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.

NORTHSHORE UNIVERSITY HEALTHSYSTEM - EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON, IL 60201 Feb. 19, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 (Pt #1) of 10 clinical records reviewed for in-house transfer due to change of condition, the Hospital failed to ensure the patient's Power of Attorney (POA) was notified of the transfer.

Findings include:

1. Policy entitled "Patient Rights and Responsibilities" (reviewed 5/2014) indicated "Definitions: Agent: A person who is legally authorized to act on behalf of the patient. In Illinois, this would be a person who is named in a valid Power of Attorney for Healthcare document. 5. Information The patient has the right to obtain complete and current information about his/her diagnosis to the degree known, treatment ...and any known prognosis. In those cases when not medically advisable to provide such information to the patient, the information will be provided to a legally authorized individual. When so designated, the patient's agent or personal representative has the right to receive the required notice of patient's rights, to be involved in the development of the patient's plan of care, and receive the information required to help the patient make informed decisions. The patient and, when appropriate, the patient's family or legally authorized agent, has a right to be informed about outcomes of care, including unanticipated outcomes."

2. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of pulmonary edema/embolism. The clinical record contained a copy of Pt. #1's daughter as the POA. Pt. #1's medical history included dementia. On 11/28/15 at 2:30 PM due to recurrent desaturation (decreased oxygen levels) Pt. #1 was transferred to the intensive care unit (ICU). Pt. #1's clinical record lacked documentation that the Hospital notified Pt. #1's POA of the transfer.

3. The complaint investigation report was reviewed on 2/17/16. Pt. #1's daughter filed a complaint with multiple allegations that included she was not notified when Pt. #1 was transferred to the ICU. An internal investigation was performed and resulted in a "substantial event". The corrective actions included "MD (physicians) are responsible for the communication when patients are transferred to the ICU....document the communication ...in the record."

4. On 2/17/16 at approximately 12:30 PM the Intensivist (MD #1) was interviewed via telephone. MD #1 was the Intensivist who provided care to Pt. #1 while in the ICU. MD #1 stated, "typically, if urgent, the nurse will notify the family if the patient was transferred."

5. On 2/17/16 at approximately 1:00 PM the Resident of Internal Medicine (MD #2) was interviewed via telephone. MD #2 was the physician who attended Pt. #1 while admitted to the Medical unit (5 South). MD #2 stated there is not a set time to notify the relative that the patient was transferred to the ICU. MD #2 stated it is not required to document when the family had been transferred to another unit due to a change of condition. MD #2 "you can add the note in the progress note, but there is no rule that the family/POA be notified and that it needs to be documented."

6. On 2/18/15 at approximately 11:45 AM the findings were discussed with the Director of Accreditation and acknowledged that the medical staff who were interviewed were not clear on what the expectations are, of notifying the patients family member when they are transferred to the ICU. The Director stated "it's an issue that will be addressed."
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview, it was determined for 2 of 2 (Pts. #2 & 3) clinical records reviewed, the Hospital failed to ensure a discharge planning evaluation included an assessment of the patient's ability to perform activities of daily living (e.g. personal hygiene, grooming, dressing, feeding, bowel and bladder control, etc.)

Findings include:

1. On 2/17/16 at 2:05 PM, Hospital policy #CP-2025, titled, "Discharge Planning: Implementation and Documentation", approved 10/17/14, was reviewed. The policy required, "4. Procedure: 5. Document the initial assessment and identified needs in a preliminary plan in the medical record in the Interdisciplinary Care Plan..."

2. On 2/16/16 at 11:10 AM, Pt. #2's clinical record was reviewed. Pt. #2 was a [AGE] year old female, admitted on [DATE], with diagnoses of sepsis, urinary tract infection, and dementia. A "discharge planning" note dated 2/15/16 at 3:15 PM, included Pt. #2's family considering hospice and long term care. There was no documentation of Pt. #2's activities of daily living being evaluated. Pt. #2's Interdisciplinary Care Plan dated 2/10/16, did not include activities of daily living, other than bowel and bladder regulation.

