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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure appropriate supervision and monitoring to prevent psychiatric patient from eloping. See A-144 A.

2. The hospital failed to ensure care in a safe setting by failing to ensure staff followed the response and notification process for patients that eloped. See A-144 B.

The immediate jeopardy (IJ) was identified on 7/25/2024 at 42 CFR 482.13 Patient Rights, due to the Hospital's failure to ensure appropriate supervision for 1 of 2 patients (Pt. #1) on high suicide risk and the failure to follow the emergency response and notification processes for 2 of 2 patients (Pt. #1 and Pt. #7) on suicide risk that eloped from the Emergency Department. The IJ was announced on 6/25/2024 at 3:15 PM during a meeting with the Chief Clinical Officer, Executive Director of Nursing, and Executive Director of Quality, Informatics, and Diversity Equity and Inclusion, and was not removed by the survey exit date of 6/25/2024.

A. Based on document review, video surveillance review, and interview it was determined that for 1 of 2 patients (Pt. #1) reviewed with high risk for suicidal ideation (SI) in the Emergency Department (ED), the hospital failed to ensure appropriate supervision and monitoring to prevent psychiatric patients from eloping. This has the likelihood to cause serious harm to any suicidal patient that presents to the hospital.

Findings include:

1. The hospital's policy titled, "Suicide Risk Assessment" (revised 04/2022) was reviewed and required "One to one observation (1:1) means one observer to one patient within line of sight ... If the suicide risk identifies a high suicide risk, the nursing staff will place the patient on one to one (1:1) precautions at all times by a competent health care provider who is constantly observing the patient ...V. Procedure... 4. Emergency Department ... c. If one to one ... is required based upon the patient's level of suicide risk, the required observation will be recorded on a Constant Observation (CO) flowsheet (every 15-minute recording of a patient's activity, behavior, and location) ..."

2. On 6/20/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to hospital ED on 06/16/24 via ambulance from a psychiatric hospital due to chest pain. The clinical record included the following:

-On 06/16/24 at 11:48 AM, a Petition for Involuntary/Judicial Admission from psychiatric hospital, included, "(Pt. #1) here with plan to OD (overdose) on medication with SI."

-On 06/16/24 at 1:27 PM, the ED Triage note by E #1 (ED Charge Nurse), included, " ... CSSRS (Columbia Suicide Severity Rating Scale) Screen: Assessed Risk: High ..."

-On 06/16/24 at 3:27 PM, ED Nursing note (by E #1) included, "(Pt. #1) from (psychiatric hospital) certified and petitioned. (Pt. #1) had sitter from (psychiatric hospital) at bedside. (Pt. #1) arrived with phone ... had visitor arrive; (visitor) left shortly after arriving to bring (Pt. #1) food ... (Pt. #1) told sitter (Pt. #1) had to use the bathroom ... walked over with sitter ... (Pt. #1) eloped with IV (intravenous catheter) through open door. Security chased (Pt. #1). A vehicle was parked right outside ER(emergency room) entrance, (Pt. #1) entered vehicle and drove with door open and almost hit staff/security. CPD (Chicago Police Department) called, notified them of the details at approximately 3:25 PM."

The clinical record did not indicate that the hospital provided a competent health care provider employed by the hospital to conduct one-to-one observation for Pt. #1. There was no constant observation flowsheet completed by staff for Pt. #1.

3. On 06/20/24 at 1:30 PM, a video surveillance for the ED on 06/16/24 during Pt. #1's elopement was reviewed with the Manager of Public Safety (E #7):

-At 3:18:40 PM, Pt. #1 along with a visitor (male) walked around the side of the ED registration desk and exited the hospital via the ED entrance. There were no attempts by staff to prevent Pt. #1 from exiting the ED.
-From 3:18:56 PM to 3:21:10 PM, a Registered Nurse (RN/E #8), the Security Officer (E #10), an ED Technician (E #9) and the sitter from the psychiatric hospital is observed walking out the ED entrance door toward the direction Pt. #1 eloped and then return to the ED.

4. An interview was conducted with the Manager of Public Safety (E #7) on 06/20/24 at 12:35 PM. E #7 stated that today (6/20/24) is the first time that the video footage has been reviewed by the hospital.

5. On 6/20/2024 at 1:10 PM, the Executive Director of Nursing (E #3) and the Chief Clinical Officer (E #6) were interviewed. E #3 and E#6 stated they were not made aware of this incident, and there has not been an incident report created other than a nurse's note in the patient's (Pt. #1's) clinical record. E #6 stated that CPD was notified of (Pt. #1's) elopement, and there has not been a follow up.

6. An interview was conducted with an ED Charge Nurse (E #1) on 06/21/24 at 10:10 AM. E #1 also stated that the hospital does not provide a sitter if a patient comes with a sitter from the psychiatric hospital. Regarding monitoring of suicidal patients, E #1 was not aware if the hospital provides training or competency to the sitters from the psychiatric hospital. E #1 stated E #1 was not present when Pt. #1 eloped. E #1 stated that since the incident, E #1 has not been approached by leadership or administration to discuss this incident.

