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.

VISTA MEDICAL CENTER EAST 1324 NORTH SHERIDAN ROAD WAUKEGAN, IL 60085 Jan. 9, 2014
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 for 1 of 11 (Pt. #1) clinical records reviewed of psychiatric patients in the Emergency Department, the hospital failed to ensure patients were free from physical abuse, per policy.
Findings include:
1. Hospital policy titled, "Patient Rights and Responsibilities" lacking an effective date, was reviewed on 1/8/14 at 11:15 AM and required, " IV Patient Rights - All patients (or family when appropriate) have the right to... Be free from... mental, physical... abuse."
2 On 1/7/14 at 9:50 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an [AGE] year old female, treated in the ED on 8/5/13, with diagnoses of disequilibrium, disease and disorder of ear, nose, mouth, and throat, dementia, hypertension, and urinary tract infection (UTI). A physician ' s note dated 8/5/13 at 7:58 PM, included, " ...While waiting [for admission] in the ER, another patient [Pt. #2] attached... [Pt. #1] repeatedly hitting her in the head. The assaulter [Pt. #2] was removed by ED staff. Afterwards patient [Pt. #1] was crying but consolable and on repeat exam PEERL [pupils equal and equally reactive to light] with a hematoma on the left posterior scalp, no ttp [tender to pressure] of neck, and no other apparent abrasions at this time. Head CT was repeated which demonstrated interval hematoma but no intracranial pathology.
3. Pt. #1 ' s history and physical dated 8/6/13 at 11:26 AM, included, Pt. #1 was observed in the intensive care unit during the night (8/5/13). A nursing note dated 8/6/13 at 10:24 AM, included, " discharged home accompanied by family. Condition stable. Discharge instructions given including follow-up appointment. "
4. On 1/8/14 at 9:40 AM, an interview was conducted with the Director of Emergency Services (E #3). E #3 stated that Pt. #2 was one to one while in restraints but the sitter was discontinued after restraints were removed because Pt. #2 was calm and cooperative.
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 5 of 7 (Pt #s 2, 6, 7, 8 and 9) clinical records reviewed of patients in restraints, the hospital failed to ensure a physician ' s order was obtained for restraints as per policy.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self-Destructive Patient (revised 9/13) " included, " Orders for Restraints: The initial and all subsequent restraint orders shall expire: 4 hours or less for patients 18 years of age and older. Each order must be provided by a physician ... "
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a [AGE] year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. Pt. #2 ' s Restraint and Seclusion Observation Flow Sheet dated 8/5/13, indicated Pt. #2 was placed in restraints at 5:30 PM through 6:15 PM, when he was transferred to another hospital. The clinical record lacked documentation of a physician's order for the restraints.
3. The clinical record of Pt. #6 was reviewed on 1/8/14. Pt. #6 was a [AGE] year old male admitted on [DATE] with the diagnosis of psychosis. The nursing progress notes included Pt. #6 was placed in behavioral restraints due to aggression on 10/7/13 at 3:00 PM and removed from restraints on 10/8/13 at 2:45 PM. The clinical record included a physician ' s orders for behavioral restraints dated 10/7/13 at 3:00 PM, 10/8/13 at 1:00 AM and 10/8/13 at 5:00 AM. The clinical record lacked documentation of a physician ' s order every 4 hours as per policy.
4. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a [AGE] year old male admitted on [DATE] with the diagnosis of suicide attempt. The nursing progress notes included Pt. #7 was placed in behavioral restraints due to patient becoming aggravated on 10/31/13 at 12:30 PM and removed from restraints on 10/31/13 at 7:40 PM. The clinical record lacked documentation of a physician's order for restraints.
5. The clinical record of Pt. #8 was reviewed on 1/8/14. Pt. #8 was a [AGE] year old female admitted on [DATE] with the diagnosis of overdose of heroin. The nursing progress notes included Pt. #8 was placed in behavioral restraints by security due to " emergency physician states that patient is a deserter and needs to be restrained " on 9/3/13 at 5:16 PM and removed from restraints on 9/3/13 at 5:17 PM (RN felt restraints not needed). The clinical record lacked documentation of a physician ' s order for restraints.
