HospitalInspections.org

Based on document review, and interview, it was determined that the Hospital failed to ensure that patient's rights were promoted and protected regarding the usage of restraints on the Behavioral Health Unit, by failing to provide a safe environment while in restraint; failure to obtain a physician order for restraints; failure document the discontinuation of the use of restraint; failure to monitoring of patient while on restraint and the one hour face to face evaluation after the application of restraints. As a result, the Condition of Participation, 42.CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that care was provided in a safe environment while patient was on physical restraints (A-0144).

2. The Hospital failed to ensure that physician order was obtained for restraints (A-0168).

3. The Hospital failed to ensure that the documentation of date and time of discontinuation of 4-point violent behavioral restraints (A-0174).

4. The Hospital failed to ensure patient monitoring while on behavioral restraints (A-0175).

5. The Hospital failed to ensure the documentation of one-hour face-to-face evaluation was done while the patient was on restraints (A-0184).

Based on document review and interview it was determined that for 1 of 3 (Pt. #2) clinical records reviewed for admission to Behavioral Health Unit, the Hospital failed to ensure that Legal Guardian consent was obtained for admission and psychotropic medication treatment, to ensure that the patient or legal guardian made an informed decision regarding his care.

Findings include:

1. On 4/7/2022, the Hospital's policy titled, "Consent: For Treatment, Operation and Autopsy" dated 02/2019 was reviewed. The policy included, "To establish guidelines for obtaining Consent for Treatment...A. General Guidelines: Hospital personnel have a legal duty to refrain from treating a patient unless the patient has authorized the treatment ...An incompetent adult patient is a person who has been declared incompetent by a court and for whom a "guardian of the person" has been appointed. Thereafter, the guardian consents for treatment on behalf of the incompetent patient..."

2. On 04/06/2022 at 10:30 AM, the clinical record for Pt. #2 was reviewed. Pt. #2 was brought into the Emergency Department (ED) on 02/24/2022 at 7:00 PM by the local police with chief complaint of behavioral aggression at home. Pt. #2 was admitted to the Inpatient Behavioral Health Unit (IBHU) with a diagnosis of psychosis. Pt. #2's clinical record included the following:

-The RN (E #13) progress note dated 02/25/2022 at 12:27 AM, included, "At approximately 12:15 AM, patient [Pt. #2] was presented with the consent for psychotropic medication consent ...ripped/tore the endorsed consent and seized clipboard ..."

-The Psychiatrist (MD #3) evaluation note 02/25/2022 at 8:00 AM, included, " ...past psychiatric history of bipolar type, intellectual disability, ...multiple inpatient psychiatric hospitalizations ...admitted to unit for behavioral agitation ...on unit patient was presented with a consent for psychotropic medication ..."

- The document titled, "Letter of Office -Plenary Guardian of Person of a Disabled Person" dated 06/05/2014 included, "Pt. #2's (mother) has been appointed plenary guardian of the person of [Pt. #2] a disabled person, and is authorized to have under the direction of the court of the custody of the ward and to do all acts required by law." The plenary guardian of the person ...within 30 days after the expiration of one year from the date of this order ...or shall appear before the court on July 16, 2015 at 10:00 a.m/p.m (not more than 13 months after the date of this order) ..." Pt. #2's clinical record lacked the updated plenary Guardian for Disabled Person.

- The clinical record of Pt. #2 did not include the Legal Guardian Consent for Admission and Treatment, Physician Order for Physical Restraints, Consent for Psychotropic Medication from the Legal Guardian and Restriction of Rights Physician order while administering as required psychotropic medication during patient agitated behavior.

3. On 04/07/2022 at 11:45 AM, an interview was conducted with the Psychiatrist/Medical Director of IBHU (MD #3). MD #3 stated that patient (Pt. #2) was developmentally delayed and had mental capacity of a 4-year-old.

4. On 04/12/2022 at approximately 1:00 PM, an interview was conducted with the Nurse Manager (E #8). E #8 stated, "There should have been a consent obtained from the legal guardian."

5. On 04/12/2022 at approximately 1:10 PM, an interview was conducted with the Director of Quality (E #20). E #20 stated, "I am not sure, why they did not obtain a consent for admission and psychotropic medication treatment from the legal guardian as the patient was intellectually disabled."

Based on document review, and interview it was determined for 1 of 3 (Pt. #2) patients reviewed for restraints, the Hospital failed to ensure that care was provided in a safe environment while patient was on physical hold. This potentially could affect all patients that require physical restraints.

