Carle Health Methodist Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50645 Based on document review, video review, and interview, it was determined that the Hospital failed to comply with Condition for Coverage 42 CRF 482.13, Patient Rights. Findings include: 1. The Hospital failed to effectively monitor behavioral health patients by conducting safety rounds every 15 minutes per facility policy, resulting in the sexual assault of Pt #6 by Pt #5. (A-144) The Immediate Jeopardy (IJ) began on 12/10/24 due to the facility’s failure to effectively monitor behavioral health patients by conducting safety rounds every 15 minutes per facility policy, resulting in the sexual assault of Pt #6 by Pt #5. The IJ was identified on 1/27/25 under 42 CFR 482.13, Patient Rights. The IJ was announced on 1/27/25 at 4:30 PM during a meeting with VP Quality, Chief Nursing Officer, Nursing Director Emergency Department, Chief Quality Officer, Chief of Hospital Operations, and Director of Quality and was not removed by the survey exit date of 1/27/25”

“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: 50645 Based on observation, document review and interview, it was determined that the facility failed to monitor behavioral health patients by conducting safety rounds every 15 minutes per facility policy for two of two patients (Pt #5 and Pt #6) in a sample of 10, resulting in the sexual assault of Pt #6 by Pt #5. Findings include: 1. Policy BH-40 Management of Sexual Misconduct and Aggression (approved 10/8/2024) was reviewed on 1/22/2025 at 3PM and it states: “PROCEDURE A. All patients are assessed upon admission for recent or past history of sexual misconduct or sexual aggression. The following information is collected, but not limited to: 1. Previous history of sexual acting out behaviors ...3. Preoccupation with sexual matters. 4. Current seductive behaviors and inappropriate undressing ...B. Patients assessed (as above) to have a history of or current behavior indication actual or potential sexual misconduct is placed on “Sexual Inappropriate Behavior Precautions (SIBP) ...C. “Sexual Inappropriate Behavior Precautions” status will be entered in the plan of care and in the EMR (Electronic Medical Record). D. Interventions may include, but not limited to: 1.Private room 2.Bedside sitter for additional monitoring 3. Individualized programming...” 2. Policy BB-14 Suicide Prevention (approved 10/4/2024) was reviewed on 1/22/2025. The policy states, “ ...2. Ligature Resistant Settings (Behavioral Health Inpatient) Risk Mitigation Plan. General considerations for Ligature Resistant Settings: ...c. Safety Rounds are completed approximately every 15 minutes at a minimum of 4 times an hour. The level of precautions are indicated on the behavioral health precautions flow sheet or electronic device ...” 3. Review of Pt#6’s medical record revealed that Pt #6 presented to the Hospital’s Emergency Department (ED) on 12/10/24 via ambulance at 9:01 AM. The Patient Care Timeline included, “Stated Reason for Visit: EMS (Emergency Medical Services) sts (states) pt (patient) took 8 effexor (medication used to treat adults with anxiety and depression) 75mg (milligrams) between 1430 (2:30 PM)- 1500 (3:00 PM) yesterday. Sts took to make feel better and harm self ...Suicide Risk-Initial: High Risk.” -Suicide Precaution Orders on Pt #6’s record noted, “High/Moderate Risk Ligature Resistant Environment (Inpatient Mental Health/ED Psych area) *Safety Rounding *Scrubs without strings or cords *Remove all personal items *Consider Safety meal trays *Reassess risk level every shift ...” -Staff Progress Note dated 12/10/24 at 4:08 PM written by E #3 stated, “This RN (Registered Nurse) was made aware at this time that this (Pt #6-minor female) was in a room with (Pt #5-adult male) ... The other patient (Pt #5) and this patient (Pt #6) exited the room the male (Pt #5) walked directly to his room BH2, where this patient (Pt #6) walked to the desk of BH ... I immediately called my Charge nurse... I was directed by my manager (E #1) to ask the patient if (Pt #6) wants to press charges and notify PD (Police Department) if so. It was also agreed to notify legal guardian of the patient as well ...I asked if (Pt #6) wanted to press charges and (Pt #6) said yes ...After the discussion I ...called (Police Department), then I called the legal guardian to notify him of the incident ...” - ED Provider Note dated 12/10/24 at 4:13 PM written by Medical Doctor (MD- E #4) stated, “1604 (4:04 PM) Patient was seen