of Pt. #11 by Pt. #12. During the course of the document review for Pt. #s 11 and 12, Pt. #12 remained in the same unit as Pt. #11 and with orders to be monitored for frequent observation (FO) for sexually acting out behavior (SAO). The Hospital did not have an effective process to address sexual acting out behaviors of patient nor a policy on sexual assault of a patient by a patient. This exposed both Pt #s 1 and 11 to abuse and care in an unsafe setting.

The Medical Director, Director of the Department of Psychology, and the representative for DHS(Department of Human Services)/ DMH (Department of Mental Health) Central Office were notified of the Immediate Jeopardy Hospital was notified of the IJ on 2/16/16 at 4:55 PM. The IJ was not removed at the time of exit.

Based on document review and interview it was determined that for 2 ( Pt #1 and #3) of 3 clinical records reviewed for psychotropic medications, the Hospital failed to ensure an informed consent was obtained as required per policy.

Finding include:

1. Policy entitled "Administration of Psychotropic Medication (Revised 8/3/10) indicated "... 'Informed Consent.' The voluntary and knowing choice by an individual or his or her legal guardian. 'Psychotropic Medication.' Medication used for anti-psychotic, anti-depressant, anti-manic, anti-anxiety, behavior modification or behavioral management purposes... II. Informed Consent Prior to prescribing psychotropic medications in non-emergency situations, the treating physician shall ascertain and document whether the individual is capable of giving informed consent. 3. If an individual is unable to make reasoned decisions regarding treatment alternatives, including psychotropic medication...the treating physician ...shall consider obtaining a guardian of the person for the purposes of consenting to psychotropic medication. 4 Informed written consent shall be obtained from the individual.

2. Policy entitled "Medication Counseling - Informed Consent" (Revised 7/20/13) indicated "Prior to prescribing psychotropic medication, a legally competent patient shall be informed in a language appropriate for the individual...and written consent shall be obtained on the Medication Counseling- Consent to Medication Form (DHS Form IL462-0012MA). This form must be completed for every psychotropic medication being recommended to the patient (whether or not an order for that medication is ultimately written)...A signed consent is valid for up to one calendar year...A new consent is required if the physician plan for initiation of any new psychotropic medication not listed on the consent form."

3. Pt #3 was a 57 year old female admitted to the extended care unit (A-South) on 1/26/12 with a diagnosis of schizophrenia. Pt #3's clinical record, reviewed on 02/09/16 contained 2 renewals for a physician's order dated 1/8/16 and 2/4/16 for diazepam (antianxiety medication) 5 milligrams orally twice a day as needed for anxiety. The Medication Administration Record (MAR) was reviewed from 12/2015 to 2/9/2016. The diazepam was administered on several dates.

-12/16/15 at 11:15 PM
-12/19/15 at 10:00 PM
-1/13/16 at 10:50 PM
-1/24/16 at 10:45 PM
-2/3/16 at 11:15 PM

-The form "Consent to Medication (IL462-0012MA)" obtained on 11/27/13 (valid until 11/26/14), and 3/3/15 (valid until 3/2/16) failed to include diazepam. The clinical record lacked a consent for medications from 11/26/14-3/3/15 (approximately 4 months).

4. On 2/9/16 at approximately 11:00 AM the findings were discussed with the Clinical Manager of A-South (E #1). E #1 stated Pt #2 clinical record failed to include a consent for diazepam.
5. On 2/10/16 at approximately 10:00 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 27 year old female admitted on 6/19/15 with a diagnosis of bipolar disorder and history of post partum depression. Patient was given clonazepam (antianxiety) on 9/14/15; however, the psychotropic medication consent form did not include clonazepam. The Hospital failed to obtain a consent from patient to take clonazepam.

6. An interview was conducted on 2/11/16 at approximately 12:44 PM with the Director of the Department of Psychology who stated that there should be a psychotropic drug consent obtained for clonazepam.

