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Based on document review and interviews, it was determined that for: 5 of 9 (Pts #4, 2, 5, 6 & 7) clinical records reviewed for patients on the psychiatric unit, the hospital failed to ensure staff monitor the safety of all patients and investigate a maternal death. The cumulative effects of these systemic practices resulted in the Hospital's failure to comply with the Condition of Patient Rights.

Finding include:

1. The hospital failed to ensure ongoing patient safety rounds were completed. The Hospital failed to and investigate/report a maternal death on the psychiatric unit as required per policy. See deficiency at A 144.

Based on document review and interviews, it was determined for 5 of 9 (Pts #4, 2, 5, 6 & 7) clinical records reviewed for patients on the psychiatric unit, the hospital failed to ensure ongoing patient safety monitoring, and investigate/report a maternal death on the psychiatric unit as required per policy.

Findings include:

1. The hospital's policy entitled, "Precaution" (revised 04/2014) was reviewed on 4/21/15 and required, "...Precaution Frequency of Monitoring:...Close Observation (CO) - Every 15 minutes...The registered nurse assigned to the patients and the charge nurse is responsible and accountable for ensuring that the observation technician is monitoring the patients according to the ordered/required precautions..."

2. The hospital's policy entitled "Adverse Sentinel Event" (revised 3/2014) required, "...A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk therof...Sentinel Events that are subject to review by the Joint Commission, CMS and other regulatory agencies includes any occurrence that meets any of the following criteria: The event has resulted in an unanticipated death...Within 2 working days, consult with EVP (Executive Vice President) and President of the hospital to determine if the event is to be report to the Joint Commission, CMS or other regulatory agencies...conduct a root cause analysis of the event..."

3. The Mental Health Disabilities Code (405 IL CS 5) was reviewed on 4/23/15 and included, "All admissions to and discharges from ...the psychiatric department or service of a general hospital shall be in accordance with the Mental Health and Developmental Disabilities Code ...(405 IL CS 5/) Mental Health and Disabilities Code. Chapter V General Provisions ...Written notice of the death of a recipient of services ...shall within 10 days of the death of a recipient be mailed to the Department of Public Health ... "

4. The clinical record for Pt #4 was reviewed on 4/21/15. Pt #4 was a 22 year old female admitted to the hospital's psychiatric unit (4 South) on 3/23/15 with a diagnosis of schizophrenia. Pt #4's medical history included only that she was 11 weeks pregnant. Pt #4 was placed on close observation, seizure, and fall precautions which required every 15 minute safety checks upon admission. Pt #4's clinical record lacked documentation of patient safety rounds on 3/27/15 from 9:00 PM - 10:10 PM. On 3/27/15 at approximately 10:10 PM, Pt #4 was found unresponsive in her room by the RN (E #11). A Code Blue was called at 10:10 PM, CPR was initiated and Pt #4 was transferred to the Intensive Care Unit. Resuscitation attempts were unsuccessful, and Pt #4 was pronounced dead at 10:48 PM.

5. The clinical record for Pt #2 was reviewed on 4/20/15 and included Pt #2 was a 56 year old male admitted to the hospital's male locked psychiatric unit (4 East) on 3/31/15 with a diagnosis of schizophrenia. Pt #2 was placed on close observation precautions from admission on 3/31/15 through discharge on 4/6/15. Pt #2's clinical record lacked documentation of the completion of patient safety rounds on 4/2/15 from 7:00 AM - 10:45 PM.

6. The clinical record for Pt #5 was reviewed on 4/22/15 and included Pt #5 was a 24 year old female admitted to the female locked psychiatric unit (4 South) on 3/24/15 with a diagnosis of schizophrenia and put on close observation precautions on admission. Pt #5's clinical record lacked documentation of patient safety rounds on 3/24/15 from 5:00 AM to 6:00AM.

7. The clinical record for Pt #6 was reviewed on 4/22/15 and included Pt #6 was a 45 year old female admitted to 4 South on 3/22/15 with a diagnosis of bipolar disorder and put on close observation precautions on admission. Pt #6's clinical record lacked documentation of patient safety rounds from 3/29/15 at 7:00 AM to 3/30/15 at 7:00 AM.

8. The clinical record for Pt #7 was reviewed on 4/22/15 and included Pt #7 was a 53 year old female admitted to 4 South on 3/23/15 with a diagnosis of schizophrenia and put on close observation precautions on admission. Pt #7's clinical record lacked documentation of patient safety rounds from 3/27/15 at 7:00 AM to 3/28/15 at 3:15 PM.

