The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GOTTLIEB MEMORIAL HOSPITAL 701 WEST NORTH AVE MELROSE PARK, IL 60160 Feb. 6, 2014
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to ensure patient care plans were updated when the patient's needs/requests changed.

Findings include:

1. On 2/6/14 at 2:30 PM, hospital policy titled, "GMH Inpatient Electronic Medical Record (EMR) Documentation", effective date January 2013, was reviewed. The policy required, "J. Plan of Care: The nurse will begin documenting the plan of care... The RN will select an RN Diagnosis and document the current status... daily..."

2. From 2/5/14 at 10:00 AM through 2/6/14 at 3:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was an [AGE] year old male, admitted on [DATE], with a diagnosis of mental status changes. A physician's (MD #1's) order dated 12/29/13 at 3:38 pm included Ativan, 0.5 mg every 6 hours as needed for agitation. Ativan was administered on 1/5/14 at 11:58 PM. The ICU physician's (MD #2's) note dated 1/6/14 at 3:37 PM included, Pt. #1's daughters were upset because Pt. #1 was so drowsy and they requested Ativan not be administered to Pt. #1. MD #2 discontinued the Ativan order, which was transcribed by the ICU RN (E #7). However, the RN did not update Pt. #1's care plan to include the family request not to administer Ativan.

3. The 6 south unit RN's (E #4) note on 1/8/14 at 5:02 am, indicated Pt. #1 was agitated and MD #1 was called. MD #1's order dated 1/8/14, included Ativan 1mg intravenously now. Ativan was administered on 1/8/14 at 5:45 am, two days after the family requested no Ativan to be given.

4. On 2/6/14 at approximately 3:30 pm, the director of nursing stated that the request by the family to not administer Ativan should have been included in Pt #1's plan of care.