Saint Francis Medical Center

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 52206 Based on document review and staff interview, the Hospital failed to report allegations of abuse within 24 hours to the State Agency. Findings include: 1. During record review, 1 (pt #1) of 10 patients reviewed, filed a sexual assault allegation while hospitalized and a report was not filed with Illinois Department of Public Health (IDPH) within 24 hours. 2. Review of the Hospital’s Allegations of Abuse or Neglect While Patients are Receiving Care: Illinois policy (Effective 05/22/2025) states “Policy: ...9. Upon a designated Facility administrator receiving a report from any Facility administrator, agent, Mission Partner or medical staff member of the Facility stating their reasonable belief that any patient with whom such individual has had direct contact has been subjected to abuse in the Facility: a. Event is reported to Illinois Department of Public Health (IDPH) within 24 hours after the designated Facility administrator receives such report ...d. Under no circumstances may the organization’s internal review of an allegation of abuse or neglect replace the need for a report to IDPH, or an investigation of the allegation by federal or state authorities. 3. In an interview with the Regulatory Coordinator (E #1), E # 1 verbally confirmed that the facility did not file a report with the Illinois Department of Public Health. E #1 stated verbally that the hospital did not interpret the Illinois Administrative Code as requiring reporting if the internal investigation did not find the allegation to be founded.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50688 Based on document review, record review and interview, it was determined the Facility failed to ensure, for 1 of 2 (Pt #1) patients with violent restraints, that a face-to-face assessment of a patient within 1 hour of initiation of restraint for violent behavior was completed. Findings include: 1. The nursing note dated 3/2/2026 at 2:01 AM stated, “...Patient was redirected to being at the hospital to which the patient responded with ‘I (expletive) know.’ Security called to help deescalate. Patient still attempted to leave, yelling and pushing security. Security assisted patient back to bed...” 2. An order for “Restraint for Violent/Self-Destructive Behavior 18 yrs and Up” was placed on 3/2/2026 at 12:14 AM, stating, “...Events leading up to the need for restraint...Patient exhibiting violent or aggressive threats/behaviors...Type of Restraint...Physical Hold...” 3. The policy titled “Restraint and Seclusion Management: Illinois” states, “DEFINITIONS...3. Restraint for Violent and/or Self-Destructive Behavior: Safe and therapeutic restraint is used for the management of patients whose Violent or Self-Destructive Behavior jeopardizes the immediate physical safety of patients, staff, or others...POLICY...2. When a patient’s Violent or Self-Destructive Behavior jeopardizes the immediate physical safety of the patient, staff and others, use of Restraint or Seclusion for Violent and/or Self-Destructive Behavior may be warranted...PROCESS...2. Ensure face-to-face evaluation is performed within one hour of initiation of a restraint and/or seclusion for Violent and/or Self-Destructive Behavior.” 4. During an interview with the Risk Manager on 5/14/2026 at approximately 2:00 PM, the Risk Manager stated, “placing hands on a patient” to assist the patient back to bed is considered a physical hold, and noted that regardless of how short the hold is, it is considered a violent restraint and a face-to-face evaluation is to occur within one hour of initiation of the restraint. 5. During an interview with the Regulatory Coordinator on 5/14/2026 at approximately 2:35 PM, the Regulator Coordinator noted she was unable to locate documentation of a face-to-face evaluation being completed following the initiation of the physical hold on Pt #1.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 50688 Based on document review, record review and interview, it was determined the Facility failed to ensure, for 1 of 2 (Pt #1) patients with violent restraints, that a 1-hour face-to-face medical and behavioral evaluation was documented in the patient medical record. Findings include: 1. The nursing note dated 3/2/2026 at 2:01 AM stated, “...Patient was redirected to being at the hospital to which the patient responded with ‘I (expletive) know.’ Security called to help deescalate. Patient still attempted to leave, yelling and pushing security. Security assisted patient back to bed...” 2. An order for “Restraint for Violent/Self-Destructive Behavior 18 yrs and Up” was placed on 3/2/2026 at 12:14 AM, stating, “...Events leading up to the need for restraint...Patient exhibiting violent or aggressive threats/behaviors...Type of Restraint...Physical Hold...” No documentation of a 1 hour face-to-face was noted. 3. The policy titled “Restraint and Seclusion Management: Illinois” states, “ PROCESS...2. Ensure face-to-face evaluation is performed within one hour of initiation of a restraint and/or seclusion for Violent and/or Self-Destructive Behavior.” 4. During an interview with the Risk Manager on 5/14/2026 at approximately 2:00 PM, the Risk Manager stated, “placing hands on a patient” to assist the patient back to bed is considered a physical hold, and noted that regardless of how short the hold is, it is considered a violent restraint and a face-to-face evaluation is to occur within one hour of initiation of the restraint. 5. During an interview with the Regulatory Coordinator on 5/14/2026 at approximately 2:35 PM, the Regulator Coordinator noted she was unable to locate documentation of a face-to-face evaluation being completed following the initiation of the physical hold on Pt #1.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50688 Based on record review and interview, it was determined that for 1 of 10 patients (Pt #1), the Hospital failed to ensure patient privacy by allowing visitors in the patient room during a procedure without patient consent. Findings include: 1. A transthoracic echocardiogram was completed at Pt #1’s bedside, in Pt #1’s hospital room, which was shared with another patient, on 10/1/2025. 2. During an interview on 12/12/2025 at approximately 10:45 AM with the Cardiac Sonographer, (E #3), E #3 noted visitors for the other patient were in the room at the time of Pt #1’s procedure, stating, “Their conversation was very colorful.” E #3 noted the roommate patient stating “I haven’t had a man in a long time. I need a man.” E #3 stated “the daughter told the roommate she needed to be quieter, telling her “You can’t say that.” E #3 stated the roommate then said to the elderly male “You haven’t been with a woman in a long time. You need to find a woman.” E #3 noted Pt #1’s eyes getting wide and stating Pt #1’s eyes were “very expressive, like I can’t believe they’re saying that.” E #3 additionally stated “There was awkward conversation happening.” During a subsequent interview with E #3 on 12/12/2025 at approximately 3:50 PM, E #3 noted she did not ask the visitors to leave the room for the procedure, stating “We just never do. It’s pretty customary to just continue the test.” E #3 further stated “I never had any interaction (with the visitors). I pulled the curtain closed and kept my patient separate.” 3. During an interview with E #1 on 12/12/2025 at approximately 1:30 PM, E #1 noted the Hospital does not have a specific policy for bedside procedures. E #1 further stated “We follow HIPAA as much as we can, and try to provide as much privacy as we can. We don’t have a policy that says we have to have other people leave.””