6. The clinical record of Pt. #9 was reviewed on 1/8/14. Pt. #9 was a [AGE] year old male admitted on [DATE] with the diagnosis of alcohol intoxication. The nursing progress notes included Pt. #9 was placed in behavioral restraints due to patient becoming aggressive on 9/18/13 at 5:00 AM and removed from restraints on 9/18/13 at 9:00 AM. The clinical record lacked documentation of a signed physician ' s order for restraints.
7. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated, " there should be a physician orders for restraints on all of the reviewed records."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 7 (Pt. #4) clinical records reviewed of patients in restraints, the hospital failed to discontinue the restraints at the earliest possible time.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self -Destructive Patient (revised 9/13) " included, " A trained staff member provides continuous monitoring, needs assessment and comfort measures that include the following: Readiness for discontinuation of restraint. "
2. The clinical record of Pt. #4 was reviewed on 1/8/14. Pt. #4 was a [AGE] year old male admitted on [DATE] with the diagnosis of drug abuse. The nursing progress notes included Pt. #4 was placed in behavioral restraints due to agitation on 10/29/13 at 3:57 PM and removed from restraints on 10/29/13 at 8:04 PM. The nursing assessment dated [DATE] at 5:06 PM included, " Patient is alert and oriented times 3 (person, place and time).
The " Restraint and Seclusion Observation Flow Sheet " included that Pt. #4 was calm and cooperative during the entire restraint occurrence. Pt. #4 remained in restraints for 4 hours and was discharged home when the restraints were removed.
3. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated she could not find documentation of why Pt. #4 remained in restraints for that period of time or if an assessment was completed to remove the restraints earlier.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview it was determined for 1 of 7 (Pt. # 2) clinical records of patients in restraints, the hospital failed to ensure the patients in restraints were monitored every 15 minutes, as required by policy.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self-Destructive Patient (revised 9/13)" was reviewed on 1/9/13 at 11:00 AM. The policy included, " [Physical Restraint] Documentation... Continuous monitoring and documentation every 15 minutes of the patient's status... Chemical Restraint (drug used as a restraint)... 6. Monitor the patient at 15 minute intervals for the first two (2) hours for behavioral status and effects(s) of medication administered."
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a [AGE] year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. The nursing progress notes dated 8/5/13 at 1:16 PM, included, "On arrival [9:30 AM] patient is violent striking out at staff placed in 4 point restraint." Nursing notes dated 10:00 AM; included Pt. #2 was administered Ativan 1 mg and Haldol 5 mg "for therapeutic reasons." Pt. #2's "Restraint and Seclusion Observation Flow Sheet" included documentation of 30 minute monitoring, not 15 minute monitoring, during restraint, from 9:30 AM to 1:30 PM.
3. On 1/8/14 at 9:40 AM, an interview was conducted with the ED Manager (E #3). E #3 stated that there should have been documentation of 15 minute monitoring for Pt. #2 while in restraints. The reassessment for Ativan and Haldol was documented at 11:30, 1 1/2 hours after administration. The nurse responsible for Pt. #2's 15 minute monitoring has resigned.
B. Based on document review and interview it was determined for 5 of 7 (Pt. #s 2, 4, 5, 6 and 7) clinical records of patients in restraints, the hospital failed to ensure extremity circulation was monitored while the patient was in restraints.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self -Destructive Patient (revised 9/13) " included, " A trained staff member provides continuous monitoring, needs assessment and comfort measures that include the following: ... Circulation and range of motion of the extremities. "
2. The hospital " Restraint and Seclusion Observation Flow Sheet (revised 10/11) " required, " The following are continuously monitored and recorded at a minimum of every: 1 hour - circulation check. "
3. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a [AGE] year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. The nursing progress notes dated 8/5/13 at 1:16 PM, included, "On arrival patient is violent striking out at staff placed in 4 point restraint." Pt. #2's "Restraint and Seclusion Observation Flow Sheet" lacked documentation of hourly circulation being monitored, while Pt. #2 was in restraints from 9:30 AM to 1:30 PM.
