Shirley Ryan Abilitylab

“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: 34411 Based on document review, video review and interview, for 1 of 1 (Pt #1) patient who reported allegations of abuse reviewed, the Hospital failed to immediately remove an accused staff member from direct patient care, following notification of an abuse allegation, and failed to initiate and thoroughly investigate allegations of abuse promptly to ensure patients are free from abuse. Findings include: 1. The Hospital’s policy titled, “Reporting Abuse of Shirley Ryan AbilityLab Patients by SRAlab Personnel” (dated 3/2023), was reviewed and required, “Ensuring patient safety is a critical focus at Shirley Ryan Abilitylab ...Physical abuse, sexual abuse, or mental injury, as defined in this policy, of SRAlab patients by SRAlab Team Members is strictly prohibited ...’Mental injury’ means using words or gestures to intentionally inflict emotional distress upon a patient that would be considered by a reasonable person to be humiliating, harassing, or threatening and which causes observable and substantial impairment ...SRAlab will promptly conduct an investigation to ensure the patient who is the alleged victim is safe. In consultation with the President, Chief Administrative Officer and his/her designee, measures deemed necessary to protect the patient must be taken and shall include but are not limited to: 1. Removing suspected violators from further patient contact ...” 2. The Hospital’s policy titled, “Abuse and Neglect-Objective Criteria for Identification” (dated 3/2023), was reviewed and required, “ ...The following criteria while not exhaustive can serve as guidelines to help identify abusive/neglectful situations ...Behavior of Caregiver: verbal threats of abuse, harassment or intimidation ...” 3. The clinical record for Pt #1 was reviewed on 11/18/2025. Pt #1 was admitted to the 25th Floor TBI (traumatic brain injury) unit on 10/11/2025, due to a traumatic brain injury. - Initial History and Physical (dated 10/11/2025 at 9:52 AM), documented by the Attending Physician (MD #1) included, “ ...history of polysubstance abuse, and possible bipolar disorder [serious mental illness] who, on 9/25/2025, presented to [outside acute care Hospital] after a severe MVC [motor vehicle crash] resulting in b/l [bilateral-both sides] frontal lobe contusion [bruise] ...” The clinical record indicated that Pt #1 had a Sitter in place for continuous observation of Pt #1 from 10/12/2025 through current (Pt #1 remains inpatient at the hospital as of 11/18/2025). 4. On 11/18/2025, the Director of Patient Safety (E #1), presented a complaint submission to IDPH (Illinois Department of Public Health). The submission regarding a patient (Pt #1) on the 25th Floor’s TBI (traumatic brain injury), included, “[Pt #1] was admitted to [Hospital] on October 11, 2025, for acute inpatient rehabilitation for a severe traumatic brain injury following a motor vehicle accident on or about September 24, 2025. On October 25, 2025, a patient care technician (“PCT”) [E #2] was present in the patient’s room [Pt #1] with the patient, in the role of a sitter. Two nurses [E #3, E #12] and the patient’s [parent] entered the room where [Pt #1] and [E #2] were present. They did not witness any inappropriate conduct but the closed door to [Pt #1’s] room was unusual. At that time, [E #2] was relieved of [E #2’s] assignment to [Pt #1]. At no time was [E #2] further assigned to [Pt #1]. [Hospital] interviewed [E #2], who stated that [Pt #1] was verbally and physically abusive to [E #2] but [E #2] denied any wrongdoing in [E #2’s] response to [Pt #1’s] actions. On October 27, 2025, [Hospital] interviewed the nurses [E #3, E #12] and [Pt #1’s parent/C #1] who did not observe any wrongdoing. On October 28, 2025, [Hospital] obtained and reviewed video footage of [Pt #1’s] room. The recording shows that after the PCT [E #2] closed the door to [Pt #1’s] room, the PCT [E #2] aggressively pushed the patient in [Pt #1’s] wheelchair and struck [Pt #1] with a gait belt [used to assist with transfer]. 5. On 11/19/2025, E #1 presented a “timeline of events” from the investigation regarding the 10/25/2025 incident with Pt #1 and E #2. The timeline indicated that on 10/25/2025, Pt #1 was in Pt #1’s room, when (Pt #1’s parent) and two nurses (E #3, E #12) entered [Pt #1’s] room together while the PCT (E #2) was sitting in room with (Pt #1) and (E #2) had gait belt (used to assist with transfers) on (E #2’s) lap. When (Pt #1’s parent) was in the room with staff, (E #2) made some comments that patient was hitting and that (E #2) told patient that if (Pt #1) don’t stop hitting, (E #2) was going to ‘whip (Pt #1) with this gait belt.’ (Pt #1’s parent) responded to the effect that ‘you can’t threaten my (child) like that’ and (E #2) states, ‘I didn’t actually do it, I just told (Pt #1) what I would do.’ PCT (E #2) was removed from the situation. Although nobody observed any improper actions (E #2) was re-assigned to a different mod and no longer interacted with (Pt #1). Two days later on 10/27/2025, the Nurse manager (E #4) interviewed (E #2) who fully denied any wrongdoing and acknowledged that (E #2’s] comments were inappropriate but that (E #2) was just upset. On 10/28/2025, the Nurse Manager obtained and reviewed video. On video observed that [E #2] had tried to restrain (Pt #1) from hitting and swatted (Pt #1) on arm/shoulder with a gait belt. On 10/29/2025, E #2 was terminated by the Hospital. - E #2 was not immediately removed from patient care when abuse allegations were reported on 10/25/2025, and E #2 was allowed to continue direct patient care on 10/25/2025 and 10/26/2025. The investigation was not initiated until 10/27/2025 (two days after abuse allegations were reported). 6. On 11/20/2025, E #11 (Associate Chief Nursing officer) presented the investigation notes regarding a 2nd abuse allegation involving Pt #1. The notes included the following: “ ...On October 29. 2025, a PCT [E #16] approached the Nurse Manager [E #4] and stated that E #16 suspected another PCT [E #6] of being aggressive with patient while showering patient. Upon learning this information on Thursday, October 30, 2025, [E #4] suspended [E #6] pending investigation. [E #6] last day worked was October 28, 2025. On Monday November 3, [E #6] resigned from employment. On November 18, 2025, [Hospital] learned additional information. [Pt #1’s parent] shared with [Hospital] that [parent] heard of an incident where [E #6] struck [Pt #1] while showering [Pt #1]. On November 19, 2025, [Hospital] learned that on October 26, 2025, [E #6] a patient care technician along with two RNs [E #17 and E #14] were showering [Pt #1] in patient’s room after patient had an incontinent void that soiled the bed and [self]. During the shower, [Pt #1] became very agitated toward staff, including punching staff, grabbing the shower head, hitting [E #6] with the shower head, yelling profanity and attempting to stand in the shower chair, although being buckled in [Pt #1’s] shower chair. One of the RNs involved stated that [E #6] retrieved the shower head from [Pt #1] and hit [Pt #1] on the left arm. The RN [E #14] describes the hit as ‘firm’ but not forceful and did not result in any redness or injury to the patient. Per the RN [E #14] the shower ended shortly thereafter and although patient was still agitated, [Pt #1] began to calm down. The other RN [E #17] involved in showering [Pt #1] observed [Pt #1’s] extreme agitation but did not observe [E #6] hitting [Pt #1] ...” 7. The video review from the 1st abuse allegation on 10/25/2025 (involving E #2) was reviewed on 11/20/2025 with E #1 and E #10 (Chief Nursing Officer). The video was from 10/25/2025 at 3:32 PM-3:50 PM, in Pt #1’s room. The video included footage showing E #2 in the chair next to Pt #1 while on 1:1 observation. E #2 was seen grabbing Pt #1’s collar after Pt #1 attempted to hit E #2. E #2 was seen trying to restrain Pt #1’s right arm. E #2 then sat back down. E #2 was seen having verbal interaction with Pt #1. E #2 was then seen grabbing a gait belt and struck Pt #1 twice on the right arm. E #2 was then seen hanging the belt back up. Pt #1’s parent, and the 2 RNs (E #3, E #12) were seen walking into the room. There was verbal communication seen on video. However, there is no audio with the video. E #2 was seen exiting out of the room at 3:50 PM. 8. E #2’s timecard from 10/25/2025-10/29/2025, was reviewed. The timecard indicated that E #2 worked the complete shift from 7:00 AM-7:30 PM on 10/25/2025 and a complete shift on 10/26/2025. The Hospital failed to suspend E #2 immediately after being aware of an abuse allegation towards a patient (Pt #1). E #2 was allowed to provide direct patient care to other patients and was not removed from patient care/suspended immediately, after awareness of an abuse allegation and during investigation. 9. E #6’s timecard from 10/26/2025-11/3/2025, was reviewed. The timecard indicated that E #6 worked up to 10/28/2025. E #6 was allowed to provide direct patient care and was not removed from patient care/suspended immediately after awareness of an abuse allegation and during investigation. 10. On 11/19/2025 at 2:20 PM, an interview was conducted with the 25th floor Charge RN (E #3). E #3 stated that Pt #1 had a sitter due to aggressive behavior. E #3 stated that E #3 was the Charge RN on 10/25/2025, when an incident occurred involving Pt #1 and the PCT (E #2). E #3 stated that E #3 heard a lot of commotion coming from Pt #1’s room. E #3 stated that Pt #1’s door was closed, which was not usual. E #3 stated that E #3 entered Pt #1’s room when Pt #1, Pt #1’s parent (C #1), the assigned sitter/PCT (E #2), and the assigned RN (E #12), were in the room. E #3 stated that E #2 was escalated, and E #2 said, ‘if [Pt #1] don’t stop hitting at me, I will hit [Pt #1] with this gait belt’. E #3 stated that C #1 told E #2 to not threaten C#1’s child (Pt #1). E #3 stated that at that point, E #3 told E #2 to leave the room. E #3 stated that E #2 was still allowed to work the remainder of their shift (just not caring for Pt #1). E #3 stated that E #3 did call the Unit Manager (E #4) that same day to inform E #4 of the situation. E #3 stated that the House Supervisor (E #13), was also made aware of the situation on the day of the incident. E #3 stated that if there is an abuse allegation against a staff member, the incident should be escalated right away to the manager. E #3 stated that the patient should be removed from the situation right away, to protect the patient. 