Based on document review and interview, it was determined that for 2 (Pt. #s 1 and 11) of 12 patients reviewed for patient rights, the Hospital failed to ensure an effective process in addressing sexual acting out behaviors of patients was in place to ensure care is provided in a safe setting.

Findings include:

1. The Policy on Sexual Abuse of patient by patient was requested from E #6. E #6 provided "Prevention of Abuse and/or Neglect of Individuals," (revised 12/30/10) required "Policy Statement... it is the policy of DHS... to ensure a safe and secure environment for individuals served." This policy referred to the abuse of a patient by staff.

2. Pt. #1 was a 27 year old female admitted on 6/19/15 with a diagnosis of bipolar disorder and history of postpartum depression. On 8/6/15 at 4:40 PM, Pt. #1 alleged that while sleeping in her room, Pt. #2 touched her buttocks. Pt. #2 escaped the hospital on the day of the incident and was brought back to the hospital by security at approximately 5:00 PM, and placed in restraint as well as 1:1 observation for less than an hour. However, after Pt. #2 was released from restraints, Pt. #1 remained on the same unit as Pt. #2 until the following day (8/7/15) when Pt. #2 received orders for 1:1 observation and transfer to another unit (A North).

3. Pt. #11 was a 37 year old female admitted on 1/1/16 with a diagnosis of bipolar disorder. On 1/7/16 at around noon time, Pt. #11 was reportedly touched by a male patient's (Pt. #12) erect sexual organ in the back, while waiting in line for a meal. Pt. #12 was placed on frequent observation (FO) and sexually acting out (SAO) precaution. Pt. #11 was discharged on 1/7/16 at approximately 4:40 PM as Pt. #11 requested to go home. Pt. #12 remained on the same unit as Pt. #11 until Pt. #11 was discharged.

4. Policy ID PC-03-30-45.00 titled, "Special Observation" (revised 4/17/13) required, "Policy/Purpose: A safe and therapeutic environment is maintained by providing a level of observation for each individual that is appropriate to the individual's clinical needs...Definitions... Frequent observation. The level of special observation where individuals are observed and monitored by staff every 15 minutes... One to One (1:1) observation. A level of special observation where one staff person will be assigned to continuously observe and monitor one individual. The staff person will remain just outside of the individual's arm's length while the individual is awake and the staff person will be in visual line of sight of the individual while the individual is asleep at a distance not to exceed 12 feet or beyond the doorway to the room..."

5. On 2/11/16 at approximately 4:00 PM, an interview with E #6 was conducted. E #6 stated that there is no specific policy on sexual abuse to patient by another patient. Another interview was conducted with E #6 on 2/16/16 who stated that the Hospital does not have a specific policy defining elopement precaution and sexually acting out behavior precaution.

6. On 2/16/16 at approximately 12:50 PM, an interview was conducted with the Clinical Manager of C North who stated that in cases of sexual assault of a patient by another patient, "We inform the medical doctor, psychiatrist, the psychologist, as well as the charge nurse of the incident. The psychiatrist has to make the decision if the aggressor needs to be transferred to another unit."

7. On 2/16/16 at approximately 1:30 PM, an interview was conducted with MD #2 who stated that the whole treatment team (medical director, psychiatrist, supervisor, charge nurse, etc.) are involved in making a decision on what to do with both the victim and the aggressor. Regarding Pt. #11's discharge, MD #2 stated that Pt. #11 wanted to go home according to his recollection.

Based on document review and interview, it was determined for 1 (Pt. #1) of 12 patients reviewed for patient rights, the Hospital failed to ensure that appropriate measures were taken to protect patients from abuse.

Findings include:

1. Policy on Sexual Abuse of patient by patient was requested from E #6. E #6 provided "Prevention of Abuse and/or Neglect of Individuals," (revised 12/30/10) required "Policy Statement... it is the policy of DHS to protect those individuals from abuse and/or neglect, and to ensure a safe and secure environment for individuals served." This policy referred to the abuse of a patient by staff.