4. The clinical record of Pt. #4 was reviewed on 1/8/14. Pt. #4 was a [AGE] year old male admitted on [DATE] with the diagnosis of drug abuse. The nursing progress notes included Pt. #4 was placed in behavioral restraints due to agitation on 10/29/13 at 3:57 PM and removed from restraints on 10/29/13 at 8:04 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
5. The clinical record of Pt. #5 was reviewed on 1/8/14. Pt. #5 was a [AGE] year old male admitted on [DATE] with the diagnosis of drug abuse. The nursing progress notes included Pt. #5 was placed in behavioral restraints due to agitation on 9/4/13 at 3:39 PM and removed from restraints on 9/4/13 at 7:22 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
6. The clinical record of Pt. #6 was reviewed on 1/8/14. Pt. #6 was a [AGE] year old male admitted on [DATE] with the diagnosis of psychosis. The nursing progress notes included Pt. #6 was placed in behavioral restraints due to aggression on 10/7/13 at 3:00 PM and removed from restraints on 10/8/13 at 2:45 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
7. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a [AGE] year old male admitted on [DATE] with the diagnosis of suicide attempt. The nursing progress notes included Pt. #7 was placed in behavioral restraints due to patient becoming aggravated on 10/31/13 at 12:30 PM and removed from restraints on 10/31/13 at 7:40 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
8. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated, " There seems to be a pattern of not documenting circulation, all these patients do not have it documented."
C. Based on document review and interview, it was determined for 2 of 2 (Pts. #2 & 7) clinical records reviewed of patients on suicide precautions, the hospital failed to ensure visual monitoring by a support person, occurred per policy.
Findings include:
1. Hospital policy titled, "Suicide Risk Assessment and Interventions in Acute Care Setting (revised 8/13)", was reviewed on 1/8/14 at 11:10 AM and required, " Interventions relative to level of suicide risk: Immediate Risk Patients: ... including actual suicide attempt. Level of Supervision: Continuous visual surveillance (line of sight) with 1:1 observation. "
The policy also required, (pg 5) " Moderate Risk Patients (level 3): Close Observation ... (pg 2) Levels of Supervision ... C. Close Observation: Patients may not be left alone without support person (may be reliable family/friend). "
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a [AGE] year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. A nursing assessment on 8/5/13 at 1:16 PM included a " suicide lethality assessment " which placed Pt. #2 at " suicide risk moderate". "Suicide interventions done include... continuous 1:1 direct observation..."
3. On 8/5/13 at 1:30 PM, when restraints were removed, one to one care provided for suicidal protection and during restraint was removed and Pt. #1 was cared for and monitored by a registered nurse (E #7) every 15 minutes, not constantly, as required by policy.
4. During a phone interview with E #7 on 1/8/14 at 2:00 PM, E #7 stated on 8/5/13 on the 11:00 AM to 11:00 PM shift, he was assigned to 4 patient rooms, including Pt. #2's, and Pt. #2 was not one to one after the restraints were removed. Pt. #2 attacked and injured another patient when E #7 was out of the room.
5. On 1/8/14 at 9:40 AM, an interview was conducted with the Director of Emergency Services (E #3). E #3 stated that Pt. #2 was one to one while in restraints but the sitter was discontinued after restraints were removed because Pt. #2 was calm and cooperative.
6. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a [AGE] year old male admitted on [DATE] with the diagnosis of suicide attempt. Pt. #7 was assessed as a high suicide risk per " overall suicide lethality score. " The nursing progress note dated 11/1/13 at 12:56 AM included, " patient was reassessed at 11:30 PM, sitter leaves at this time. " The nursing progress note dated 11/1/13 at 7:49 AM included, " The patient was reassessed at 7:30 AM, and sitter arrives at this time. " Every 15 minute safety checks were documented throughout the night by the RN caring for the patient.
7. During another interview on 1/8/14 at 1:30 PM with E #3, E #3 stated, " I cannot explain why a sitter was not present for the night shift [for Pt. #7], but there definitely should have been one."