A Chicago hospital with a history of patient-care violations didn’t tell police that a patient in its psychiatric unit may have been sexually assaulted by another patient, even though the incident was caught on surveillance video.

Nor did the facility, Roseland Community Hospital on the far South Side, closely monitor the alleged attacker — identified in records as a 49-year-old man with a history of sexual violence and aggression — as it was supposed to do.

Five months after the June 24 incident, hospital officials acknowledged, Roseland still has not identified the potential victim.

Roseland president and CEO Tim Egan said the hospital did not become aware of the incident until about two months after it happened. Yet even then, the hospital did not notify regulators at the Illinois Department of Public Health, as the agency said it should have done. The agency investigated the incident about a week after the hospital learned of it, after the first of two complaints to the agency.

The state public health department also did not contact law enforcement officials, doing so only last week after ProPublica raised questions about how the agency had handled the possible assault.

IDPH reported the incident to the Chicago Police Department and the Illinois State Police. Chicago police said Monday they have opened an investigation into the incident; Egan said police asked the hospital to hold the video footage. State Police have confirmed they received the report.

In response to ProPublica’s questions, IDPH also said that it is exploring changes to state public health regulations that would require hospitals to report suspected patient-on-patient sexual assaults to law enforcement. Currently, only alleged staff-on-patient assaults must be reported.

While Roseland knows the identity of the apparent aggressor, the identity of the potential victim is still in question. A complaint to state officials obtained by ProPublica identified the alleged victim as a 21-year-old developmentally disabled man with autism.

His caregivers said the young man, who lives in a state-funded group home, functions like a 9- to 11-year-old, is fascinated by fire trucks and bounces up and down at the sight of Christmas lights. They said the young man recently told a nurse he had been touched inappropriately at a hospital, which he didn’t name.

The caregivers have filed a report with Chicago police and also retained an attorney for him.

Egan, however, said in an interview that the 21-year-old, who is white, is “unequivocally” not the second patient. An internal hospital investigation has eliminated him because, he said, both patients in the video are Black. Federal records do not identify the two patients by race and say the face of the second patient is not visible.

Roseland’s behavioral health unit has a capacity of 24 patients, yet Egan said hospital officials had not interviewed any of the patients who were there the day of the alleged assault.

“The video depicts unacceptable behavior and is completely counter to Roseland Community Hospital’s commitment to providing safe and effective patient care,” Egan said.

He said the hospital continues to investigate the circumstances surrounding the incident, including whether it was consensual. Roseland began its investigation after it discovered the footage in August, Egan said, but IDPH arrived and asked for the video before the hospital was able to get answers.

The hospital would have called police immediately, Egan said, if it “looked like there was a crime committed.”

Egan said Roseland has implemented a number of changes over the past several months. The hospital has cut ties with the unit’s former medical director. Roseland also fired an employee who had been outside the day room in the psychiatric unit when “confirmed inappropriate sexual behavior between two patients” occurred, according to hospital records obtained by ProPublica.

“We have new policies and procedures. New physicians in charge of the behavioral health unit and a new chief quality officer being hired, and they will ensure this and other protections and precautions will be taken,” Egan said.

Roseland, a small nonprofit hospital, has long struggled financially and has faced repeated scrutiny from state and federal authorities. More than 70% of its patients received Medicare or Medicaid last year; around 90% of the facility’s patients were Black. After closing its adolescent behavioral unit in February, Egan said, it opened its adult unit in March. The hospital hopes to receive state funding to expand the adult unit and reopen the adolescent unit, he added.

“There is a tremendous need for behavioral health expansion on the South Side of Chicago specifically,” Egan said.

The Centers for Medicare and Medicaid Services, which regulates hospitals receiving federal funding, cited Roseland four times between July and September for incidents where its behavioral health unit placed patients in “immediate jeopardy,” its most serious citation that indicates patients had been in imminent danger of serious injury or death.

The hospital failed to properly monitor patients, adequately investigate the incident involving the two men and ensure the safety of its patients, “potentially affecting the care of all psychiatric patients,” according to documents obtained through open records requests.

At the time of the June 24 incident, Roseland had no social worker on staff in the behavioral health unit, an omission that allowed for more than 50 patients to be discharged from the hospital without proper planning for follow-up treatment, medication assistance or housing arrangements, according to federal records. Egan attributed those problems to former personnel.

“All the deficiencies that were uncovered since the IDPH survey have been corrected,” Egan said. “That’s why we’ve launched the investigation so we better understand any mistakes so they would be corrected immediately.”

“We meet every regulatory survey with absolute transparency,” he added.

The video of the two patients, according to federal inspection records, was discovered when hospital staff were looking at footage during an unrelated internal investigation. It was turned over to state investigators during a surprise visit in early September that was prompted by a complaint to the IDPH about the incident between the patients.