7. An interview was conducted with a Registered Nurse (RN/E#2/Pt. #1's ED RN) on 06/21/24 at 11:53 AM. E #2 stated that the hospital does not provide a sitter if they come with their own sitter from the psychiatric hospital. E #2 did not witness Pt. #1 elope from the hospital. E #2 only became aware from another ED staff that Pt. #1 asked to use the bathroom which was near an entrance and ran away when the door opened. E #2 stated that other than the sitter from the psychiatric hospital, there was no staff monitoring Pt. #1 while E #2 was attending the needs of other patients. E #2 stated that E #2 has not been approached by administration to discuss this incident or provided with education on this type of incident.


B. Based on document review, and interview, it was determined that for 2 of 2 patients' clinical records (Pt. #1 and Pt. # 7) reviewed for elopement, the hospital failed to ensure care in a safe setting by failing to ensure staff followed the response and notification process for patients that eloped.

Findings include:

1. The hospital's policy titled, "Code Gold-Elopement" (revised 08/2018) was reviewed and required, "Elopement: legally defined as a patient who is incapable of adequately protecting himself and who departs the health care facility ... Staff member discovering the absence of a patient will immediately: 1. Call the emergency number ... give the location and description of patient to the operator so that the alert can be sent out through the overhead and text paging system ..."

2. On 6/20/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the ED on 06/16/24 via ambulance from a psychiatric hospital for complaint of chest pain. The clinical record included the following:

-On 06/16/24 at 11:48 AM, a Petition for Involuntary/Judicial Admission from psychiatric hospital, included, "(Pt. #1) here with plan to OD (overdose) on medication with SI."

-On 06/16/24 at 1:27 PM, the ED Triage note by E #1 (ED Charge Nurse), included, " ... CSSRS (Columbia Suicide Severity Rating Scale) Screen: Assessed Risk: High ..."

-On 06/16/24 at 3:27 PM, the ED Nursing note (by E #1) included, "(Pt. #1) from (psychiatric hospital) certified and petitioned. (Pt. #1) had sitter from (psychiatric hospital) at bedside. (Pt. #1) arrived with phone ... had visitor arrive; (visitor) left shortly after arriving to bring (Pt. #1) food ... (Pt. #1) told sitter (Pt. #1) had to use the bathroom ... walked over with sitter ... (Pt. #1) eloped with IV (intravenous catheter) through open door. Security chased (Pt. #1). A vehicle was parked right outside ER (emergency room) entrance, (Pt. #1) entered vehicle and drove with door open and almost hit staff/security. CPD (Chicago Police Department) called, notified them of the details at approximately 3:25 PM." Pt. #1 was not apprehended.

The clinical record did not indicate that a Code Gold was activated when Pt. #1 eloped from the ED.

3. Pt. #7's clinical record indicated that on 4/22/2024 at 10:38 PM, Pt. #7 was brought to the hospital's ED due to self-harming behavior. Suicide risk for Pt. #7 was rated as moderate. The clinical record included the following:

- On 4/23/2024 at 12:44 AM, the ED nurses' notes indicated, "(Pt. #7) went to use bathroom accompanied by sitter. Sitter attempting to redirect (Pt. #7) back to bed. Registration requesting (Pt. #7) sign consent paperwork ... Registration opened doors to speak to (Pt. #7's) boyfriend, (Pt. #7) then ran through double doors, (Pt. #7) pushed registration clerk away from door, running through doors ..." Pt. #7 was not apprehended.

The clinical record did not indicate that a Code Gold was activated when Pt. #7 eloped from the ED.

4. The hospital's security/code response logs from 4/1/2024 through 6/20/2024 was reviewed. The logs did not indicate that Code Gold was activated when Pt. #1 and Pt. #7 eloped from the hospital's ED.

5. On 6/20/2024 at 12:35 PM, an interview was conducted with the Manager of Public Safety (E #7). E #7 stated that a "Security Code Log" did not indicate that a Code Gold was activated for (Pt. #1's) elopement and should have been called. E #7 stated that the Code Gold provides staff with the location and description of the patient. This information is needed to ensure all staff are aware and on the lookout.

6. On 6/20/2024 at 1:10 PM, the Executive Director of Nursing (E #3) and the Chief Clinical Officer (E #6) stated they were not made aware of these incidents, and no incident reports were created. E #6 stated that CPD was notified of (Pt. #1's) elopement, and there has not been a follow up. The ED Director (E #11) and the ED Medical Director (MD #1) could not provide documentation regarding the outcome of the investigation regarding Pt. #7's elopement.

7. On 6/21/2024 at approximately 12:00 PM, interviews were conducted with E #11 and the (MD#1). E #11 and MD #1 could not provide documentation that a Code Gold was activated when Pt. #7 eloped from the ED. E #11 stated it should be documented in Pt. #7's clinical record.

