HospitalInspections.org

Based on document review and interview, it was determined that for 4 of 4 patients' (Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding care planning, the hospital failed to ensure that the patients participated in the development of interdisciplinary treatment (IDT) plans.

1. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital's psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). On 7/26/2024, IDT plan was developed for Pt. #1. The IDT plan of care or the clinical record did not indicate that Pt. #2 participated in the development of the treatment plan.

2. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital's psychiatric unit with a diagnosis of schizophrenia. On 7/29/2024, an IDT plan was developed for Pt. #3. The IDT plan or the clinical record did not indicate that Pt. #3 participated in the development of the treatment plan.

3. On 8/05/2024, the clinical record for Pt. #4 was reviewed. On 7/28/2024, Pt. #4 was admitted to the hospital's psychiatric unit with a diagnosis of schizoaffective disorder. On 7/28/2024, an IDT plan was developed for Pt. #4. The IDT plan or the clinical record did not indicate that Pt. #4 participated in the development of the treatment plan.

4. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital's psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). On 7/30/2024, an IDT plan was developed for Pt. #5. The IDT plan or the clinical record did not indicate that Pt. #5 participated in the development of the treatment plan.

5. On 8/05/2024, the hospital's policy titled, "Interdisciplinary Plan of Care [IPC], Treatment and Services" (9/2022) was reviewed and included, "... Definitions: 1. Patient Plan of Care - The patient's plan of care and goals are developed with the patient/family and reflect individualized care and treatment approved by the multidisciplinary team... Policy... 3... The IPC includes actual problem/measurable goals/needs pertinent admission. It also includes input and preferences from the patient and family/significant others..."

6. On 8/05/2024 at approximately 11:00 30 AM, findings were discussed with E #3 (Director Of Patient Care Services, Psychiatry). E #3 stated that there were no patients' signatures or documentation that the patients participated in the development of the IDT plans.

Based on document review and interview, it was determined that for 4 of 4 patients' (Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding the right to make informed decision, the hospital failed to ensure that the consent to administer psychotropic medication was completed, as required.

Findings include:

1. On 8/05/2024, the hospital's policy titled, "Consent to Administer Psychotropic Medication" (9/2021) was reviewed and included, "... It is the policy of (Name of the hospital)... in accordance with... the Illinois Mental Health Code have access to psychotropic medication... that it is prescribed in a clinically appropriate manner... The physician or LIP (licensed independent practitioner) shall advise the recipient in writing of the side effects of the medication and his right to refuse a psychotropic drug... Procedure: 1. When an order for scheduled psychotropic medication is initiated, a consent from the patient must be obtained... 3. The patient and physician must sign the "Psychotropic Notice and Consent" form and have it witnessed by the registered nurse..."

2. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital's psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). On 7/31/2024 at 9:00 PM, Olanzapine (psychotropic medication) 10 mg (milligram) tablet was given as a scheduled bedtime dose to Pt. #2. There was no "Psychotropic Medication Notice and Consent Form" completed for Pt. #2.

3. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital's psychiatric unit with a diagnosis of schizophrenia. On 7/30/2024, 7/31/2024, and 8/01/2024, Paliperidone (psychotropic medication) 6 mg tablet was given as a scheduled daily dose to Pt. #3. There was no "Psychotropic Medication Notice and Consent Form" completed for Pt. #3.

4. On 8/05/2024, the clinical record for Pt. #4 was reviewed. On 7/28/2024, Pt. #4 was admitted to the hospital's psychiatric unit with a diagnosis of schizoaffective disorder. On 7/29/2024, 7/30/2024, and 7/31/2024, Fluoxetine (antidepressant) 10 g tablet was given as a scheduled daily dose to Pt. #4. There was no "Psychotropic Medication Notice and Consent Form" completed for Pt. #4

5. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital's psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). On 7/30/2024, 7/31/2024, and 8/01/2024, Haldol (psychotropic) 10 mg tablet as a scheduled every 12-hour dose was given to Pt. #5. There was no "Psychotropic Medication Notice and Consent Form" completed for Pt. #5.

6. On 8/05/2024 at approximately 11:30 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the Psychotropic Medication Notice and Consent form should be completed.

Based on document review and interview, it was determined that for 3 of 4 patients' (Pt. #2, Pt.#3, and Pt. #5) clinical records reviewed regarding notification of admission, the hospital failed to ensure that the patients' right to notify a family member or representative regarding their admission to the hospital was provided.