2. Pt. #1 was a 27 year old female admitted on 6/19/15 with a diagnosis of bipolar disorder and history of postpartum depression. On 8/6/15 at 4:40 PM, Pt. #1 alleged that while sleeping in her room, another male patient (Pt. #2) touched her on her buttocks.

3. Pt. #2's nursing note dated 8/6/15 timed 1:15 PM indicated, "... patient observed on unit... Pt. #2 is focusing on female patient making special comment about sex to Pt. #1 stating wait until evening I am going to join you in your room. Will contact his social worker and doctor to be aware... will continue to observe Pt. #2 for safety." An order was noted on 8/6/15 at 3:10 PM to monitor patient on frequent observation (FO) for sexually acting out (SAO) behavior. Pt. #2 was still able to sexually assault Pt. #1.

4. Policy ID PC-03-30-45.00 titled, "Special Observation" (revised 4/17/13) required, "Policy/Purpose: A safe and therapeutic environment is maintained by providing a level of observation for each individual that is appropriate to the individual's clinical needs...Definitions... Frequent observation. The level of special observation where individuals are observed and monitored by staff every 15 minutes... One to One (1:1) observation. A level of special observation where one staff person will be assigned to continuously observe and monitor one individual. The staff person will remain just outside of the individual's arm's length while the individual is awake and the staff person will be in visual line of sight of the individual while the individual is asleep at a distance not to exceed 12 feet or beyond the doorway to the room..."

5. On 2/11/16 at approximately 4:00 PM, an interview with E #6 was conducted. E #6 stated that there is no specific policy on sexual abuse of a patient by a patient.

6. On 2/16/16 at approximately 9:00 AM, another interview was conducted with E #6 who stated that the Hospital does not have a specific policy defining elopement precaution and sexually acting out behavior precaution.

7. On 2/16/16 at approximately 1:30 PM, an interview was conducted with MD #2 who stated that the whole treatment team (medical director, psychiatrist, supervisor, charge nurse, etc.) are involved in making a decision on what to do with both the victim and the aggressor.

Based on document review, observation and interview it was determined that for 1 of 1 (E #2) staff observed performing blood glucose, the Hospital failed to ensure staff adherence to hand hygiene policy. This potentially affected 2 patients who were receiving blood glucose monitoring.

Finding include:

1. Policy entitled "Hand Washing Technique" (Revised 6/13/13) indicated "Staff shall wash hands with soap and running water: 3. Before and after donning gloved... 2. After direct patient contact...6. After working with chemical of any type...Procedure 7. Alcohol-based hand rub may be used unless hands are visibly soiled and when soap and water is not readily available."

2. Policy entitled "Hand Hygiene Policy" (Revised 5/5/14) required "Indications on when to wash hands with soap and warm running water or to use alcohol based hand sanitizer: 2. Before and after direct patient contact...3. Before and after donning gloves... 6. After working with chemicals of any type. Use of gloves: Gloves are not a substitute for hand hygiene. Healthcare workers must use gloves properly: 3. Change or remove gloves if moving from contaminated to clean patient sites or the environment."

3. On 2/10/16 at approximately 11:30 AM the Registered Nurse (E #2) performed a finger-stick blood glucose test on a patient. E #2 removed her gloves and walked to the Medication Room and disposed of the lancet in the sharps container. E #2 then donned gloves, returned to the treatment area, and disinfected the glucometer and wrapped it with a disinfectant wipe. No hand hygiene was done. E#2 removed her gloves and documented in the patient Medication Administration Record (MAR). No hand hygiene was done after glove removal.

E #2 donned a new pair of gloves to disinfect the glucometer for the second time. E #2 entered the required information in the glucometer for Pt #5. E #2 obtained a blood sample from Pt #5 and performed the blood glucose test. E #2 then disinfected the machine and removed her gloves.

4. On 2/10/16 at approximately 2:00 PM, the Infection Control Manager was interviewed who stated that hand hygiene should be performed between glove changes and gloves should be changed between cleaning the machine and when performing a test on another patient.