and evaluated by SASS (Screening Assessment Support Services) ...1650 (4:50 PM) Patient was awaiting transfer to (Mental Health Facility) I was informed by the ED staff at some point while waiting here in the Emergency behavioral health unit another patient from a room entered the patient’s room. That is some point while the two were in the room together they were eventually noted to be engaging in oral sex. The patient was delivered in {sic} the oral sex to the other patient. When this was discovered, the patients were separated. The patient wishes to file charges against the other patient stating that this was a nonconsensual encounter. I went with one of the ED managers and the charge nurse and the patient wishes to have an evidence kit per the patient’s wishes.” -Pt #6’s record indicated on 12/10/25 at 5:24 PM SANE (Sexual Assault Nurse Examiner) was contacted and Pt #6 was evaluated and treated per Sexual Assault policy. Police contacted and was at bedside. -Pt #6 was discharged from Hospital on 12/11/24 at 7:52 AM to a Mental Health Facility. -The Patient Safety Companion Frequent Observation Flowsheet-ED dated 12/10/24 that started at 1:03 PM for Pt #6 was reviewed. No staff signature is noted during the following times to indicate the observational checks were completed by hospital staff for Pt #6: 1:30 PM, 1:45 PM, and 4:00 PM. 4. The medical record of Pt#5 was reviewed during the entire survey. Pt#5 was an adult male patient that presented to the Emergency Department on 12/10/24 at 09:47 AM for a psychiatric evaluation. A panel of laboratory work was ordered, and Pt#5 was cleared medically for a psychiatric evaluation. Pt#5 was admitted to the Behavioral Health (BH) Unit in the ER, room 2 (two). ED Provider Note written by Advanced Practice Registered Nurse (E#5) and dated 12/10/24 at 9:59 AM stated, “MENTAL HEALTH ADMISSION: This patient is a danger to themselves and/or others ...” -Progress Note written by Registered Nurse (E#6) and dated 12/10/24 at 10:12 AM stated, “Presenting Concerns ...-pt attempting sexual acts with (family). Has been turning off all the home lights and laughing ...Recently diagnosed with depression, take fluoxetine.” Past family history of schizophrenia ...COLLATERAL RESPONSE: (Family) ...reports (sibling) stated “(Pt #5) pulled (Pt #5) di*k out. Reports (family) told (Pt#5) to go to (Pt #5’s) room but (Pt#5) came down there and was repeating “can you help me, can you help me” and had a condom on. Reports “(Pt#5) was trying to rape my (child) ...SAFETY/RISK CONSIDERATIONS ... Sexual Misconduct: Yes-attempted sexual acts with (family).” -Staff Progress Note written by Registered Nurse (E#3) on 12/10/24 at 4:08PM stated, “This patient was found in the BH5 (Behavioral Health room 5) with a female pediatric patient without knowledge of our BH staff ...after this the patient received a 1 (one) to 1 sitter to stay with the patient at all times. This patient had performed sexual acts on the patient that was in BH5. (Police Department) notified of this patient’s behaviors. This patient also gave this RN permission to discuss their actions today with family. Family reported to me on the phone (Pt#5) was sick and apologized for them ...” -Progress Note written by Health Care Tech (E#7) dated 12/10/24 at 7:36 PM stated, “Upon returning back from doing a transfer with another patient, (E#7) saw Pt#5 on camera in another patient’s room [Pt #6’s room]. (E#7) went into the room the patient was in and told the patient to leave as they can’t be in another patient’s room. Patient [Pt #5] got up and left the room and returned to their room.” - Pt #5’s “Patient Safety Companion Frequent Observation Flowsheet” indicated 15-minute rounds monitoring was started on 12/10/24 at 9:50 AM. The record lacked monitoring at 1:30 PM, 1:45 PM, 4:00 PM, and 5:30 PM. The record lacked monitoring on 12/11/24 at 2:15 PM and 2:30 PM. 5. An interview with the Nurse Manager Emergency Department (ED) (E#1) on 1/24/25 at approximately 10:15 AM. E #1 reviewed Pt #5 and Pt #6’s “Patient Safety Companion Frequent Observation Flowsheet” and verbally agreed the records lacked the monitoring as required. E #1 was also interviewed regarding the policy “BH-40 Management of Sexual Misconduct and Aggression.” E #1 stated, “Patients are assessed ... (Pt #5) was placed in a private room, but the bedside sitter was not implemented until after the incident occurred with (Pt#6).” 