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.

PRESENCE SAINT FRANCIS HOSPITAL 355 RIDGE AVE EVANSTON, IL 60202 Sept. 16, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, it was determined that for 1 (Pt #1) of 10 clinical records reviewed for Patients Rights, the Hospital failed to ensure patient care was provided in a safe manner. As a result the Condition of Participation 42 CFR 482.13 Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure the patient's care was provided in a safe environment (A-144).

2. The Hospital failed to ensure the patient was free from abuse (A-145)

3. The Hospital failed to ensure staff used de-escalation techniques with a disruptive patient, provide a safe environment and prevent harm (A-199).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 (Pt #1) of 3 clinical records reviewed , the Hospital failed to ensure the patient was not injured during provision of care.

Findings include:

1. Policy entitled " Patient Rights and Responsibilities" (revised 7/12/13), indicated "VI. A 1. Patients Rights - All patients have the right: ...g. ... to have a safe environment..."

2. On 9/8/2016 the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male that arrived on 8/29/2016 to the Emergency Department (ED) escorted by the local fire department for a medical evaluation due to agitation and combativeness. Pt #1 was assigned to the Crisis Room (CR). The clinical record of Pt #1 contained pictures dated 8/30/2016 at 10:00 AM that included Pt #1's facial bruises and back lacerations.

3. The "Risk Management Worksheet" dated 8/29/2016 at 11:45 PM written by E #8 (Pt #1's assigned nurse in the ED) indicated "Patient became combative and aggressive. Security was at bedside and patient (Pt #1) was to be medicated...Staff got patient down on cart. Patient was hit in the face by one of the bedside officers. Patient had bruising to left eye after the incident."

4. On 9/8/2016 at approximately 2:48 PM the ED physician on duty (MD #1) assigned to Pt #1 was interviewed. MD #1 stated Pt #1 was very agitated and required to be physically and chemically restrained. MD #1 stated I was observing the video monitor and I saw two security officers in the (CR) with Pt #1. MD #1 stated "one (1) of the 2 officers appeared to have taken a swing at the patient (Pt #1). The other security officer put his hands around the patient's (Pt #1) neck." MD #1 stated she entered the CR and noticed Pt #1 had a bruise on his forehead and a laceration on his nose. MD #1 stated Pt #1 did not have any injury to the face when she initially evaluated him."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 (Pt #1) of 10 clinical records reviewed for abuse, the Hospital failed to ensure the patient was free from abuse.

Findings include:

1. Policy entitled, "Abuse Prevention" (revised 3/2016) indicated "V. Definitions A. 1. Abuse: Abuse means any physical ...inflicted upon a resident other than by accidental means at the facility.... 2. Physical Abuse includes hitting...and controlling behavior through corporal punishment...VI. (Hospital) is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff...A. The facility (Hospital) prohibits ...abuse of its residents. (Hospital) has attempted to establish a resident sensitive and resident secure environment by: 2. Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse."

2. On 9/8/2016 the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male that arrived on 8/29/2016 to the Emergency Department (ED) escorted by the local fire department for a medical evaluation due to agitation and combativeness. Pt #1 was assigned to the Crisis Room (CR) in the ED. The clinical record of Pt #1 contained pictures dated 8/30/2016 at 10:00 AM that included Pt #1's facial bruises and back with lacerations.

3. The "Risk Management Worksheet" dated 8/29/2016 at 11:45 PM written by E #8 (Pt #1's assigned nurse in the ED) indicated "Patient became combative and aggressive. Security was at bedside and patient (Pt #1) was to be medicated...Staff got patient down on cart. Patient was hit in the face by one of the bedside officers. Patient had bruising to left eye after the incident."

4.On 9/8/2016 at approximately 2:48 PM the ED physician (MD #1) assigned to Pt #1 was interviewed. MD #1 stated Pt #1 was very agitated and required to be physically and chemically restrained. MD #1 stated "I was observing the video monitor and I saw two security officers in the (CR) with the patient (Pt #1). I could not identify the Security Officers due to there backs were toward the surveillance camera." MD #1 stated "one (1) of the 2 officers appeared to have taken a swing at the patient (Pt #1), the other security officer put his hands around the patient's (Pt #1) neck." MD #1 stated she went to the CR and noticed Pt #1 had a bruise on his forehead and a laceration on his nose. MD #1 stated Pt #1 did not have any injury to the face when initially evaluated.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 (Pt #1) of 3 clinical records reviewed for patients requiring restraints, the Hospital failed to ensure the staff used proper techniques. This resulted in Pt #1 reportedly sustaining a bruise on the face and back lacerations.

Findings include:

1. On 9/8/2016 the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male that arrived on 8/29/2016 to the Emergency Department (ED) escorted by the local fire department for a medical evaluation due to agitation and combativeness. The clinical record of Pt #1 contained pictures dated 8/30/2016 at 10:00 AM that included Pt #1's facial bruises and back lacerations.

2. The "Risk Management Worksheet"" dated 8/30/2016 at 8:11 PM indicated that the Security Officer (E #6) responded to a code gray (emergency management response due to someone in danger to self or other) in the emergency room . Upon arrival, patient (Pt #1) was rocking the bed and yelling in the crisis room...Momentarily, after we left the room, the patient (Pt #1) started yelling again and physically struggling with officer (E #5)...Officer on the scene were (E #5), Contracted security officer (E #7) and myself.

3. On 9/8/2016 at approximately 2:48 PM the ED physician (MD #1) assigned to Pt #1 was interviewed. MD #1 stated Pt #1 was very agitated and required to be physically and chemically restrained. MD #1 stated I was observing the video monitor and I saw two security officers in the (CR) with Pt #1. MD #1 stated she could not identify the Security Officers due to there backs were toward the surveillance camera . MD #1 stated "one (1) of the 2 officers appeared to have taken a swing at the patient (Pt #1), the other security officer put his hands around the patient's (Pt #1) neck." MD #1 stated she went to the Crisis Room (CR) and noticed Pt #1 had a bruise on his forehead and a laceration on his nose. MD
#1 stated Pt #1 did not have any injury to the face when initially evaluated.

4. On 9/8/2016 at approximately 4:05 PM the Regional Supervisor Manager (E #4) was interviewed. E #4 stated E #5 (Security Officer) and E #6 (Security Supervisor) "are new to the Hospital and are not Crisis Prevention Intervention (CPI) certified." E #4 stated the Officers (E #5 and E #6) are allowed to physically intervene in de-escalating a patient with behavior issues although they have not received training on de-escalating a patient.

5. On 9/9/2016 at approximately 4:05 PM the Regional supervisor Manager (E #4) was interviewed. E #4 stated the officers involved in the incident with Pt #1 allegation of abuse do not have the CPI or de-escalation training. E #4 stated these employees are new to the Hospital and have 180 days to complete their training. However are allowed to intervene in attempting to de-escalate a patient.