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Based on observation, document review, and interview, it was determined that the Hospital failed to protect and promote patient rights by ensuring that the patient's were provided care in a safe setting. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights was NOT met, as evidenced by:


1. The Hospital failed to ensure patients or their representatives participated in the treatment plan process. (A-130)


2. The Hospital failed to provide care in a safe setting by failing to ensure appropriate monitoring and reporting of a change in a patients condition, which resulted in Pt #1's elopement attempt. ( A-144A)

3. The Hospital failed to ensure patients received care in a safe setting by ensuring and maintaining a ligature and fall risk free environment, throughout the Specialty Pediatric Unit. (A-144B)

Based on document review and interview, it was determined, for 3 of 10 (Pt's #1, Pt #2, Pt #3) patients in the inpatient adult Behavioral Health Unit (2nd floor), the Hospital failed to ensure patients or their representatives participated in the treatment plan process. This has the potential to affect all patients in the inpatient Behavioral Health Unit.

Findings include:

1. On 7/22/2020 at approximately 10:00 AM, the Illinois "Mental Health and Developmental Disabilities (405 ILCS 5/) Mental Health and Developmental Code" was reviewed. Under Article I. Rights Sec. 2-102 "The recipient's preferences regarding emergency interventions under, subsection (d) of Section 2-200 shall be noted in the recipient's treatment plan".

2. On 7/21/2020 at approximately 1:00 PM-4:00 PM, the records of Pt's #1, Pt #2, and Pt #3 were reviewed with the Behavioral Health Unit Manager (E#1):

- Pt #1 was admitted on 5/26/2020 with a diagnosis of psychosis and suicidal ideation. The patients' preferences regarding emergency interventions or advanced directives was not indicated on the plan of care..

- Pt #2 was admitted on 5/23/2020 with a diagnosis of adjustment disorder. The patients' preferences regarding emergency interventions or advanced directives was not indicated on the plan of care..

- Pt #3 was admitted on 5/19/2020 with a diagnosis of schizo-affective bipolar type. The patients' preferences regarding emergency interventions or advanced directives was not indicated on the plan of care..
care.

3 During an interview on 7/21/2020 at approximately 4:00 PM, E#1 stated that the patients are given the "Statement of Illinois Law on Advance Directives" on admission. The patient can make the decision on discharge when they are stable, related to the mental health treatment preference. This is not a part of the plan of care.

4. During an interview conducted on 7/22/2020 at approximately 1:45 PM, the Nurse Manager of Quality (E#5) stated that we do not have the patient complete an advance directive of any type while the patient is a inpatient. The patient has to be psych stable to make this decisions. Rarely do we have an advance directive filled out on a psych patient regarding treatment preference."

A. Based on document review and staff interview it was determined in 1 of 10 patients (Pt#1), admitted to the Adult Behavioral Health Unit, the Hospital failed to provide care in a safe setting by failing to ensure appropriate monitoring and reporting of a change in a patients condition, which resulted in Pt #1's elopement attempt. This has the potential to affect all patients receiving care in the Behavioral Health Unit (current census of 16).

1. On 7/21/2020 at 1:00 PM, the medical record of Pt #1 was reviewed. Pt#1 presented to the emergency room on 5/25/2020 at approximately 5:05 AM, with a chief complaint of psychosis and suicidal ideation. Based on Pt#1's emergency room evaluation, Pt#1 was admitted to the adult psych unit as an involuntary admission on 5/26/2020 at 2:38 PM. Pt#1's treatment plan included being placed on suicide precautions 2, elopement precautions, aggressive behavior precautions. On 5/27/2020 at 2:49 PM, MD #1 wrote an order to discontinue SP2 (elevated suicide precautions), ordered SP (suicide precautions) and discontinued the elopement precautions "as patient had been calm and cooperative since her admission on 5/25/2020 and is denying any current plan or intent to harm self on unit or elope. The aggressive behavior precautions were still in effect.


