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A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that for 2 of 2, (Pt. #3 and #4) clinical records reviewed on the 3 South Unit, the Hospital failed to ensure advance directives were addressed in accordance with Hospital policy.

Findings include:

1. Hospital policy #65.007.002 entitled, "Advance Directives," was reviewed on 2/2/10 at approximately 2:00 P.M. The policy requires, "the existence of any advance directives will be documented in each patient's record."

2. Hospital policy entitled, "Living Will (Illinois Declaration)," reviewed on 2/2/10 at approximately 2:00 PM required, "..V. Procedure:..B. Procedure for Executing a Living Will...2. Once completed, the form should be copied, with the copy placed in the medical record, and the original returned to the patient for safe keeping."

3. The clinical record for Pt. #3 was reviewed on 2/2/10 at approximately 11:30 A.M. This was an 87-year-old female admitted 1/28/10 with a diagnosis of Hip Fracture. The record included documentation on the Nursing Admission Assessment, dated 1/28/10 that the patient had a Living Will. The record failed to include a copy of the Living Will or documentation of any attempts to obtain a copy.

4. The clinical record for Pt. #4 was reviewed on 2/2/10 at approximately 11:04 A.M. This was an 85-year-old female admitted 1/28/10 with a diagnosis of Acute Cerebral Vascular Accident. The record included documentation on the Nursing Admission Assessment, dated 1/28/10 that the patient had a Living Will. The record failed to include a copy of the Living Will or documentation of any attempts to obtain a copy.

5. The above findings were confirmed with the 3-South Nurse Manager, during an interview on 2/2/10 at approximately 12:00 P.M.

A. Based on a review of Hospital policy, observation, clinical record review, and staff interview, it was determined that for 2 of 2, (Pt. #3 and #4) clinical records reviewed for patients who were restrained, the Hospital failed to ensure a physician's restraint order was obtained.

Findings include:

1. Hospital policy #90.017.031 entitled, "Utilization of Restraint and Seclusion," was reviewed on 2/2/10 at approximately 2:30 P.M. The policy includes, "Restraint is any manual method, physical or mechanical device... that immobilizes or reduces the ability of a patient to move... freely... Inclusions... Side-rails to the bed, when all side-rails are in use simultaneously."

2. On 2/2/10 at approximately 10:58 A.M. a tour of room 315 was conducted. Pt. #3 was observed in bed with all side rails up.

3. The clinical record for Pt. #3 was reviewed on 2/2/10 at approximately 11:04 A.M. This was an 87-year-old female admitted 1/28/10 with a diagnosis of Hip Fracture. The record lacked documentation of a physician's order dated 2/2/10 for restraints (all side rails up).

4. On 2/2/10 at approximately 10:54 A.M. a tour of room 321 was conducted. Pt. #4 was observed in bed with all side rails up.

5. The clinical record for Pt. #4 was reviewed on 2/2/10 at approximately 11:30 A.M. This was an 85-year-old female admitted 1/28/10 with a diagnosis of Acute Cerebral Vascular Accident. The record lacked documentation of a physician's order dated 2/2/10 for restraints (all side rails up).

6. The above findings were confirmed with the 3-South Nurse Manager, during an interview on 2/2/10 at approximately 12:00 P.M.


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B. Based on review of the Hospital's "Restraint Order Form For Non Violent Behavior," clinical record review and staff interview, it was determined that in 1 of 1 (Pt. #2) clinical record reviewed for restraints, the Hospital failed to ensure the restraint order included documentation of justification for a patient placed on non-behavioral restraints.

Findings include:

1. The Hospital's "Restraint Order Form For Non Violent Behavior," was reviewed on 2/1/10 at 10:30 AM. The form required, "Justification for Restraints..."

2. The clinical record of Pt. #2 was reviewed on 2/1/10 at 10:30 AM. Pt. #2 was an 86 year old female admitted on 1/29/10 with diagnoses of Exploratory Laparotomy, Bowel Resection due to a Perforated Bowel. A signed physician restraint order form dated 1/29/10, indicated that soft limb restraints were initiated at 11:30 AM, on 1/29/10. The restraint order lacked the justification for the restraint.

3. The above finding was confirmed with the Nurse Manager of ICU during an interview on 2/1/10 at 10:30 AM

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 1 (Pt. #2) record reviewed for restraints, the Hospital failed to ensure patients placed on non-behavioral restraints were assessed every 2 hours as required by Hospital policy.

Findings include:

1. The Hospital policy #90.017.031 titled, "Utilization of Restraints and Seclusion" was reviewed on 2/1/10 at 11:00 AM. The policy required, "C. Restraints for NON-VIOLENT and NON-SELF-DESTRUCTIVE...2.a Ongoing RN assessments...1. RN reassessment of the patient will occur no less often than every 2 hours...the assessment may include, but not limited to...a. signs of injury associated with the restrains or seclusion...b. Circulation and range of motion in the extremities...e. hygiene and elimination...."

2. The clinical record of Pt. #2 was reviewed on 2/1/10 at 10:30 AM. Pt. #2 was an 86 year old female admitted on 1/29/10 with diagnoses of Exploratory Laparotomy, Bowel Resection due to a Perforated Bowel. A signed physician restraint order form dated 1/29/10, indicated that soft limb restraints were initiated at 11:30 AM, on 1/29/10. The clinical records lacked documentation of assessments for signs of injury (skin assessment) with the restraints, circulation and range of motion in the extremities, and hygiene and elimination from initiation at 11:30 AM until 7:30 PM (8 hours).

3. The above findings were confirmed with the Nurse Manager of ICU during an interview on 2/1/10 at 10:30 AM

A. Based on a letter of attestation and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days of discharge.

Findings include:

1. An Attestation letter from the Director of Health Information Management was presented on 2/1/10 at 11:00 AM. The letter indicated that as of survey date 2/1/10, there were 432 clinical records incomplete greater than 30 days.

2. The finding was confirmed with the Director of Health Information Management during an interview on 2/1/10 at 11:05 AM.