The footage showed “sexual activity” between two men in the corner of the day room; one of the patients has his hospital gown raised above his waist and is leaning into the other patient.

When the psychiatric unit’s director was told about the video by employees, she did not begin an immediate investigation or interview workers because she was scheduled to have time off the next three days, she told state investigators.

Roseland officials told state investigators that the hospital had begun an inquiry into the incident on Aug. 31. But by Sept. 2, the hospital’s quality department had not received a report from the unit’s director, despite hospital policy that requires employees to report situations that could or did result in physical or psychological harm, federal records show.

“This occurrence should have been reported and an investigation should have been conducted immediately,” the chief nursing officer told the state investigators.

An advocate for people with disabilities said hospital officials lost valuable time.

“Memories do fade,” said Stacey Aschemann, a vice president at Equip for Equality, a nonprofit with offices across Illinois. “So timely investigating is essential to figuring out who was involved, maybe who wasn’t doing their job, if that was a concern. Timeliness is really important in these circumstances.”

And although the incident is described in federal reports as “sexual activity,” a catch-all phrase used when consent cannot be determined, it is impossible to know for sure whether consent was given without identifying the second patient, all the more reason the hospital should have investigated, Aschemann said.

Only the face of the alleged assailant was visible on the video, records show. Hospital workers told state investigators they “believed” they knew his identity: a man with a history of psychosis, aggressive behavior and an “inability to maintain safety” of himself or others, records show. But workers told state investigators that they had not definitively determined either patient’s identity, according to federal records.

The hospital was cited by inspectors for failing to provide him one-on-one monitoring.

Roseland’s risk manager also expressed concern for the safety of the patients because of the improper monitoring, telling state investigators in September: “There is potential for harm if an investigation is not done right away to maintain safety measures or correct any concerns.”

In response to the investigation’s findings, according to federal documents, the hospital built a wall to eliminate blind spots in the recessed area in the day room and to provide clear visibility for staff and cameras. The hospital, the documents show, also revised its policy to add precautions for supervising patients who act out sexually and planned staff training on identifying and reporting potential abuse.

By late September, federal officials determined that the hospital had returned to compliance.

The second complaint about the incident was filed in October and alleges that the hospital “intentionally lied” to IDPH about not knowing the identities of the two patients, both of whom are named and had been frequently admitted to the psychiatric unit. Egan disputes that claim.

The complaint, which was obtained by ProPublica, was filed with the inspector general for the Illinois Department of Healthcare and Family Services, which reached out to the state Department on Aging and the Department of Human Services to determine which agency might investigate the incident.

All three state agencies said they followed protocol and did not have the jurisdiction to investigate the complaint, which falls to IDPH. The other agencies ensured that IDPH, which licenses state hospitals and investigates complaints on behalf of the federal Medicare agency, was notified.

Federal officials determined IDPH “fully investigated the June 24, 2021, incident, cited the facility at the highest level, and did not need to reopen the prior investigation,” said IDPH spokesperson Melaney Arnold.

Arnold said hospitals should report sexual assaults to the police and IDPH. Her agency did not initially alert police, she said, in part because investigators learned of the incident more than two months after it occurred and do not know the identities of the two patients. Following questions from ProPublica, Arnold said the agency notified police.

In addition to exploring changes to its reporting regulations, IDPH is also updating its rules on how closely some patients must be monitored and procedures for how incidents involving patient sexual activity are investigated.

Three months after the incident, the 49-year-old was charged with misdemeanor battery after he shoved a man’s head against a wall in the emergency room of a hospital in Chicago’s south suburbs, court records show. After he failed to return to court, he was taken into custody and was still being held in Cook County Jail on Monday.

Efforts to reach him and his family were unsuccessful, and he is not being named because he hasn’t been charged criminally in the Roseland incident.

ProPublica also is not naming the 21-year-old because he is allegedly a victim of sexual assault. His caregivers and the home where they work are not being named because doing so could identify the 21-year-old.

The caregivers blame inaction by hospital and public health officials for a monthslong delay in reaching out to the 21-year-old to see if he needed treatment. The caregivers said they had noticed behavioral changes they couldn’t explain in the young man when he returned to the group home following his hospitalization at Roseland.

The caregivers said they learned of the incident in early November — more than four months after the alleged assault — from the Illinois Department of Human Services following ProPublica’s inquiries with the state. The caregivers said the state described the incident as an alleged assault.

“We had never heard anything. We should have been notified immediately,” one caregiver said in an interview, adding: “It makes us feel like they don’t care about the individuals — that they don’t matter. Had this happened to a well-bodied person … more would have been done.”

Since the incident, the 21-year-old has had frequent outbursts and has repeatedly tried to run away from his group home, the caregivers said. They are reluctant to send him to Roseland again.

“We don’t know what’s been done to him,” one of the caregivers said.