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Based on document review, observation and interview, it was determined that for 1 of 1 patient (Pt. #26) on the Pediatric Intensive Care Unit (PICU) and 1 of 3 patients (Pt. #23) with restraint usage, the Hospital failed to ensure patients' rights were protected. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not met. This potentially placed all patients at risk for harm.

Findings include:

1. The Hospital failed to ensure immediate and coordinated action was taken during an unwitnessed infant/child abduction drill. See deficiency at A -144 A.

2. The Hospital failed to ensure all Hospital disciplines participated in an unwitnessed infant and/or child abduction drill. See deficiency at A - 144 B.

3. The Hospital failed to ensure restraint orders were complete, to include proper length of time for restraint application. See deficiency at A - 171.

A. Based on document review, interview, and observation, it was determined that for 1 of 40 pediatric patients (Pt. #26) on the Pediatric Intensive Care Unit (PICU), the Hospital failed to ensure immediate and coordinated action was taken during an unwitnessed infant/child abduction drill. This potentially affects all 215 patients on census on 8/8/17.

Findings include:

1. On 8/9/17 at 2:00 PM, the Hospital policy titled, "Management of Infant or Child Abduction", effective 5/13/11, was reviewed. The policy required, "I. Purpose..If the infant or child is presumed to be missing...refer to Administrative Policy entitled 'Elopement Risk Response'...IV. Procedures: A. First Response... 2. Reported Abduction. Staff who discovers the possibility of child abduction incident should search the entire area where the child was last seen immediately. a. Perform a head count of all patients to confirm missing child...3. Immediately notify Medical Center Operator [x 7444] to make the announcement throughout the Medical Center, 'Code Pink'..."

2. The Hospital Administrative policy entitled, "Elopement Risk Response," (approval date 8/1/2016) required, "...Definitions...Missing Person: a patient who is not in his or her room and who cannot be quickly located on the inpatient unit...IV Procedures...D. Response to the Discovery of a Missing Patient: 1. The nurse responsible for the patient's care and/or the Charge Nurse will perform the following: a. contact the Security Services Department promptly. b. Perform a search of the inpatient unit with other unit staff. 2. The Security Services Department will perform the following..."

3. The Security Department policy entitled, "Infant Abduction (Code Pink)," (effective date 5/11/16) required, "...II. Procedures: A. First Response. Once Security is notified Officer will need to get the following information...Security immediately responds to last known location of infant or child and secures the area. Dispatcher will immediately place Camera Monitors on Code Pink Settings..."

4. The Hospital's Switchboard policy entitled, "Code Pink," (effective 6/11/13) required, "Purpose...A report of an infant or child abduction should only be implemented if it is either known or believed a child has been abducted. Procedure: I. Staffs who discovers the possibility of child abduction should immediately notify Lurie Children's Hospital operator to make the announcement..."

5. On 8/9/17, between 10:30 AM and 11:50 AM, an observational tour was conducted on the PICU. At 11:25 AM a Code Pink Drill for an "unwitnessed" abduction for the infant in room 1618, with the consent of the Mother, was initiated. At 11:25 AM, the Manager of the PICU (E #6) called extension 7444, Medical Center Operator, to report a Code Pink and then at 11:27 AM, E #6 called the PICU Clerk, to inform staff of the Code Pink. At approximately 11:28 AM, one (1) Security Officer (E #15) arrived on the PICU (prior to the Code Pink announcement).

6. At 11:34 AM, the overhead page announced a Code Pink (infant/child abduction) drill for room 1616 and not for room 1618. The Code Pink Drill was announced 8 minutes after the initial call to extension 7444 call and 6 minutes after calling the PICU Clerk.

7. A Housekeeper (E #7), was cleaning a room and paid no attention to the Code Pink Drill. E #7 was asked what he was supposed to do during a Code Pink. E #7 stated that he did not know what to do during a Code Pink Drill.

8. Prior to beginning the Code Pink Drill, there were 10 staff, including physicians (E #8 - 12 and MD #1 - 5) making rounds on the PICU. When the Code Pink was announced on the overhead pager, the rounding staff took no action related to the Code Pink announcement, and continued rounding. The Code Pink Drill was deactivated at 11:45 AM.

9. On 8/9/17 at 10:35 AM, an interview was conducted with the PICU Manager (E #6). E #6 stated there has never been an infant or child abduction on the PICU. On 8/9/17 at 11:50 AM, a second interview was conducted with E #6, and E #6 stated that she did not know why it took so long for the operator to announce the Code Pink Drill. The rounding staff was providing patient care, so they could not participate in the Code Pink Drill.

10. On 8/11/17 at approximately 10:40 AM, E #6 was interviewed and stated that, "I called the Unit Clerk to inform her and the staff of the abduction because there was a delay in the overhead notification from the switchboard. The Security responded before the overhead call because 7444 is an emergency number and security answers at the same time as the operator. I don't know why there was a delay in the overhead announcement. The operator sounded nervous."