Findings include:

1. On 04/06/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" dated 04/2021, was reviewed and included, " ...D. Patient have the right to be comfortable and safe, including the right to: ...2. To receive care in a safe setting and be free from all forms of abuse and harassment ..."

2. On 04/06/2022, the Hospital's policy titled, "Protective and Restraint Policy - Violent and Non-violent" dated 01/03/2022 was reviewed and included, " ...Restraint for Violent Behavior: A. Restrictive Holding: ...with knowledge of using the least restrictive strategies that maximize safety while also minimizing harm ...effective to protect the patient ...from harm ..."

3. On 04/07/2022, the Hospital's policy tiled, "Code Gray/Security Assistance date 06/05/2019, was reviewed and included, " ...All caregivers ...shall be encouraged to recognize activities leading to actual or potential physical threat to staff ...prompt action shall be taken to secure assistance needed to stabilize situations that could lead to bodily harm ...when employee ...perceives that the situation becoming threatening verbally or physically, call the Hospital Operator ...and state "CODE GRAY" then give location ...Security Officers shall respond to the location on a "STAT" basis ..."

4. On 04/06/2022 at 10:30 AM, the clinical record for Pt. #2 was reviewed. Pt. #2 was brought into the ED on 02/24/2022 at 7:00 PM by the local police with chief complaint of behavioral aggression at home. Pt. #2 was admitted to the Inpatient Behavioral Health Unit (IBHU) with a diagnosis of psychosis. Pt. #2's clinical record included the following:


- The RN (E #13) IBHU admission note dated 02/24/2022 at 11:44 PM, included, " ...admitted voluntarily ...for aggressive behavior at home and an altercation with his grandmother ...escorted to room by CPD [Chicago police department] ...patient [Pt. #2] will be placed on assault precautions and close observation ..."

-The RN (E #13) progress note dated 02/25/2022 at 12:27 AM, included, "At approximately 12:15 AM, patient [Pt. #2] was presented with the consent for psychotropic medication consent ...ripped/tore the endorsed consent and seized clipboard ...assistance was sought and the board was secured but not before the patient attempted on multiple occasions to strike staff ...patient was released from the hold only to escalate ...received medication for agitation ...patient redirected and able to connect with Charge RN at this time ...Hospitalist arrived to assess the patient ...placed on one-to-one (sitter at bedside within arms reach) post violent outburst for his safety ..."

-The Psychiatrist (MD #3) evaluation note 02/25/2022 at 8:00 AM, included, " ...past psychiatric history of bipolar type, intellectual disability, ...multiple inpatient psychiatric hospitalizations ...admitted to unit for behavioral agitation ...on unit patient was presented with a consent for psychotropic medication ...without notice ripped/tore the consent and seized the clipboard ...patient attempted to strike staff ...patient banged his head against the wall and had a laceration to the back of his head ...no need for sutures ...Pt. [Pt. #2] was repeatedly asked to sign documents without being explained what they were for, leading him to steal and hide a clipboard ...He [Pt. #2] reports that the nurse [E #13] approached him with 'closed fists', causing him [Pt. #2] to swing at the nurse because 'I did not want him to hit me.' The patient [Pt. #2] reports that this caused the nurse to 'toss him' leading him to hit his head on the edge of the bed in the behavioral health unit. Patient endorses headache after that incident and states that he 'feels unsafe' and would like to be transferred to a different hospital ...Mood: 'I feel nervous and unsafe' ...alert and oriented X3 [person, place, and surrounding] ...discharge patient from inpatient psychiatric unit ...obtain CT [computerized tomography] scanning of head without contract given history of head trauma last evening ...discharge patient from inpatient psychiatric unit ...home/self-care ..."

5. On 04/06/2022 at 1:00 PM, the Nurse Manager of IBHU (E #8) was interviewed. E #8 stated that patient (Pt. #2) was placed on physical hold three times and incurred physical injury while inside the patient room. E #8 stated that he's not sure how the injury occurred since there was no camera inside the patient room. E #8 stated that he's not sure why the staff did not call code gray for extra help or assistance.

6. On 04/06/2022 at 9:15 AM, the Registered Nurse (E #12) was interviewed. E #12 stated that the patient had growth disability with the mental capacity of a 4-year-old kid. E #12 stated that not sure why he was angry at the nurse. E #12 stated that she went to administer the medication to the patient and saw there was bleeding from the back of his head.