2 Mental Health Technician (E#3) documented on 5/29/2020 at 12:57 PM, "Patient (Pt#1) was heard yelling out of Pt #1's room that (Pt#1) wants to see (Pt#1) family and if (Pt#1) can't (Pt#1) wants to leave. Unable to assess for SI/HI or AVH (assault risk), but will continue to monitor patient for SP (suicide precautions) and AP (assault precautions). Patient is focused on leaving." Pt #1's record lacked any documentation that staff identified or reassessed the safety risk for elopement or reported the issue to the charge staff and in the VERGE system. (electronic reporting system)

3 On 7/21/2020 at 2:00 PM, the Adverse Event Report dated 5/29/2020 was reviewed. The report indicated, Pt #1 was taken the patio with peers for group. Shortly after group started, Pt#1 was seen scaling the fence on the patio and climbing onto the roof. This writer (E#3) tried to redirect patient to come down, but patient continued to climb. This writer then opened the gate and ran after the patient on the roof. The writer was able to catch up to the patient and took the patient by the arm to prevent the patient from running or jumping off the roof. The tech (Mental Health Technician- E#2) then came and helped this writer. The tech (E#2) that was with this writer outside, knocked on the window to have the staff call a code and to have them bring the other patients inside. The tech (E#2) then came and helped this writer. Tech (E#2) took the patients' there arm and helped (E#3) walk the patient off of the roof. Pt#1 was resistant at first, but was able to walk back successfully. At this time additional staff and security came to assist. Pt#1 was brought back inside and staff talked to the patient and Pt #1 stated that (Pt#1) wanted to see (Pt#1) family. Denied any Suicidal ideation's. Pt #1 was able to calm down after spending a short time in the time out room and then Pt#1 was able to return to the MPR (multipurpose room)."

4 On 5/29/2020 MD#1 wrote an order to increase precautions to elopement, SP2 (suicide precautions), and assault due to Pt#1's elopement attempts and impulsive behavior. MD #1 was unavailable for interview during the survey.

5. The Hospital's Behavioral Health-Patient Safety and Monitoring policy (revised 5/2020) was reviewed on 7/22/2020 at 10:00 AM. The policy states "Staff who identify any safety risk, concern, or issue report the issue to charge staff and in the VERGE system."

6. According to hospital documents, A staff debriefing was held 5/29/2020 concerning Pt #1's attempted elopement and an action plan was implemented: 1. Patio closed until further notice 2. Sign out board for patients going outside 3. Obtain a doctor's order before patient can go outside on patio. However, the Hospital provided no documentation that re-education was conducted with E #3 concerning the reporting of changes of condition.

7. During an interview conducted on 7/21/2020 at 11:00 AM, Behavioral Health Nurse Manager (E#1) stated "I was not notified of any changes or concerns in Pt#1's elopement status or concerns of elopement. I was not made aware of this safety issue by E#3." E #1 offered no other information during the interview.

8. During an interview with E#2 on 7/22/2020 at 11:00 AM, E#2 denied being on cell phone during Pt #1's elopement attempt. E#3 was not available for interview in person and did not return phone calls to attempt phone interview on 7/22/2020. No other information was volunteered.

9. During the survey, the hospital provided no policy on taking behavioral health patients outside, only stattaing if group is held on patio 2 staff are with a maximum of 6 patients.

10. Security documentation was reviewed. Per security "the video surveillance for the camera which covers a small portion of the behavioral health patio only goes back to June 19, 2020. Therefore, no video available to review of the 5/26/2020 event.


B. Based on observation, document review, and staff interview, it was determined for all patients admitted to the Behavioral Health Specialty Pediatric Unit, the Hospital failed to ensure patients received care in a safe setting by ensuring and maintaining a ligature and fall risk free environment throughout the Specialty Pediatric Unit. This has the potential to affect all patients receiving care in the Specialty Pediatric Unit with a current census 7.


Findings include:

1. On 7/21/2020 at approximately 12:03 PM, a tour of the Behavioral Specialty Pediatric Unit was conducted with E#1. A electrical cord was noted to be plugged into the electrical outlet in the Specialty Pediatric Unit hallway. The electrical chord extended from the outlet in the hall way, down the floor for 9 feet into the entry of room B 264 to the rolling computer. The computer/cord was unattended.

2. The policy title "Mental Health Unit Safety Plan" (last revised by staff 3/2020) was reviewed on 7/22/2020 at approximately 1:30 PM. The policy states on page 2, under "11. All areas of employee, patient and visitor traffic will be kept free of obstructions, wire or chords".

3. During an interview conducted on 7/21/2020 at 1:30 PM, E#1 stated that extension cord was not to be left unattended in the hall. No further information was volunteered.