B. Based on document review and interview, it was determined that for 12 of 12 Code Pink Drills reviewed, for 2016 and 2017, on the Pediatric Intensive Care Unit (PICU), the Hospital failed to ensure all Hospital disciplines participated in an infant and/or child abduction drill. This potentially placed 40 PICU patients on census on 8/8/17 at risk.

Findings include:

1. On 8/9/17 at 2:00 PM, the Hospital policy titled, "Management of Infant or Child Abduction", effective 5/13/11, was reviewed. The policy required, "I. Purpose...If the infant or child is presumed to be missing ...refer to Administrative Policy entitled, 'Elopement Risk Response'...3. Immediately notify Medical Center operator..."

2. The Administrative Policy entitled, "Elopement Risk Response," (approval date 8/1/2016) required, "...IV. A. Prevention. 1. While this policy and procedure establishes general and specific guidelines for a secure environment for patients, a key component to achieving successful implementation of the policy is clinician awareness and clear communication... a. Physicians, Nurses , Security Services Department staff and support staff will complete mandatory,scenario-based education...D. Response to the Discovery of a Missing Patient: 1. The nurse responsible for the patient's care and/or the Charge Nurse will perform the following: a. Contact the Security Services Department promptly. b. Perform a search of the inpatient unit with other unit staff...."

3. On 8/9/17 at 2:15 PM, the Hospital's PICU Code Pink (infant/child abduction) Drill Critique Forms for 2016 and 2017 were reviewed. The PICU Code Pink Drill Reports included attendance of 37 nursing staff out of a roster of 169, during 12 drills on the day, evening and night shifts. The reports did not indicate that physicians, respiratory therapists, housekeeping, or other disciplines participated in the drills.

4. On 8/10/17 at 12:20 PM, an interview was conducted with the the Director of Security Services (E #5). E #5 stated that the expectation for Code Pink Drill staff attendance is to get as many staff as possible involved in the drill, but there is no set requirement. All staff receive annual Code Pink education. E #5 stated that during a Code Pink Drill, all staff should be involved, including housekeeping and physicians.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #23) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure restraint orders were complete to include proper length of time for restraint application.

Findings include:

1. On 8/10/17 at 11:35 AM, the Hospital policy titled, "Restraint and Seclusion", effective date 9/9/08 was reviewed. The policy required, "Order is time limited as follows: 4 hours for patients age 18 years and older; 2 hours for patients age 9 - 17..."

2. On 9/10/17 at 10:48 AM, Pt. #23's clinical record was reviewed. Pt. #23 was a 16 year old male seen in the Emergency Department on 8/3/17 for a complaint of acute alcohol intoxication. Pt. #23's restraint order dated 8/3/17 at 2:57 PM, included, "Duration: 4 hours (age 18 and over)". Pt. #23 was 16 years old.

3. On 8/10/17 at 10:50 AM, an interview was conducted with the ED Manager (E #2). E #2 stated Pt. #23's order should have been for 2 hours, not 4 hours.

Based on document review and interview, it was determined that the Hospital's Health Information Management Department failed to ensure the completion of medical records within 30 days of discharge, as required.

Findings include:

1. The Hospital's Medical and Dental Staff policy entitled, "Delinquent Records" (revised 10/31/13) was reviewed on 8/9/17 and required, "...Delinquent records are defined as those that remain incomplete 30 days post discharge..."

2. On 8/9/17 at approximately 3:00 PM, the Director of Health Information Management (E #3) presented the surveyor with a letter of attestation which included, "...[Hospital], as of 8/9/17, has a total of 55 delinquent records."

3. During an interview with the Senior Director of Accreditation (E #4) on 8/10/17 at approximately 9:30 AM, E #4 stated that the clinical records should be complete within 30 days after discharge.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on August 8 through August 10, 2017 the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on August 8 through August 10, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, interview, and document review it was determined that for 1 of 4 physicians (MD #1) observed on the Pediatric Intensive Care Unit (PICU), the Hospital failed to ensure PPE (personal protective equipment) was utilized as required.

Findings include:

1. On 8/9/17 from 10:50 AM to 11:55 AM, an observational tour was conducted on the Pediatric Intensive Care Unit (PICU). Signage posted outside room 1618 included, "Stop all persons entering-Contact Isolation...Wear an isolation gown."

2. On 8/9/17 at 11:40 AM, a Fellow (MD #1) was observed entering room 1618, posted as Contact Precautions, without wearing a gown.

3. On 8/9/17 at 11:44 AM, an interview was conducted with MD #1, who stated "I should have put a gown on."

4. On 8/9/17 at 1:00 PM, the Hospital policy titled, "Isolation Transmission-Based Precautions, effective date 2002, was reviewed. The policy included, "...L. Physician Responsibility: It is the responsibility of the Physician staff caring for a patient in isolation to... practice the proper technique of barrier use... IV. Procedures.... A. 2. Personal Protective Equipment (PPE) use for all patients on Transmission- Based Isolation... b. Don appropriated PPE for each entry into the room regardless of purpose of entry...."