Methodist Hospital of Chicago

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 36774 Based on observation, document review, and interview, for one of one OR/Operating Room (Room #4) observed, the hospital failed to ensure that medications in the OR were kept secured, as required by policy. Findings include: 1. On 10/31/2025 between 10:30 AM through 12:00 PM, observational tour of the hospital’s OR/Operating Room, was conducted. At approximately 12:00 PM, inside OR Room 4 was an unlocked anesthesia cart. The cart had three vials of unopened fentanyl injection (sedating agent). 2. On 10/31/2025, the hospital’s OR policy titled, “Medications in the OR” (8/2025) was reviewed and indicated, “... I. Policy: Ensure that the safe medication practices are followed within the intra-operative setting... IV. security of Medications. 1. All medications should be secured... 2. Anesthesia cart should be locked...” 3. On 10/31/2025 at approximately 12:00 PM, findings were discussed with E #2 (OR RN). E #2 stated that OR Room can be accessed by staff who are not allowed to handle medications. E #2 stated that the anesthesia cart should be locked at all times. E #2 stated that the anesthesiologist prepared the medication, and should have locked the cart.”

“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: 40079 Based on document review, video surveillance review, and interview, for 1 of 2 (Pt. #1) patients with an allegation of abuse, the hospital failed to follow the process for conducting a thorough investigation and protecting patients for an allegation of abuse per hospital policy. Findings include: 1. On 06/13/25, the hospital’s policy titled, “ Response to Abuse and Neglect Allegations “ (revised 01/2023) was reviewed and required, “All patients have the right to be free from all forms of abuse ... and protected if abuse and neglect is alleged or suspected ... All staff are required to report immediately ... suspected abuse ... or any received report of alleged abuse to their immediate supervisor ... complete an incident report ... an internal investigation is initiated ... interview with other patients as appropriate ... interviews with staff members ...Investigation: After receiving an allegation of abuse or neglect occurring in the hospital premises, an internal investigation is initiated by the Chief Nursing Officer and/or ... Nursing Supervisor after business hours with the collaboration with other departments deemed as necessary ... ensures, in a timely and thorough manner, objective investigation of all allegations of abuse ... B) Investigation process include but not limited to ... d. Investigation of all other possible sources of information relating to the incident and/or persona involved ... Investigation: After receiving an allegation of abuse or neglect occurring in the hospital premises, an internal investigation is initiated by the Chief Nursing Officer and/or ... Nursing Supervisor after business hours with the collaboration with other departments deemed as necessary ... ensures, in a timely and thorough manner, objective investigation of all allegations of abuse ... Protection: Any person alleged to have committed abuse ...will be removed from patient care until a preliminary investigation is completed. The organization shall provide appropriate medical attention based on assessment of patient...” 2. The clinical record of Pt.#1 was reviewed on 06/13/25. Pt.#1 was admitted to the Adult Behavioral Health Unit (5-S) on 02/19/25 at 11:30 PM through 03/06/25 at 1:45 PM. The clinical record included the following: -Nurse Note (by E#6/RN assigned to Pt.#1) dated 02/25/25 at 5:55 PM, “(Pt.#1) approached this writer and stated, ‘They attacked me, and I feel unsafe.’ When asked who attacked (Pt.#1), again stated ‘They.’ When (E#6) asked this question, only staff were around. This writer asked if (Pt.#1) would like to go and speak somewhere privately, (Pt.#1) stated no ... was offered grievance form and stated, ‘I just don’t feel safe and can I please be transferred to a different unit?’ Patient assessed and no apparent injuries observed ... report given to nurse on (transferring unit) and (Pt.#1) was accompanied to other unit by female CNA (certified nurse aid) and unit security officer ... Supervisor (E#16) and (MD#1/Internal Medicine Physician on-call) notified via phone, currently no new orders from (MD#1).” -Internal Medicine Progress Note (E#14) dated 02/26/25 at 11:13 AM, “(Pt.#1) seen awake and alert, interactive in the day room, (Pt.#1) has a bruise on rt (right) cheek bone, denies pain, (Pt.#1) unable to provide information on how (Pt.#1) sustained that injury ... Apply ice and Tylenol for pain ...” The Internal Medicine Progress Notes prior to 02/26/25, did not indicate that there was a bruise on (Pt.#1’s) right cheek bone. 3. On 6/13/2025, the hospital’s incident investigation/follow-up report (dated 2/26/2025) was reviewed and noted, “Pt. #1’s reported complaint or incident - On 2/25/2025 at approximately 5:55 PM, Pt. #1 told RN (E#6) that [They attacked me, and I (Pt. #1) feel unsafe.] When asked who attacked Pt. #1, Pt. #1 again stated, [They.] Summary/Conclusion: Based on my (Nursing Supervisors E#2/E#15) investigation, I concluded that the reported incident is unfounded. This determination was made based on patient and staff interviews, incident investigation, video surveillance and medical record review. The incident report and investigation summary did not indicate that after review of the surveillance video conducted by the nursing supervisors (E#2 and E#16) conducted follow up interviews and further investigation as to reason why two staff (E#8 and E#13) entered (Pt.#1’s) room and closed the door for a prolonged period. The investigation summary did not indicate that staff were taken off the schedule pending the investigation. 