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.

LOUIS A WEISS MEMORIAL HOSPITAL 4646 N MARINE DRIVE CHICAGO, IL 60640 April 6, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 4 (Pt #1) clinical records reviewed of a patient with a grievance, the Hospital failed to ensure the grievance was properly documented, as per policy. This could potentially affect all future patient's expressing grievances.

Findings include:

1. Hospital policy entitled, "Abuse and Neglect: Allegations, Reporting, Prevention and Management," (review date 1/2017) required, "...Management of Suspected Cases of Abuse...B. Allegations of Patient Abuse by a Non-Employee/Health Care Provider...8. Document in the patient's medical record."

2. The clinical record of Pt #1 was reviewed on 3/5/17 at approximately 11:00 AM. Pt #1 was a [AGE] year old female admitted on [DATE] with diagnoses of dementia with depression and delusions. Pt #1's clinical record lacked documentation of any allegation of abuse.

3. On 3/6/17 at approximately 8:30 AM an interview was conducted with the Director of Rehabilitation Services (E #9). E #9 stated, "The therapist came to me following the allegation that the patient said she was abused. She said the patient was very nonchalant about the statement. The therapist took the statement seriously when the patient said 'I think I've been abused here.' I instructed the therapist to write an incident report which was then taken to the Risk Manager for investigation."

4. On 4/6/17 at approximately 8:55 AM a phone interview was conducted with the Physical Therapist (E #10) caring for Pt #1 on 3/14/17 (day of allegation). E #10 stated, "I was getting ready to leave the patients room when she said, 'I hate to tell you, I've been abused here.' I immediately told my manager who contacted the Risk Manager. I went back to the patient and told her I reported the allegation to my manager and was there anything else you wanted to tell me. She said no and it was not everyone, just some. I told her my manager was coming to speak with her and did she want me to stay. She told me I did not have to stay with her."

5. E #9 stated during an interview on 4/6/17 at approximately 9:00 AM the patient's record does not include documentation of the patient's alleged abuse.

6. E #3 stated during an interview on 4/6/17 at approximately 9:15 AM the clinical record did not include information of the patient's allegation and should have.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 2 of 2 (Pt. #3 and #4) patients requiring restraints, the Hospital failed to ensure restraint orders included a duration for the restraint order.

Findings included:

1. The Hospital policy titled, "Restraint and Seclusion (revised 1/17)" was reviewed on 4/5/17. The policy required, "...V. Procedure...B. Authorization and Ordering of Restraints: 1.b...Restraint orders must be dated and timed by physician, and include: ... specify duration of restraint order."

2. The clinical record of Pt. #3 was reviewed on 4/5/17. Pt. #3 was an [AGE] year old male admitted on [DATE] with the diagnoses of dementia and depression. The following physician's orders lacked documentation of the duration for the restraint order: 3/28/17, 3/29/17, 3/30/17, 3/31/17 and 4/2/17.

3. The clinical record of Pt. #4 was reviewed on 4/5/17. Pt. #4 was a [AGE] year old female admitted on [DATE] with the diagnoses of dementia and aggressive behavior. The physician's order dated 3/23/17 lacked documentation of the duration for the restraint order.

4. During an interview on 4/5/17 at 12:45 PM, the Chief Nursing Officer (E#3) stated, "A duration of 24 hours should have been filled in the blank spot".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 2 (Pt. #3) patients requiring restraints, the Hospital failed to ensure a new restraint order was written with each restraint episode.

Findings included:

1. The Hospital policy titled, "Restraint and Seclusion (revised 1/17)" was reviewed on 4/5/17. The policy required, "...III. Definitions: A. Restraint means any method, physical, or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body...freely...V. Procedure...Restraint orders are never written on an 'as needed' basis or as PRN orders or standing order. Trial releases are not permitted as the release of the patient is considered as discontinuation of the restraint order. Therefore, to allow the patient to again be restrained using the same order equals a PRN restraint order".

2. The clinical record of Pt. #3 was reviewed on 4/5/17. Pt. #3 was an [AGE] year old male admitted on [DATE] with the diagnoses of dementia and depression. A physician's order dated 4/2/17 at 8:00 AM included restraints of a geri-chair (chair with a locked table) for 24 hours. The restraint monitoring form included that Pt. #1 was in restraints on 4/2/17 from 8:00 AM to 1:00 PM. Pt. #1 was placed in restraints again on 4/2/17 from 6:00 PM to 10:35 PM without an additional order for the restraints.

3. During an interview on 4/5/17 at approximately 10:35 AM, the Program Manager of Psychiatric Department (E#1) stated, "each restraint episode requires a new order".