6. On 1/22/25 at 12:00 PM an observation of the video footage from the incident on 12/10/2024 involving Pt #5 and Pt #6 was conducted with Security Officer (E #14). Identity of Pt #5 and Pt #6 were verified on video by E #14. -Pt#5 entered room of Pt#6 at 3:46PM while Pt#6 was standing in hallway -Pt#6 enters their room at 3:47PM -Pt #6 got on their knees in front of Pt #5 and performed oral sex on Pt #5 at 3:52PM -Staff open door to Pt#6’s room at 4:07PM -4:08PM Pt#5 exits Pt#6’s room 7. An interview was conducted with Emergency Department (ED) Nurse Manager (E #1) on 1/21/25 at approximately 1:15 PM. While discussing the process of how they monitor the cameras in the Behavioral Health Unit (BH) E #1 stated, “Our staff checks the cameras every 15 minutes, but that is not their sole job. They have other responsibilities as well. We do not have designated staff on the BH Unit watching cameras 24 hours a day. We would like to change that. Our security in the ED is watching the cameras continuously on all shifts unless they are needed elsewhere. Security will alert staff if they see anything on the cameras that needs to be addressed. We can’t lock patients in their rooms without a physician’s order, but we do expect patients to stay in their rooms. Patients can walk out of their room to the nurse’s station if they need something. When a patient scores High on the Columbia Suicide Severity Rating Scale (Suicide Risk Assessment), the interventions put in place on the BH Unit are patient’s belongings are taken, they are given paper scrubs, and jewelry is removed. 15-minute checks are completed on all patients via the BH Tech watching the video monitors.” While discussing Pt #6, E #1 stated, “Because (Pt #6) was on a ligature free unit, which is a locked unit, a sitter was not required.””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49555 Based on document review and staff interviews, it was determined that for 3 of 4 (Pt. #21, Pt #23, and Pt #24) patient requests for transfer acceptance, the Hospital failed to accept transfer of patients who needed specialized ENT (ear, nose and throat) or otolaryngology care. Findings include: 1. A review of the on call schedule for “2024 ENT Call” was conducted during the survey. The on call schedule indicated there was ENT coverage throughout 2024 without any gap in coverage. MD (E #7) was on call on 8/23/24 and MD (E #10) was on call on 7/7/24 and 7/10/24. 2. A review of the Hospital Declination log (7/5/24-8/27/24) was conducted during the survey. The Declination log included declined transfers for Pt #21, Pt #22, Pt #23 and Pt #24. 3. Pt #21’s referral was made on 7/7/24 at 11:55 AM, chief complaint anemia. The disposition noted “Denied (service not available- ENT (ear, nose, and throat).” Pt #21’s “Intake Communication Log “ noted, “11:20:...requested ICU (Intensive Care Unit) transfer. Patient needing ENT on ventilator ...11:55: intubated 7/4 for oropharyngeal bleeding and airway compromise, unknown etiology ...12:10: Discussed with ENT Physician (E#7): (E#7) refused transfer to (Hospital). “ENT available in Bloomington.” Transfer Svcs (Services) explained that there is no IP (inpatient) coverage at (two other outlying hospitals), but they refused to consult and stated patient “should not be transferred to (Hospital).” It was also noted on the intake communication log, “12:34: Discussed with (referring hospital staff) - only adding patients within (Hospital) system to the waitlist.” Pt #21 was ultimately kept at the original transfer requesting hospital in the ICU. Pt #21 was discharged 10 days later. 4. Pt #23’s referral was made on 7/10/24 at 9:48 AM, chief complaint abscess. The disposition noted “Denied (service not available- ENT)”. A review of the intake communication log of Pt #23 noted “0302: (E#8) requesting transfer for pt with large abscess on floor of mouth with fluid and gas collection. Dr. states it has deviated mouth structure and airway...ENT consult not available for (referring Hospital) pts...05:29:...ENT not available for non (Hospital) pts...05:47:...ENT unable to take (referring Hospital) pts (patients) d/t (due to) their contract.” Six hospitals had been contacted to transfer Pt #23 from (transferring hospital) and all six had declined. Five of the six declined due to no bed availability. Pt #23 ultimately was transferred to (higher level of care hospital in Rockford). The Discharge summary from the receiving hospital stated, “Patient underwent surgery for “I&D (incision and drainage) left submandibular (below the jaw) abscess with placement of penrose drains and extraction of tooth #19 on 7/12/24.” Pt #23 was discharged from the hospital 3 days later on 7/13/24. 