4. On 6/13/2025, the hospital’s video footage was reviewed along with the Nursing Supervisors (E#2 and E#15) (dated 2/25/2025 from 5:00 PM to 5:30 PM). The following was noted: -5:10:52 PM - Pt. #1 was seen entering Pt. #1’s room with door open. -5:12:52 PM - E #13 (Agency Mental Health Counselor/MHC) enters Pt. #1’s room and closes door. E #13 remains in Pt. #1’s room with the door closed until 5:19:54 (7 minutes). -5:13:44 PM - E #8 (MHC) enters Pt. #1’s room at 5:13:44 and closes Pt. #1’s door. E #8 comes out of Pt. #1’s room at 5:14:08, closes Pt. #1’s door and stands outside Pt. #1’s room (with door closed - E #13 remains in room). E #8 goes back into Pt. #1 room at 5:14:35, closes the door and does not come out until 5:19:44 (5 minutes and 9 seconds). -5:19:54 - E #13 comes out of Pt. #1’s room. -5:30:44 - Pt. #1 observed ambulating in the hallway with Pt. #1’s head lowered with both hands holding Pt. #1’s face. Pt. #1 goes back into Pt. #1’s room with door open. The video surveillance shows that E#8 and E#13 were in the patients room with the door closed for a prolonged time. 5. On 06/13/25 at 10:30 AM and at 1:45 PM interviews were conducted with a Mental Health Counselor (E#8/MHC). E#8 stated that patient room doors should be kept open for safety of staff and the patient. E#8 stated that they do not recall why E#8, and another staff would be in (Pt.#1’s) room on 02/25/25 at approximately 5PM with the door closed for about 7 minutes. 6. On 6/13/25 at 10:45 AM, an interview was conducted with the Expressive Therapist (E#9). E#9 stated that E#9 met with (Pt.#1) during their hospitalization and noticed a small bruise around the cheekbone. E #9 stated Pt. #1 didn’t have a black eye. E #9 stated that they did not report because patient would not elaborate when asked how Pt. #1 got the bruise. 7. Interviews were conducted with two nursing supervisors (E#2 and E#15) on 06/14/25 at approximately 9:50 AM. E#2 and E#15 confirmed that they conducted a video review to investigate the allegation of (Pt.#1) being attacked. E#2 and E#15 stated that they did not question the staff (E#8 and E#13) for reason they entered (Pt.#1’s) room with the door closed for prolonged time. E#2 stated that the normal procedure for rounding is to visualize the patient to ensure safety. E#2 and E#15 stated that it was not appropriate to close the door to a patient’s room unless they are providing care that required privacy, however the clinical record did not include any documentation that (E#8 and E#13) provided care to (Pt.#1) during this time. E#15 stated that they were notified by (E#6) on 02/25/25 of the incident, E#15 spoke with (E#6) on the phone and instructed to move (Pt.#1) to another unit. E#15 did not come to the unit to speak with (Pt.#1) or to assess the situation. During the investigation the staff E #8 and E #13 were not removed from patient care pending the results of the investigation as indicated in their abuse policy.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 3 of 4 patients’ (Pt.#2, Pt. #9, and Pt. #10) clinical records reviewed for suicide risk assessment and reassessments, the hospital failed to ensure that staff completed the suicide risk re-assessments for behavioral health patients as required. Findings include: 1. The hospital’s policy titled, “Suicide Risk Assessment” (revised 03/2022) was reviewed and required, “It is the policy (name of hospital) and the Adult Mental Health Unit to assess each patient every shift for suicidal ideation or thoughts. Each RN (Registered Nurse) is to assess the patient every shift and document that as a part of their nursing reassessment ... Early awareness and assessment of suicidal intent is a major aspect of preventing its occurrence.” 2. The clinical record for Pt. #2 was reviewed on 10/22/24. The intake report dated 8/15/2024 indicated that Pt.#2 was transferred from another hospital on 8/15/2024 for paranoia and delusion (believes someone is trying to harm [Pt.#2]). The patient has a history of bipolar disorder. The clinical record lacked documentation that a suicide risk reassessment was completed for the day and evening shifts on 08/16/24 through 08/20/24. 3. The clinical record for Pt. #9 was reviewed on 10/23/24. Pt. #9 was admitted to 5-South (Adult Behavioral Health Unit) on 10/21/24 with a diagnosis of aggressive behavior. The clinical record lacked documentation that a suicide risk assessment was completed for the day and evening shifts on 10/22/24 and 10/23/24. 4. The clinical record for Pt. #10 was reviewed on 10/23/24. Pt. #10 was admitted to 5-South on 10/05/24 with a diagnosis of schizophrenia (mental disorder affecting the ability to think and behave clearly). The clinical record lacked documentation that a suicide risk reassessment was completed by the nurse for the following dates: 10/06/24, 10/08/24, and 10/22/24. 5. An interview was conducted with the Chief Nursing Officer (CNO/E #1) on 10/23/24 at approximately 1:15 PM. E #1 stated that suicide risk assessment and re-assessments should be conducted on all patients every shift by the nurse and document the assessment in the clinical record. E #1 confirmed that for (Pt.#2, Pt.#9, and Pt.#10) the suicide risk re-assessments were not documented in their clinical records.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 40079 A. Based on document review, observation, and interview, it was determined that for 1 of 1 operating room (OR) cleaning and disinfection observed in (OR #1), the hospital failed to ensure that the operating room was maintained clean and disinfected as required by policies governing surgical care. Findings include: 1. The hospital’s policy titled, “Environmental Cleaning” (revised 01/2023) was reviewed and required, “A. Effective housekeeping will be established and maintained to reduce and control the possibility of cross-contamination and infection of the patient and assigned employees ...” 