8. On 6/21/24 at approximately 12:00 PM, interviews with E #1 and E #2 (ED Registered Nurses) were conducted. E #1 and E# 2 stated that they did not activate or hear that a Code Gold was activated for Pt. #1. E #1 stated that a Code Gold was not called because the patient had already left the facility. E #2 stated there was no code called since staff saw the patient leave and was no longer in the ED, therefore a Code Gold was not needed.

Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #8 and Pt. #9) clinical records reviewed regarding use of violent restraints, the hospital failed to ensure that documentation of every 15-minute monitoring was completed, as required.

Findings include:

1. On 6/25/2024, the hospital's policy titled, "Restraint and Seclusion" (2/2022) was reviewed and included, "... V. Procedure... 3. Once the restraints are applied begin documentation in the EMR (electronic medical record) C... 3... Violent Restraint Track. Continuous monitoring with real time documentation of assessment of restrained patient at least every 15 minutes..."

2. On 6/25/2024, the clinical record of Pt. #8 was reviewed. On 6/08/2024, Pt. #8 was in the hospital's ED (emergency department) due to alcohol intoxication. On 6/8/2024 at 1:22 AM, the physician's progress notes indicated that Pt. #8 was placed in physical restraint, and a physician's order for a violent restraint was also ordered. However, there was no every 15-minute documentation while Pt. #8 was placed in restraints.

3. On 6/25/2024, the clinical record of Pt. #9 was reviewed. On 6/18/2024, Pt. #9 was in the hospital's ED due to alcohol intoxication. On 8/8/2024 from 5:26 PM through 7:29 PM, Pt. #9 was placed in violent restraints. There was no every 15-,minute documentation while Pt. #9 was placed in restraints.

4. On 6/25/2024 at approximately 10:00 AM, findings were discussed with E #11 (ED Director). E #11 confirmed that the clinical records indicated that Pt. #8 and Pt. #9 were placed in violent restraints. E #11 stated that there should be every 15-minutes documentation while Pt. #8 and Pt. #9 were in restraints.

A. Based on observation, document review, and interview, it was determined that for 2 of 3 emergency crash carts (#68548 and #68535) in the ED (emergency department), the hospital failed to ensure that that crash carts were checked, as required.

Findings include:

1. On 6/20/2024 from 9:45 AM through 11:30 AM, an observational tour of the hospital's ED was conducted. The ED has a capacity of 12 beds with a current census of three patients. The ED has three emergency crash carts. The Emergency Equipment Checklist for Crash Carts with lock #68548 and #68535 were not checked on 6/12/2024 and 6/17/2024.

2. On 6/20/2024, the hospital's policy for the ED titled, "Crash Carts: Emergency Medication Audits and Replacement" (10/2021) was reviewed and included, " ... III ... Emergency medication carts ... will be accurately stocked and available for use in the event of sudden, unforeseen, and life-threatening patient care emergencies ... IV. Procedure.. 2. Once a day, the integrity of each crash cart will be checked by nursing and documented on the Emergency Equipment Checklist ..."

3. On 6/20/2024 at approximately 11:30 AM, findings were discussed with E #4 (ED Charge Nurse). E #4 stated that the crash carts should be checked daily.

B. Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #3 and Pt. #4) clinical records reviewed for assessment/reassessment in the ED, the hospital failed to ensure reassessment was conducted, as required.

1. On 6/20/2024, the clinical record of Pt. #3 was reviewed. On 6/20/2024, Pt. #3 was in the hospital's ED due to leg swelling. Pt. #3 was triaged with an ESI (emergency severity index of 3/urgent). There was no reassessment for Pt. #3 from 2:55 AM through 9:47 AM (approximately 5 hours and 8 minutes).

2. On 6/20/2024, the clinical record of Pt. #4 was reviewed. On 6/19/2024, Pt. #4 was in the hospital's ED due to suicidal ideation. Pt. #4 was triaged with an ESI of 2/emergent. On 6/20/2024 at 3:15 AM, Pt. #4 was transferred to another hospital . There was no reassessment for Pt. #4 from 6/19/2024 at 6:36 PM through 6/20/2024 at 3:15 AM (approximately 9 hours).

3. On 6/25/2024, the hospital's policy in the ED titled, "Patient Screening, Assessment, Reassessment and Plan of Care" (2/2021) was reviewed and included, " ... IV ... 4. Screening & Reassessments for Emergency ... i. Each patient is screened/reassessed as necessary based on their current condition and identified problems ... ii. At the direction of the licensed practitioner, patient care setting, standard of care ... reassessment of patients may include the following ... a. vital signs ..."

4. On 6/25/2024 at approximately 10:00 AM, findings were discussed with E #11 (ED Director). E #11 stated that vital signs in the ED should be checked at least every 4 hours.