7. On 04/07/2022 at 9:30 AM, the Registered Nurse (E #13) was interviewed. E #13 stated that patient tried to strike at him so the Mental Health Worker inside the room along with him (E #13) tried to avoid patient from hitting the nurse, during the process patient was put on physical hold. E #13 stated that patient was on physical hold three times, during the altercation while inside the room patient bumped his head on the edge of the plastic bed.

8. On 04/07/2022 at 11:45 AM, an interview was conducted with the Psychiatrist/Medical Director of IBHU (MD #3). MD #3 stated that patient hold is considered as a restraint. MD #3 stated that appropriate technique for crisis intervention and providing patient safety as highest priority should have been considered during the staff altercation with the patient (Pt. #2).

Based on document review and interview, it was determined that for 1 of 2 (Pt. #2) clinical records reviewed for allegation of abuse, the Hospital failed to ensure the incidents of abuse was reported to the Illinois Department of Public Health, in accordance with applicable local, State or Federal law.

Findings include:

1. On 04/06/2022 at approximately 11:00 AM, the Hospital's Incidents log from 10/01/2021 to 04/05/2022 was reviewed. From the log one (Pt. #2) patient's abuse allegation was reviewed for incident of abuse allegation reporting and handling.

-Pt. #2's clinical record included the allegation of physical abuse on 02/25/2022 at 12:05 AM. The incident #22-135 included, Pt. #2 alleged being punched by the registered nurse causing bleeding from back of his head, was reviewed and analyzed by the hospital. The incident log indicated the documentation notifying the local state agency on 03/04/2022.

2. The Hospital's policy titled, "Patient Safety Event Reporting/Sentinel & Never Event Management" dated 07/2020 was reviewed and included, " ...Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient ...subjected to abuse in the hospital ...report to Patient Safety Department ...shall submit the report to the Illinois Department of Public Health within 24 hours after obtaining such report ..."

3. On 04/08/2022 at 1:30 PM, an interview was conducted with the Executive Director of Quality (E #20). E #20 stated that she would like to submit a preliminary notification regarding any type of abuse occurrence to the state agency. E #20 stated that the notification letter must be approved by the executive team, and it takes time and sometimes causes delay.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for restraints, the Hospital failed to ensure a physician's order was obtained for placing patient on physical restraints, as required by the Hospital's policy and procedure regarding use of restraints.

Findings include:

1. On 04/07/2022, the Hospital's policy titled, "Protective and Restraint Policy - Violent and Non-violent" dated 01/03/2022 was reviewed and included, " ...Restraint for Violent Behavior: A. Restrictive Holding: ...with knowledge of using the least restrictive strategies that maximize safety while also minimizing harm ...effective to protect the patient...from harm ...attending physician or designee shall be notified within twenty-four (24) hours of the initiation of the restraints...A restraint order must be obtained from a physician or nurse practitioner for each restraint episode..."

2. On 04/06/2022 at 10:30 AM, the clinical record for Pt. #2 was reviewed. Pt. #2 was brought into the ED on 02/24/2022 at 7:00 PM by the local police with chief complaint of behavioral aggression at home. Pt. #2 was admitted to the Inpatient Behavioral Health Unit (IBHU) with a diagnosis of psychosis. Pt. #2's clinical record included the following:

-The RN (E #13) progress note dated 02/25/2022 at 12:27 AM, included, "At approximately 12:15 AM, patient [Pt. #2] was presented with the consent for psychotropic medication consent ...ripped/tore the endorsed consent and seized clipboard...assistance was sought and the board was secured but not before the patient attempted on multiple occasions to strike staff...patient was released from the hold only to de-escalate..."

3. On 04/06/2022 at approximately 12:30 PM, the Hospital's document titled, "RN Witness Statement" dated 02/25/2022 at 7:09 AM, included, " ...patient [Pt. #2] placed in a physical hold three times, after he lunged at staff with intent to cause bodily harm...he was released no less than 3 times but proceeded to re-engage staff in a hostile manner. I witnessed multiple staff trying to de-escalate until patient capitulated and preventing 4-point restraint placement..."

4. On 04/07/2022 at 9:30 AM, the Registered Nurse (E #13) was interviewed. E #13 stated that patient was on physical hold three times, during the altercation while inside the room. E #13 stated that there is no electronic or paper format to document physical hold as restraints.

5. On 04/06/2022 at 1:00 PM, the Nurse Manager of IBHU (E #8) was interviewed. E #8 stated that patient (Pt. #2) was placed on physical hold three times. E #8 stated that physical hold is considered as physical restraints, he was not sure why a physician order was not obtained.