5. Pt #24’s referral was made on 8/23/24 at 11:50 AM, chief complaint necrotizing fasciitis. The disposition noted “Denied (service not available- ENT)”. A review of the intake communication log of Pt #24 noted “... male with worsening airway due to mandibular abscess ...ENT consulted at referring facility states pt cannot be intubated orally but will need emergent trach. Imaging shows more than mandibular abscess ...Pt condition has continued to worsen. Return call made to ED provider. Pt will now need ICU (Intensive Care Unit) level of care ...Pt is needing intubation ...Contacted physician access to be connected with ENT Physician (E#7) with (City) ENT. (E#7) was resistant to joining the call since it was an outlying hospital. ENT/OMFS (oral maxillofacial surgeon) do not accept (referring Hospital) consult requests.” Pt #24 was transferred to (higher level of care hospital in Champaign). Pt #24’s transferring hospital record indicated the Hospital had tried 5 other hospitals (including hospital listed in complaint) for transfers before Pt #24 was accepted at the receiving hospital. Pt #24’s receiving hospital record stated, “... transfer from outside facility for necrotizing fascitis of the left maxillary region that started as a dental abscess... airway is intact on arrival... No indication for emergent intubation at this time... patient was transferred to OR in stable condition with no impeding airway impingement.” Pt #24’s record indicated, “incision and drainage of submandibular, sublingual (under the tongue), and massateric (cheek) space abscesses, extraction of tooth #17, #18 and any other teeth indicated.” Pt #24 was admitted after surgery “for IV (intravenous) antibiotics/further monitoring for infection resolution.” Pt #24 was discharged from the hospital on 8/27/24. 6. A phone interview was conducted with Transfer Coordinator (E #5) on 8/28/24 at 1:55 PM. While discussing the intake process for patients transferring into the hospital, E #5 stated, “Providers, or their nurses call the intake phone number and request a patient transfer and request the level of bed the patient will need. Once the patient is accepted the referring provider is then connected with the accepting physician to relay information regarding the patient.” While discussing the process when a transfer request for a patient is declined, E #5 stated, “Usually when patients are declined it is because we do not have a bed, we are full, or we do not have a safe staffing ratio. Sometimes it’s because we have a lack of coverage for a service.” E #5 stated, “A couple of times a transfer request was declined by ENT because the provider said they only take transfers within our (City) region. Intake manager (E #4) talked to the referring physicians after reviewing ENT’s contract. It doesn’t happen a lot because we do not get a lot of consult requests for ENT.” 7. An interview was conducted with Vice President and Chief of Hospital Operations (E #6) on 8/28/24 at 2:30 PM. While discussing the contract the Hospital has with the ENT providers, E #6 stated the “ENT group consists of four providers who are committed to providing ENT care to patients at their hospital and two of their sister hospitals. The providers provide phone and in-person coverage for their hospital, and phone coverage only for their sister hospitals ... The contract does not specifically say the providers only accept (Hospital system) transfer patients, but the group of ENT providers do not have the capacity to be on call for all of downstate Illinois. When ENT referrals come in, we address each referral on a case-by-case basis.” 8. An interview was conducted with ENT Physician (E#10) on 8/29/24 at 4:15 PM. While discussing the Declination Log, E #10 observed the Declination Log dated 7/5/24 through 8/27/24 and denied recognizing any of the patient’s names on the log who requested ENT services. I’m a general ear nose and throat doctor, (E#7) is a general ear nose and throat doctor. We are what we would call a community-based practice. We do tonsils and tubes, and we might have different areas that we’re comfortable in, but I stopped doing complicated head neck cancers 10 years ago.” E #10 observed the Intake Communication log for Pt #21 and stated, “So, when somebody calls me and says there’s a patient with oropharyngeal bleeding who’s on Eliquis, when you say ‘oropharyngeal bleeding’ on somebody like that we’re all automatically