2. The hospital’s policy titled, “Aseptic Technique in the O.R. (Operating Room)” (revised 05/2022) was reviewed and required, “I. Policy: Basic principles of asepsis and aseptic technique shall be strictly adhered to in creating and maintaining a sterile field for every surgical procedure ... ensure and provide a safe environment for the surgical patient by controlling sources of contamination that may cause surgical site infections.” 3. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of cleaning and disinfection of the OR #1 after a procedure and during set up of the OR the following was observed: -At 11:52 AM to 12:00 PM, E #6 (Enviromental Staff/EVS) was observed disinfecting equipment including an IV (intravenous pole), E #6 wiped the bottom of the pole, then wiped the top of the pole. E #6 then walked over to the garbage receptacle, lifted the lid with gloved hands instead of using the foot pedal to discard garbage then continued to move two mayo stands (small surgical tables) that had already been disinfected without performing hand hygiene. E #6 then started to mop the floor, E #6 was observed picking up something from the floor and discarded the item into the garbage receptacle, and again moved the two mayo stands without performing hand hygiene. There was also a brown leather purse on the bottom shelf of a table that was near the entrance of the OR, this item remained in the OR during and after the disinfection of the OR and when the next patient was brought into OR #1 at 12:15 PM. Additionally there was no visible alcohol based rub for staff to perform hand hygiene. 4. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:15 PM. E #4 stated that during the cleaning and disinfection of the OR after a procedure, staff are required to perform hand hygiene and don new gloves prior to touching equipment that has already been disinfected. E #4 was asked where the alcohol based rub was located in OR #1. E #4 stated that E #4 puts the alcohol based rub under a cabinet. E #4 stated that personal items such as bags or purses are not allowed in the OR. E #4 confirmed that the brown purse belonged to the surgeon. B. Based on document review, observation, and interview, it was determined that for 2 of 5 staff (Surgical Assistant E#2 and Anesthesiologist/MD #2) the hospital failed to ensure that the policy regarding surgical attire was not followed by not ensuring hair was completely covered by a head covering in the operating room. Findings include: 1. The hospital’s policy titled, “Surgical Attire” (revised 09/2022) was reviewed and required, “III. Guidelines: 1. Persons who enter the semi-restricted and restricted areas of the OR will wear appropriate OR scrub attire ... 7. All persons entering restricted areas of the surgery department ... Head covers/surgical hats must cover all exposed head and facial hair ... 12. Universal precautions will be adhered to all times in the OR.” 2. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of a set up of OR #1 the following was observed: -At 12:00 PM to 12:15 PM, during the set up of OR #1, an OR Technician (E #5) and the Surgical Assistant (E #3) started to prepare the sterile field to set up surgical equipment and supplies. E #3 was assisting E #5 in opening sterile packages and dropping onto the sterile field, E #3 had arm hair exposed during this time. An Anesthesiologist (MD #2) entered the room during this time and had approximately 3-4 inches of hair exposed at the neck. 3. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:18 PM. E #4 stated that staff are required to have all hair covered, including facial and arm hair when entering the semi-restricted and restricted areas. C. Based on document review, observation, and interview, it was determined that for 1 of 1 Anesthesiologist (MD #2) observed for medication preparation, the hospital failed to ensure that staff adhered to the hospital’s policy governing surgical care. Findings include: 1. The hospital’s policy title, “Medication in the O.R. (Operating Room)” (revised 09/2022) was reviewed and required, “I. Policy: Ensure that the safe medication practices are followed within the intra-operative setting. 6. All medications containers (syringes, medications cups, basins) and other solutions on and off the sterile field must be labeled even if there is only one medication involved ... need to occur when medications have been removed from the original packaging ... 7. Discard any solution or medication found in the OR without an identification label in the biohazardous sharps container ...” 2. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of a set up of OR #1 the following was observed: -At 12:13 PM, the Anesthesiologist (MD #2) was observed by the anesthesia cart preparing a medication from a new vial that was taken out of the locked medication drawer. MD #2, did not label the syringe after the preparation of the syringe. MD #2 set the syringe on top of the cart and left the room for approximately 5 minutes leaving the unlabeled syringe unattended on top of the cart. 3. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:15 PM. E #4 stated that after a medication is prepared, the medication should be labeled and not left unattended.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32741 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).”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 32741 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.”

“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: 40079 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.”