9. On 4/22/15 at approximately 9:00 AM, an interview was conducted with the RN (E #8) who worked from 7:00 PM on 3/27/15 to 7:00 AM on 3/28/15. E #8 stated there were eight patients on the unit and staffing included one RN and one LPN from 7:00 PM - 10:00 PM. E #8 stated the 15 minute safety checks were not completed from 7:00 PM - 10:00 PM. E #8 stated that she wasn't feeling well and stayed in the office doing paperwork. E #8 stated that the LPN was passing medications during this time and E #8 assumed that the safety rounds had been completed. E #8 stated the LPN reported that all patients were in bed. At 10:00 PM, an agency RN (E #11) came to the unit to relieve the LPN, and the LPN was reassigned to another unit. E #11 completed the safety precaution rounds at 10:00 PM and found Pt #4 unresponsive in bed.

10. On 4/22/15 at approximately 9:30 AM, the Chief Nursing Officer (E #2) stated that the safety rounds should have been completed.

11. During an interview with the hospital's Vice President of Quality and Compliance (E #1) on 4/21/15 at approximately 2:00 PM, E #1 stated that the hospital had not determined this to be a sentinel event due to the unknown cause of death and had not reported this unanticipated death to any regulatory agencies. E #1 stated that the hospital was waiting for the Coroner's report. E #1 stated that the hospital had initiated an investigation of this event. However, E #1 was unable to provide documentation of any hospital investigation or initiation of a root cause analysis by the survey exit on 4/23/15.

Based on document review and interview, it was determined for 1 of 1 (E #6) hospital staff who witnessed an altercation between patients, the hospital failed to ensure the completion of an occurrence report per policy to track and trend data.

Findings include:

1. The hospital's policy entitled "Incident Reporting" (reviewed 5/2010) required, "...An Incident Report must be completed anytime a patient, employee or visitor is injured or encounters an unusual occurrence - regardless of severity. An employee observing or responding to the incident must complete and sign an Incident Report Form...and document information about the incident in the Progress Notes of the patient's medical record..."

2. On 4/21/15 at approximately 1:20 PM, an interview was conducted with the Activity Therapist (E #6) on the male psychiatric unit. E #6 stated that he had witnessed an altercation between two patients (Pt #2 and could not recall name of other patient) after a group session (could not recall date) in the day room. E #6 stated " Blows were thrown between Pt #2 and another patient. I tried to intercede but then it was over. I told the nurse (could not recall nurse) " . E #6 stated that he did not complete an incident report.

3. The Hospital's Quality Assessment Committee meeting minutes (01/2014 - 03/2015) were reviewed and did not include any data related to the tracking and trending of incident reports.

4. On 4/21/15 at approximately 1:25 PM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated that an incident should be completed for this incident.

A. Based on document review and interview it was determined for 1 of 1 (Pt. #1) patient, the Hospital failed to ensure the patient did not develop skin breakdown.

Findings include:

1. On 4/21/15 the Hospital policy titled "Patient Admission Assessment and reassessment" (7/06), was reviewed and required, "H...RN's are responsible for patient's reassessment through evaluation of the patient's nutritional, physical, functional...needs...J...RN must address newly identified problems/needs..."

2. On 4/21/15 the Hospital's policy titled, "Skin Care (12/06)" was reviewed and required..."The RN will assess each patient for altered skin integrity on admission and every shift..."

3. On 4/21/15 the medical record of Pt. #1 was reviewed. Pt. #1 was a 65 year old male admitted on 12/24/14 with a diagnosis of altered mental status, dehydration, poor oral intake, and decreases mobility related to left below the knee amputation. Pt. #1 was also documented with incontinence of bowel and bladder. On admission Pt. #1 was documented with a Braden score of 14 (moderate risk for skin break down) and on 12/24/14 a physician ordered an air mattress. On 12/26/14 a physician also ordered turn and repositioning every 2 hours.

4. On 4/22/15 the nursing progress notes and daily assessment reports for Pt. #1 was reviewed. The record contained only 2 documented times of Pt. #1 being turned and repositioned: 12/30/14 at 10:05 PM and 1/2/15 at 12:58 PM.

5. The medical record documented on admission that Pt. #1 did not have any skin breakdown. However, on the day of discharge 1/2/15, the medical record documented Pt. #1 had an abrasion to the buttock, and a blister on the right foot.

6. On 4/23/15 during an interview the Director of Quality (E#3) stated that the repositioning should have been documented.

B. Based on document review and interview, it was determined for 1 of 1 patient (Pt. #3) on a specialty bed, the Hospital failed to ensure the patient was turned as ordered.