3. On 2/17/16 at 11:00 AM, Pt. #3's clinical record was reviewed. Pt. #3 was an [AGE] year old male, admitted on [DATE], with a diagnosis of non-stemi myocardial infarction. Seven "discharge planning" notes dated 2/11/16 (2 notes), 2/12/16 (2 notes), 2/13/16, 2/14/16, and 2/16/16, included Pt. #3 would be discharged to a skilled nursing facility, however, the discharge planning notes did not include evaluation of Pt. #3's activities of daily living. Pt. #3's Interdisciplinary Care Plan dated, 2/3/16, included decreased activities of daily living for toilet transfer, standing at sink, and dressing. However, the plan did not address discharge needs related to these identified problems.

4. On 2/16/16 at 1:05 PM, an interview was conducted with the Manager of Case Management and Social Services (E #3). E #3 stated activities of daily living are discussed during multidisciplinary rounds each day and the Social Worker reviews the physical therapist's and occupational therapist's notes to determine the patient's activities of daily living when formulating a discharge plan. E #3 was unable to provide discharge assessment/planning notes for Pts. #2 & 3 addressing activities of daily living being evaluated.

B. Based on document review and interview, it was determined for 2 of 2 (Pts. #2 & 3) clinical records reviewed, the Hospital failed to implement a standard process for notifying patients, or their representatives, they may request a discharge planning evaluation.

Findings include:

1. On 2/17/16 at 2:05 PM, Hospital policy #CP-2025, titled, "Discharge Planning: Implementation and Documentation", approved 10/17/14, was reviewed. The policy required, "4. Procedure: 4. Consult with the patient, the patient's representative or other responsible party regarding the anticipated continuing care needs..."
The policy did not identify the discipline of the individual assigned to consult with the patient and there were no instructions how a patient would request a discharge planning evaluation.

2. On 2/17/16 at 2:15 PM, the patient handout folder provided to admitted patients or their representatives was reviewed. The information contained in the folder did not include information on requesting a discharge planning evaluation.

3. On 2/17/16 at 11:20 AM, an interview was conducted with Pt. #9. Pt. #9 was a [AGE] year old male, admitted on [DATE], with diagnoses of gait imbalance and diffuse weakness. Pt. #9 stated he had not been told he could request a discharge planning evaluation.

4. On 2/17/16 at 11:30 AM, an interview was conducted with Pt. #10. Pt. #10 was a [AGE] year old female, admitted on [DATE], with diagnoses of facial droop and Bells Palsy vs coronary vascular accident. Pt. #10 stated she had not been told he could request a discharge planning evaluation.

5. On 2/17/16 at 11:30 AM, an interview was conducted with the 3 East Clinical Coordinator (E #2). E #2 stated discharge planning evaluations are discussed during the interdisciplinary rounds and patients have the opportunity to request discharge planning at that time.





C. Based on document review and interview, it was determined for 1 of 2 (Pt #1) clinical records reviewed for discharge planning, the Hospital failed to ensure the assessment included the patient's insurance coverage for hospices services, thus resulted in delay of discharge.

Findings include:

1. Policy entitled "Intake Policy" ( reviewed 1/2014) indicated "5. B. When the payer source is private insurance, the insurance coverage will be verified...After this is done the form is filled out and then taken to patient for explanation and signature."

2. On 2/16/16 the clinical record of Pt #1 was reviewed, and included the patient was a [AGE] year old female admitted on [DATE] with a diagnosis of pulmonary embolism. On 11/29/15 at 1:44 PM a physician's order was obtained for a "Hospice outpatient referral". The Hospice liaison contacted Pt #1's Power of Attorney (POA-daughter). On 11/30/15 at 2:43 PM the Hospice Liaison documented, "Hospice questions were answered, daughter/POA signed the consents." Plan was for Pt #1 to return the following day 12/1/15 to the nursing home with hospice services. The arrangements were made for the durable medical equipment (DME) to be delivered to the nursing home where Pt #1 resided. The clinical record failed to include an assessment of Pt. #1's insurance to validate or verify hospice care coverage prior to obtaining consents and arranging for the DME to be delivered, resulting in a (1) day delay in discharge.

3. The above findings were discussed with E #6 and Director of Accreditation on 2/18/16 at approximately 9:40 AM, who stated that it was not their normal practice to not verify for insurance coverage, and should have should have been checked prior to making all the arrangements for the transfer, the hospice care and DME.