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.

UNIVERSITY OF ILLINOIS HOSPITAL 1740 WEST TAYLOR ST SUITE 1400 CHICAGO, IL 60612 Sept. 23, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 2 patient records (Pt. #4) reviewed regarding use of restraint or seclusion, the Hospital failed to ensure "Notice Regarding Restriction of Rights of an Individual" was completed as required.

Findings include:

1. On 9/23/16 at approximately 10:30 AM, the Hospital's policy, "Restraints and Seclusion" (effective 7/16) indicated, "... C. Documentation... 2. The registered nurse documents... b.)... 1.) Nursing staff completes the State of Illinois Department of Human Resource "Notice Regarding Restriction of Rights of an Individual" form and advises the patient it is their right to have any person of their choosing notified of their restraints and/or seclusion."

2. On 9/23/16 at approximately 10:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old female patient admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified. On 9/5/16 at 6:15 PM, a physician ordered restraints and Pt. #4 was placed in restraints from 6:15 PM to 8:00 PM. However, the clinical record lacked the "Notice Regarding Restriction of Rights of an Individual" form.

3. On 9/23/16 at approximately 11:00 AM, the finding was discussed with E #4 (Director of Patient Care Services) who stated that the "Notice Regarding Restriction of Rights of an Individual" form is part of the process and that the form could not be found.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 2 patient records (Pt. #4) reviewed regarding use of restraint or seclusion, the Hospital failed to ensure post restraint or seclusion debriefing was documented as required.

Findings include:

1. On 9/23/16 at approximately 10:30 AM, the Hospital's policy subject, "Restraints and Seclusion" (effective 7/16) indicated, "... C. Documentation... 2. The registered nurse documents ...b.)... 3) Post restraint or Seclusion debriefing occurs on the psychiatric units after restrain or seclusion is used for the management of violent or self-destructive behavior and as appropriate..."

2. On 9/23/16 at approximately 10:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old female patient admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified. On 9/5/16 at 6:15 PM a physician ordered restraints, and Pt. #4 was placed in restraints from 6:15 PM to 8:00 PM. However, the clinical record lacked the documentation of Pt. #4's post restraint or seclusion debriefing.

3. On 9/23/16 at approximately 11:00 AM, finding was discussed with E #4 (Director of Patient Care Services) who stated that the documentation of Pt. #4's post restraint or seclusion debriefing is part of the process and could not be found.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 2 patient records (Pt. #4) reviewed regarding use of restraint or seclusion, the Hospital failed to ensure an assessment was completed and documented every 15 minute as required.

Findings include:

1. On 9/23/16 at approximately 10:30 AM, the Hospital's policy subject, "Restraints and Seclusion" (effective 7/16) indicated, "... 8. Patients in restraint or seclusion for the management of violent or self-destructive behavior have continuous in-person monitoring... e.) A staff member trained and competent in restraint/seclusion application and monitoring assesses the patient every fifteen (15) minutes..."

2. On 9/23/16 at approximately 10:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old female patient admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified. On 9/5/16 at 6:15 PM, Pt. #4 was placed in restraints from 6:15 PM to 8:00 PM. However, the clinical record lacked the assessment every 15 minutes while Pt. #4 was in restraints.

3. On 9/23/16 at approximately 11:00 AM, the finding was discussed with E #4 (Director of Patient Care Services) who stated that the documentation for assessment every 15 minutes while Pt. #4 was in restraint, is part of the process and could not be found.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 2 patient records (Pt. #4) reviewed regarding use of restraint or seclusion, the Hospital failed to ensure documentation of a 1 hour face to face assessment was completed as required.

Findings include:

1. On 9/23/16 at approximately 10:30 AM, the Hospital's policy subject, "Restraints and Seclusion" (effective 7/16) indicated, "... A. Physician Orders... g)... 3) The medical staff member performs a face to face evaluation of the patient within 1 hour if the emergent initiation of the restraint or seclusion was for the management of violent or self-destructive behavior.

2. On 9/23/16 at approximately 10:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old female patient admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified. On 9/5/16 at 6:15 PM, Pt. #4 was placed in restraints from 6:15 PM to 8:00 PM. However, the clinical record lacked the documentation of a 1 hour face to face evaluation.

3. On 9/23/16 at approximately 11:00 AM, finding was discussed with E #4 (Director of Patient Care Services for Adult Psyche) who stated that the 1 hour face to face evaluation documentation is part of the process and could not be found.