11. On 11/19/2025 at 2:35 PM, an interview was conducted with the 25th Floor Manager (E #4). E #4 stated that on 10/25/2025, the Charge Nurse (E #3) let E #4 know about a situation involving a PCT (E #2) and the patient (Pt #1). E #4 stated that E #4 was told that E #2 warned Pt #1’s (parent) who was in Pt #1’s room at the time, that if Pt #1 hits at E #2 again, then E #2 would hit Pt #1 with the gait belt. E #4 stated that E #3 knew that to diffuse the situation, E #3 told E #2 to leave Pt #1’s room. E #4 stated that both the Director of Safety (E #1) and the Associate Chief Nursing Officer (E #11), were made aware of the incident on 10/25/2025 (date of incident). E #4 stated that both E #1 and E #11 were aware of the decision to keep E #2 on duty that day, but to just re-assign E #2 to other patients on that unit. E #4 stated that E #2 was still allowed to work that next day (10/26/2025). E #4 stated that on Monday 10/27/2025 (2 days later), E #4 began the investigation regarding Pt #1, by interviewing Pt #1’s assigned nurse (E #12), the Charge Nurse (E #3), and Pt #1’s (parent/C #1). E #4 stated that at that point, E #4 watched video (10/25/2025) from Pt #1’s room. E #4 stated that after watching the video, a decision was made to suspend E #2. E #4 stated that the E #2 was suspended because the video showed that E #2 hit Pt #1 on the arm twice, with a gait belt. E #4 stated that E #2 was terminated on 10/29/2025. E #4 stated that the decision to suspend an employee pending an abuse allegation, is made by Human Resources and upper management. E #4 acknowledged that E #2 making threats towards Pt #1 is considered verbal abuse. E #4 stated that abuse allegations should be reported to E #4 and/or the House Supervisor upon awareness of the allegation. E #4 stated that E #4 was not made aware of the 2nd incident involving Pt #1 (occurred on 10/26/2025) until 10/29/2025, but should have been made aware of the allegation immediately. 12. On 11/20/2025 at 10:50 AM, an interview was conducted with the 25th Floor RN (E#12/assigned to Pt #1 on 10/25/2025). E #12 stated that while E #2 was sitting with Pt #1, Pt #1’s (parent/C #1), walked into Pt #1’s room. E #12 stated that E #12 walked behind C #1 and entered Pt #1’s room. E #12 stated that E #2 was sitting in the corner, with a gait belt in E #2’s lap, when E #12 walked in. E #12 stated that E #2 told C#1 that ‘I [E #2] will whip Pt #1’s a**, if Pt #1 hits at E #2 again’. E #12 stated that C #1 said to E #2 to not talk to Pt #1 that way. E #12 stated that E #2 was upset and said, ‘I’m done’ and walked away.” E #12 stated that E #2 was removed from care of Pt #1 and assigned to other patients that shift. 13. On 11/24/2025 at 9:10 AM, a phone interview was conducted with the 25th Floor RN (E #14/present during 2nd abuse allegation). E #14 stated that on 10/26/2025, E #14 heard a lot of yelling coming from Pt #1’s room. E #14 stated that E #14 entered Pt #1’s room and Pt #1 was in the shower room with the PCT (E #6) and another nurse (E #17). E #14 stated that Pt #1 grabbed the shower head and hit E #6. E #14 stated that E #6 then grabbed the shower head from Pt #1 and hit Pt #1 on the left shoulder. E #14 stated that E #6 said to Pt #1, “If you hit me, I will hit you back.” E #14 stated that the incident was not reported that day to management. E #14 stated that E #6 remained Pt #1’s sitter that shift, since Pt #1 did eventually calm down. E #14 stated that the abuse protocol is to notify management of the allegation, soon after knowing about it. E #14 stated that E #6 should have been removed from patient care, pending an abuse allegation. 14. On 11/20/2025 at 9:20 AM, an interview was conducted with the Director of Patient Safety (E #1). E #1 stated that E #1 was aware of the incident involving Pt #1 on 10/25/2025 and on 10/28/2025. E #1 stated that E #2 was allowed to continue to work on 10/25/2025, as they were unable to clarify what happened at the time. E #1 stated that the video from 10/25/2025, was not viewed until 10/27/2025 and that is when it was determined that E #2 did strike Pt #1. E #1 stated that E #2 was suspended on 10/28/2025. E #1 stated that regarding the incident on 10/29/2025 in the shower room, it was unable determine what happened inside the shower room, as there are no cameras. E #1 stated that, however, the PCT (E #6), resigned on 11/3/2025. E #1 stated that the Hospital has started to do education with the staff, regarding when to report abuse allegations and that staff will be suspended immediately following an allegation of abuse pending investigation.”