6. On 04/07/2022 at 11:45 AM, an interview was conducted with the Psychiatrist/Medical Director of IBHU (MD #3). MD #3 stated that patient hold is considered as a restraint. MD #3 stated that the provider order for restraints should have been obtained and documented in the clinical record.

7. On 04/07/2022 at 3:00 PM, an interview was conducted with the Vice-President of Care Transitions and Clinical Excellence (E #18). E #18 stated that even though a robust extensive education on restraints was provided to the staff, she clearly sees a disconnect in the process.

Based on document review and interview it was determined that for 2 of 3 (Pt. #9 and Pt. #10) clinical records reviewed for 4-point behavioral restraints, the Hospital failed to ensure the documentation of date and time for discontinuation of restraints as required.

Findings include:

1. On 04/07/2022, the Hospital's policy titled, "Protective and Restraint Policy - Violent and Non-violent" dated 01/03/2022 was reviewed and included, "...Restraint for Violent Behavior: A. Restrictive Holding: ...restraints must be discontinued at the earliest possible time by a Physician or RN ...documentation ...the restraints are discontinued ..."

2. On 04/07/2022, Pt. #9's clinical record was reviewed and included the following: Pt. #9 was admitted to the Inpatient Behavioral Unit (IBHU) on 08/09/2021 at 5:35 AM, with a diagnosis of schizophrenia. Pt. #9's physician order dated 09/01/2021 at 10:10 AM, included, "Patient very agitated, fighting with security staff, swinging hands/legs ...warranting emergency restraint for the protection of: both -self and others ...for up to four (4) hours for adults ...Type of Restraints: Locked ...Left Arm, Right Arm, Left Leg and Right Leg ...criteria for release of restraints are: No assaultive and self-harming behavior ..." Pt. #9's nurse progress note dated 09/01/2021 at 10:48 AM, included, " ...placed in 4-point Velcro for safety ...danger for self and others ..."

3. On 04/07/2022, Pt. #10's clinical record was reviewed and included the following: Pt. #10 was admitted to the IBHU on 03/03/2022 at 8:15 PM, with a diagnosis of bipolar disorder. Pt. #10's physician order dated 03/04/2022 at 5:00 PM, included, "Patient in a panic to leave...checking the doors, unable to follow directions...warranting emergency restraint for the protection of: both -self and others...for up to four (4) hours for adults...Type of Restraints: Locked...Left Arm, Right Arm, Left Leg and Right Leg...criteria for release of restraints are: No assaultive and no panicking behavior..." Pt. #10's nurse progress note dated 03/04/2022 at 8:15 PM, included, " ...placed in 4-point Velcro for safety ...restriction of rights form to follow ..."

4. Both Pt. #9 and Pt. #10's clinical records lacked the documentation for date/time when 4-point violent restraints were discontinued.

5. On 04/07/2022 at 10:30 AM, the Nurse Manager of IBHU (E #8) was interviewed. E #8 stated that the date and time for discontinuation of 4-point locked behavioral restraints should have been included in the restraints flowsheet.

6. On 04/07/2022 at 3:00 PM, an interview was conducted with the Vice-President of Care Transitions and Clinical Excellence (E #18). E #18 stated that even though a robust extensive education on restraints was provided to the staff, she clearly sees a disconnect in the process.

Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #9 and Pt. #10) clinical records reviewed for 4-point behavioral restraints, the Hospital failed to ensure patients were monitored while on behavioral restraints.

Findings include:

1. On 04/07/2022, the Hospital's policy titled, "Protective and Restraint Policy - Violent and Non-violent" dated 01/03/2022 was reviewed and included, "...Restraint for Violent Behavior: A. Restrictive Holding: ...documentation as an assessment and then ongoing assessment until the restraints are discontinued...elements monitored every (1) hour for physical assessment of patient by the Registered Nurse and every 15 minutes by a trained caregiver...ability to follow simple direction, level of agitation..."

2. On 04/07/2022, Pt. #9's clinical record was reviewed and included the following: Pt. #9 was admitted to the Inpatient Behavioral Unit (IBHU) on 08/09/2021 at 5:35 AM, with a diagnosis of schizophrenia. Pt. #9's physician order dated 09/01/2021 at 10:10 AM, included, "Patient very agitated, fighting with security staff, swinging hands/legs ...warranting emergency restraint for the protection of: both-self and others...for up to four (4) hours for adults...Type of Restraints: Locked ...Left Arm, Right Arm, Left Leg and Right Leg...criteria for release of restraints are: No assaultive and self-harming behavior ..." Pt. #9's nurse progress note dated 09/01/2021 at 10:48 AM, included, " ...placed in 4-point Velcro for safety ...danger for self and others ..."