Findings include:

1. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital's psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). Pt. #2's "Application for Voluntary Admission" form was not complete, to indicate that Pt. #2's right to notify a family member or representative regarding their admission to the hospital was provided.

2. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital's psychiatric unit with a diagnosis of schizophrenia. Pt. #3's "Application for Voluntary Admission" form was not complete, to indicate that Pt. #3's right to notify a family member or representative regarding their admission to the hospital was provided.

3. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital's psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). Pt. #3's "Application for Voluntary Admission" form was not complete, to indicate that Pt. #3's right to notify a family member or representative regarding their admission to the hospital was provided.

4. On 8/06/2024, the hospital's policy titled, "Patient Rights and Responsibilities" (10/2022) was reviewed and required, "... A patient at (Name of the hospital), you have... The right to have a family member or representative of his or her choice... notified promptly of his or her admission to the hospital..."

5. On 8/05/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the "Application for Voluntary Admission" forms were not complete to indicate that the patients' right to notify a family member or representative regarding their admission to the hospital was provided.

Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 (Pt #1) patients reviewed for elopement, the hospital failed to fully implement measures to ensure safety of patients in the psychiatric unit following Pt #1's elopement.

Findings include:

1. The hospital's policy titled, "Patient Rights and Responsibilities" (dated 10/12/2022), was reviewed, and required, "...As a patient at [Hospital], you have the right to...receive care in a safe setting..."

2. On 8/06/2024, the clinical record for Pt. #1 was reviewed. On 7/05/2024, Pt. #1 was an involuntary transfer from a local hospital. Pt. #1 was voluntarily admitted to Hospital's 3W Behavioral Health Unit with a diagnosis of Paranoid Schizophrenia (type of mental disorder).

- The Psychiatric Evaluation dated 7/5/2024, documented by E #12 (Nurse Practitioner), included, " ...voluntary admission brought in for bizarre and erratic behavior. Aggressive and threatening ... Presents as a danger to self and others ... Past Psychiatric History: Schizophrenia, Paranoid ...Plan. 1. Patient will be admitted to locked unit. 2. Patient will participate in individual, group and milieu therapy. 3. Medication management. 4. Risk of not having treatment explained. 5. Medical service for completing H&P [History and Physical] and to evaluate, monitor and manage medical issues. 6. Education. 7. Social Worker for aftercare. 8. Estimated LOS [length of stay]; 5-7 days."

- Pt. #1's Physician orders from 7/5/24-7/6/2024 was reviewed on 8/6/2024. The orders included assault precautions (require every 15-minute checks).

- The High-Risk Precaution Observation sheets from 7/5-7/6/2024, were reviewed. The sheets indicated that Pt. #1 was on assault precautions, and the required 15-minute checks were completed. The last documented observation check was done on 7/6/2024 at 12:15 PM.

- Pt #1 eloped from the 3 West Behavioral Health Unit on 7/6/2024 at 12:24 PM.

3. The incident report regarding Pt #1 was reviewed on 8/5/2024. The incident report dated 7/6/2024 at 12:30 PM, documented by the 3 West RN (E #13), included, "This writer made hourly rounds at 12:00 PM. Patient is observed in the hallway by the dayroom. Writer came to the nursing station. An MHS [Mental Health Specialist] was doing rounds at 12:30 [PM] and realized the patient cannot be found. The MHS came to tell writer in the nursing station that patient cannot be found. Charge nurse [E #14] notified. Writer and other staff went to check every patient's room and every other place on the unit. Code Gold (Emergency Response for Patient Elopement) called. Nursing supervisor came on the unit. Patient's family member called, but no one (picked up the call. Nursing supervisor made aware that no one (picked up the phone). Unit director made aware. E #12/NP made aware."

4. A video of Pt #1's 7/6/2024 incident, was reviewed on 8/5/2024, with the Chief Nursing Officer (E #2) and the Vice President of Patient Experience and Engagement (E #10). The following was observed on 7/6/2024 on 3 West unit, the stairway, and the outside of Hospital:

At 12:24:16 PM, a MHS (Mental Health Specialist/E #4) opened the stairway door on 3 West, to escort a patient (Pt #12) out that was being discharged. As E #4 and Pt #12 left the unit through the stairway door, the door was left ajar and unsecured. Therefore, Pt #1, who was standing by the door when E #4 and Pt #12 exited, was able to exit out of that door at 12:24:50 (24 seconds behind E #4 and Pt #12). There was no staff monitoring the hallway when Pt #1 exited the stairway door. At 12:25:33 seconds, Pt #1 was seen walking through the alley outside of the hospital.