thinking like OK this is going to be a big thing. Then when I see the patient was a former smoker and on oxygen, these are the things that to me say there is a tumor in there that I may not be equipped to take care of. They should probably not send that person to me because now you’ve sent somebody to a hospital that may be able to handle it, but I can’t take out that tumor. I may not be able to stop the bleeding... In those sorts of situations, I will frequently say send the patient to a tertiary care center.” E #10 observed the Intake communication log for Pt #23 and stated, “This patient has Ludwigs Angina which is a big abscess in the mouth and is something that would require an oral surgeon in addition to ENT. It also said that there’s gas collection, so that’s something that would require potentially a fair amount of dissection in the neck. Again, that’s another one of those things that wouldn’t necessarily be something that we would have transferred here.” E #10 observed the Intake Communication log for Pt #24 and stated, “This patient doesn’t even have an airway, I don’t accept patients who don’t have airways. If this patient died in transit, everyone would be in trouble. In fact, at (another outlying hospital) we have a list of things with (another outlying hospital), because we take call there too, that we don’t accept. They know, don’t even call us because we don’t accept these types of transfers.” 9. The ENT contract was reviewed and did not include that the ENT providers could only care for their own hospital system patients. The contract states multiple times they will “follow EMTALA regulations.” 10. Attempts were made to interview the other ENT providers. E #7 never responded to facility when attempts were made to contact. Another ENT provider was on vacation and would not respond to messages left by the facility.”

“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: 34824 Based on document review and interview, it was determined for 1 of 2 (Pt #5) Emergency Department (ED) patients reviewed for 1:1 continuous monitoring, the Hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients. Findings include: 1. On 12/01/23 at approximately 11:00 AM the policy titled “Suicide Prevention (approved 01/22/23)” was reviewed. The policy stated, “... IV. Procedure/Interventions: A. Non-Behavioral Health Settings (Acute Care, Critical Care, Emergency Department) 1. Screening:... 2. Patients who present to an ED or OB triage for evaluation or treatment of a behavioral health condition will be screened for suicidal ideation using age-appropriate C-SSRS (Columbia Suicide Severity Risk Scoring) at the facility.... 7. Emergency Department Considerations: a) Follow risk-based protocols.. if a patient requires monitoring they should not be left unattended at any time during their ED evaluation.... c) if a safer room is not available, the room will be made as ligature resistant as possible.... Appendix A: Behavioral Health Risk Mitigation Plan C-SSRS/Safe-T Risk Mitigation Plan Acute Care and ED: Patient Monitoring.... High Risk: 1:1 Continuous monitoring with Patient Safety Companion, patient is never left alone... the frequent observation form is completed approximately every 15 minutes at a minimum of 4 times per hour. 2. On 12/01/23 at approximately 1:00 PM, Pt #5’s record was reviewed. Pt #5 was admitted to the ED on 11/29/23 at 4:02 PM with chief complaints of Suicidal Ideation and Homicidal Ideations. Triage note at 4:18 PM stated, “Pt states (Pt #5) was just discharge for SI and HI from here. Pt says (Pt #5) is still having HI, SI, denies drugs or alcohol usage. Pt has not been taking his medications ...” the Columbia Suicide Screening was completed at 4:21 PM and stated, “Columbia Caluclated Risk Level: High...” A note placed by an ED Physician Assistant at 7:59 PM stated, “Informed Charge RN that the patient should be roomed as (Pt #5) has been in the waiting room for almost four hours and is suicidal and homicidal. (Charge RN) was unaware that the patient had SI and HI and will bring (Pt #5) back.” Pt #5 was then placed in ED Behavioral Health Room #3 at 8:46 PM. 1:1 sitter documentation started at 8:52 PM. The record lacked any monitoring between 4:21 PM and 8:46 PM. 3. On 12/01/23 during the record review, an interview was conducted with Nursing Professional Development RN (E #6). E #6 stated, “Looks like the pt was sitting in the waiting room for almost 4 hours. I do not see any documentation of 1:1 observation and there should have been.””