3. On 04/07/2022, Pt. #10's clinical record was reviewed and included the following: Pt. #10 was admitted to the IBHU on 03/03/2022 at 8:15 PM, with a diagnosis of bipolar disorder. Pt. #10's physician order dated 03/04/2022 at 5:00 PM, included, "Patient in a panic to leave ...checking the doors, unable to follow directions ...warranting emergency restraint for the protection of: both -self and others ...for up to four (4) hours for adults ...Type of Restraints: Locked ...Left Arm, Right Arm, Left Leg and Right Leg ...criteria for release of restraints are: No assaultive and no panicking behavior..." Pt. #10's nurse progress note dated 03/04/2022 at 8:15 PM, included, " ...placed in 4-point Velcro for safety...restriction of rights form to follow..."

4. Both Pt. #9 and Pt. #10's clinical records lacked the documentation of every hour (1) - patient assessment by the registered nurse while on 4-point violent restraints.

5. On 04/07/2022 at 10:30 AM, the Nurse Manager of IBHU (E #8) was interviewed. E #8 stated that the he is not sure why the nursing assessment flowsheet was not completed while that patients were on 4-point locked behavioral restraints.

6. On 04/07/2022 at 3:00 PM, an interview was conducted with the Vice-President of Care Transitions and Clinical Excellence (E #18). E #18 stated that even though a robust extensive education on restraints was provided to the staff, she clearly sees a disconnect in the process.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for restraints, the Hospital failed to ensure documentation of a one-hour face-to-face evaluation was completed, as required.

Findings include:

1. On 04/06/2022, the Hospital's policy titled, "Protective and Restraint Policy - Violent and Non-violent" dated 01/03/2022 was reviewed and included, "...Restraint for Violent Behavior..effective to protect the patient ...every episode requires a physician or advance practice nurse complete a one hour face to face ...documentation as an assessment..."

2. On 04/06/2022 at 10:30 AM, the clinical record for Pt. #2 was reviewed. Pt. #2 was brought into the ED on 02/24/2022 at 7:00 PM by the local police with chief complaint of behavioral aggression at home. Pt. #2 was admitted to the Inpatient Behavioral Health Unit (IBHU) with a diagnosis of psychosis. Pt. #2's clinical record included the following:

-The RN (E #13) progress note dated 02/25/2022 at 12:27 AM, included, "At approximately 12:15 AM, patient [Pt. #2] was presented with the consent for psychotropic medication consent ...ripped/tore the endorsed consent and seized clipboard ...assistance was sought and the board was secured but not before the patient attempted on multiple occasions to strike staff ...patient was released from the hold only to de-escalate ..."

3. On 04/06/2022 at approximately 12:30 PM, the Hospital's document titled, "RN Witness Statement" dated 02/25/2022 at 7:09 AM, included, "...patient [Pt. #2] placed in a physical hold three times, after he lunged at staff with intent to cause bodily harm ...he was released no less than 3 times but proceeded to re-engage staff in a hostile manner..."

4. On 04/07/2022 at 9:30 AM, the Registered Nurse (E #13) was interviewed. E #13 stated that patient was on physical hold three times, during the altercation while inside the room. E #13 stated that there is no electronic or paper format to document physical hold as restraints.

5. On 04/06/2022 at 1:00 PM, the Nurse Manager of IBHU (E #8) was interviewed. E #8 stated that patient (Pt. #2) was placed on physical hold three times. E #8 stated that physical hold is considered as physical restraints, he was not sure why a face-to-face evaluation was not completed on the patient (Pt. #2).

6. On 04/07/2022 at 11:45 AM, an interview was conducted with the Psychiatrist/Medical Director of IBHU (MD #3). MD #3 stated that patient hold is considered as a restraint. MD #3 stated that the face-to-face evaluation should have been completed by the provider or Registered Nurse within 1-hour of placing patient on any type of restraints and documented in the clinical record.

7. On 04/07/2022 at 3:00 PM, an interview was conducted with the Vice-President of Care Transitions and Clinical Excellence (E #18). E #18 stated that even though a robust extensive education on restraints was provided to the staff, she clearly sees a disconnect in the process.