5. The Root Cause Analysis/RCA regarding Pt #1's incident (dated 7/10/2024) was reviewed on 8/5/2024. The RCA included:
- "MHS [E #4] staff opened the exit door and walked out in front of the patient [Pt #12] being discharged, therefore not securing the door behind [E #4]. Action item: Staff [E #4] was suspended pending investigation. Staff was terminated 7/18/24."

- Pt #1 was able to elope from a locked unit. The RCA did not include any action items indicating that staff were re-educated on precautions to prevent a patient from eloping in the future. The hospital did not provide any in-services or sign-in sheets of re-education to staff of policy review, following Pt #1's event.

6. On 8/6/2024 at 10:15 AM, an interview was conducted with the Charge Registered Nurse (E #14). E #14 stated that Pt. #1 was seen around 12:15 PM and was calm and cooperative. E #14 stated that around 12:30 PM E #6 asked E #14 if Pt. #1 was off the unit for any reason. E #14 stated that this was not the case. E #14 and E #6 then began to search the entire unit for Pt. #1 between 12:30 PM-12:40 PM. Pt. #1 was not found, and a "Code Gold" (emergency response for elopement) was called at 12:40 PM. E #14 stated that E #14 also made E #12 aware that Pt. #1 had eloped. E #14 was able to verbalize the protocol for Code Gold and Elopement. E #14 stated that there is signage posted throughout the unit to make sure staff are keeping the doors closed. E #14 stated that E #14 did not receive any additional education regarding Code Gold or Elopement.

7. On 8/6/2024 at 11:05 AM, an interview was conducted with the Director of Patient Care Services (E #3). E #3 stated there has not been any formal in-services or re-education after Pt #1's incident, just staff huddles. E #3 stated that there will be a meeting coming up this Thursday (8/8/2024) to discuss events from July.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #9) clinical records reviewed regarding use of restraints or seclusion due to violent or aggressive behaviors, the hospital failed to ensure that the care plan was modified to reflect the use of restraint or seclusion as an intervention.

Findings include:

1. On 8/05/2024, the hospital's policy titled, " Use of Restraints and Seclusion" (9/2021) was reviewed and included, "... Healthcare providers and staff will use restrains and seclusion consistent with the following... E. Documentation of Restraint... Every episode of restraint use must be documented in the patient's medical record... 7. Plan of Care based (POC) on an assessment and evaluation of the patient which reflects the use of a restraint or seclusion intervention..."

2. On 8/06/2024, the clinical record for Pt. #9 was reviewed. On 8/02/2024, Pt. #9 was admitted to the hospital with a diagnosis of psychosis (deviation from reality). On 8/03/2024, the clinical record indicated that Pt. #9 was placed in 4 -point restraints due to violent/aggressive behavior from 3:00 AM through 5:00 AM. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention.

3. On 8/06/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the care plan should be modified to indicate the use of restraint as an intervention.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #10) clinical records reviewed regarding use of restraint or seclusion due to violent or aggresssive behaviors, the hospital failed to ensure that a physician's or licensed practitioner's order regarding use of seclusion was obtained.

Findings include:

1. On 8/05/2024, the hospital's policy titled, "Use of Restraints and Seclusion" (9/2021) was reviewed and included, "... Orders for Restraint or Seclusion... Restraint and Seclusion Order for Violent/Self-Destructive Patients... 4. The order should be entered before the initiation of restraint or seclusion..."

2. On 8/06/2024, the clinical record for Pt. #10 was reviewed. On 7/22/2024, Pt. #10 was admitted to the hospital with a diagnosis of schizophrenia (type of mental disorder). On 7/25/2024 from 2:40 PM through 6:30 PM (3 hours and 50 minutes), Pt. #10 was placed in seclusion due to violent/aggressive behavior. There was no physician or licensed practitioner's order regarding the use of seclusion.

3. On 8/06/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that an order should be obtained when a restraint or seclusion is used as an intervention.