Findings include:

1. Hospital protocol titled, "Braden Scale Interventions (no date)" required, "Client at moderate risk (Braden Score 13-18) ... If on a therapeutic support surface, then reposition every 2-4 hours."

2. The clinical record of Pt. #3 was reviewed on 4/22/15. Pt. #3, a 66 year old female, was admitted to ICU (intensive care unit) on 3/6/15 with the diagnoses of acute respiratory failure (requiring intubation), septicemia (blood infection) and cellulitis (inflammation) of legs and back. The clinical record included the following orders:
3/6/15 at 8:23 PM - Specialty Bed (bariatric bed with low air mattress)
3/7/15 at 12:14 AM - Turn and reposition every 2 hours

3. Nursing notes dated from 3/18/15 to 3/23/15 (while on 2 north) included Pt. #3 had a Braden score of 14 (moderate risk for skin breakdown) and included the following documentation related to turning Pt. #3:
3/18/15 - 8:00 PM (missing 10:00 PM)
3/19/15 - 12:00 AM, 4:47 AM, 8:10 AM, 4:06 PM and 8:32 PM (missing 2:00 AM, 6:00AM, 10:00 AM, 12:00 PM, 2:00 PM, 6:00 PM and 10:00 PM)
3/20/15 - 4:07 AM, 8:15 AM and 8:29 PM (missing 12:00 AM, 2:00 AM, 6:00 AM, 10:00 AM-6:00 PM and 10:00 PM)
3/21/15 - 4:02 AM and 8:00 AM (missing 12:00, 2:00 and 6:00 AM. Plus remainder of day)
3/22/15 - no documentation of turning
3/23/15 - 12:00 PM

4. A night nurse (E#7) caring for Pt. #3 was interviewed on 4/22/15 at 9:15 AM. E#7 stated Pt. #3 was an obese woman on a big boy bed (Pt. #3 weighed 500 pounds). Pt. #3 had a Foley catheter (tube in bladder to collect urine) and only need the bedpan for bowel movements. Pt. #1 required 4-5 staff members to turn from side to side. E#7 stated, " We would get extra help from the next unit whenever we needed to turn her. Sometimes we turned (Pt. #3) less frequent than every 2 hours at night, but she was on a big boy bed.

5 Pt. #3's attending physician (MD#2) was interviewed on 4/22/15 at 12:00 PM. MD#2 stated, (Pt. #3's) family did complain to him about the patient not be turned and cleaned regularly, especially on one night in particular (did not recall the night). MD#2 stated, "I talked to the staff and was told that there just isn't enough staff on the night shift to turn the patient. Some of the motivated nurses will find help to turn patients, but most do not." Pt. #1 was involuntary of stool and MD #2 was concerned about skin breakdown.

6. The CNA (E#15) caring for Pt. #3 on the night of the complaint was interviewed on 4/22/15 at 3:35 PM. E#15 stated Pt. #3 asked to use the bedpan (was having loose stools). E#15 stated, "I needed to find help and for some reason everyone was either busy or just not available. I was unable to turn the patient by myself and she had to wait between 30 minutes and an hour each time. I had a difficult time that entire evening getting people to help me. "

7. During an interview on 4/22/15 at 3:00 PM, the Unit Vice President (E#13) of 2 north stated, "Because Pt. #3 required so many people to turn, the 2 north staff would get staff from the neighboring unit." E#13 stated the clinical record lacked documentation of every two hour turning.

Based on document review and interview it was determined for 1 of 4 (Pt. #1) medical records reviewed, the Hospital failed to ensure plan of care (POC) was individualized.

Findings include:

1. On 4/22/15 the Hospital policy titled, "Multi-Disciplinary Care Plan(11/11)" was reviewed and required "...B. The admission problem and problems requiring obvious nursing interventions or patient/family education are to be included in the patient's care plan...C. The care plan should include goals/expected outcomes, interventions and...education relevant to the patient's problem..."

2. On 4/21/15 the medical record of Pt. #1 was reviewed. Pt. #1 was a 65 year old male admitted on 12/24/14 with a diagnosis of altered mental status, dehydration, poor oral intake, and decreases mobility related to left below the knee amputation, and incontinence of bowel and bladder. On admission Pt. #1 was documented with a Braden score of 14 which required per the Hospital's Braden interventions protocol, "...develop and document individualized care plan..."

3. On 4/22/15 the POC for Pt. #1 was reviewed. The POC lacked individualization to include evaluation, goals and intervention for prevention of impaired skin integrity.

4. On 4/22/15 during in interview the Director of Nursing (E #2) stated the care plan should have included skin integrity.