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UNIVERSITY OF ILLINOIS HOSPITAL 1740 WEST TAYLOR ST SUITE 1400 CHICAGO, IL 60612 Sept. 6, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital Failed to ensure that an appropriate MSE (Medical Screening Exam) was provided. See deficiency at A-2406 A.

2. The Hospital failed to ensue that the Hospital's Medical Staff Bylaws of the University of Illinois Hospital and Health Sciences System Hospital and the Medical Staff Rules and Regulations of the University of Illinois Hospital and Health Sciences System included the responsible person to perform a medical screening exam. See deficiency at A-2406 B.

3. The Hospital failed to ensure an appropriate transfer was provided. See deficiency at A-2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) Emergency Department clinical records reviewed, the Hospital failed to ensure an appropriate medical screening examination (MSE) was provided, as required.

Findings include:

1. On 9/5/17 at approximately 9:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female that presented to the Hospital's ED via (paramedic) on 8/17/17 with a complaint of sexual assault. Pt. #1 was triaged with a Level 2 with admitting vital signs: pulse 104, blood pressure 125/74, respiration 18, temperature 37.2 and received a medical screening exam that included completion of sexual assault kit, urine pregnancy test, and blood test.

The Triage RN Notes of E #4 (Registered Nurse ED) on 8/17/17 at 11:38 AM were reviewed and indicated, " ... (Pt. #1) presents via CFD (Chicago Fire Department) states 'I was raped in my mouth.' States happened yesterday in someone's car ... (Pt. #1) aox3 (alert, oriented x 3), cooperative, calm ... ED Registration Reason for Visit: Patient states psych (psychiatric) eval (evaluation).

The Progress Notes of E #6 (Social Worker) on 8/17/17 were reviewed and indicated, "(Pt. #1) presented to the Emergency Department after experiencing a sexual assault ... She (Pt. #1) reported earlier she had felt like she (Pt. #1) wanted to kill herself ..."

The Physician's Progress Notes of MD #1 (Attending ED Physician) dated 8/17/17 at 5:36 PM were reviewed and indicated, "... History of Present Illness: The patient presents following alleged sexual assault last night by an unknown person... Medical Decision Making: Differential Diagnosis: Sexual assault... Impression and Plan: Diagnosis: Sexual Assault. Plan: Condition: Stable. Disposition: discharged : Shelter..."

The clinical record did not include that a consultation with the psychiatrist on duty occurred regarding Pt. #1's psychiatric history and symptoms. The Physician's progress notes also did not address Pt. #1's verbalization of wanting to kill herself.

2. On 9/5/17 at approximately 12:22 PM and on 9/6/17 at 9:37 AM, in-person and telephone interviews were conducted with MD #1 (Attending ED Physician). On 9/5/17, MD #1 stated that based on his assessment, "I did not see a reason for an inpatient psychiatric hospitalization or an evaluation by a psychiatrist." On 9/6/17, MD #1 stated, "I am not sure (of the social worker's note) if it was documented prior to my assessment... No one came to me to let me know... That could've changed the course of my assessment."

3. On 9/6/17 at approximately 9:51 AM, a telephone interview was conducted with MD #2 (ED Medical Director and Director of Operations). MD #2 stated that, "It is the provider's responsibility to escalate a situation that requires a psychiatric evaluation ... If there are 2 illnesses, it needs to be addressed ...It is up to the ED attending to make the determination."

4. On 9/6/17 at approximately 1:09 PM, an interview was conducted with E #6 (Social Worker ED). E #6 stated that she is an ER social worker who sees psychiatric patients in the ED. E #6 stated that the ED attending physician deemed that it was not necessary for Pt. #1 to have a psychiatric evaluation. E #6 stated that the Rape Victim Advocate told her (E #6) that Pt. #1 verbalized that she wanted to kill herself ... homeless ... and helpless. E #6 stated that she (E #6) told the ED nurse regarding Pt. #1's verbalization of wanting to kill herself.






B. Based on document review and interview, it was determined that the Hospital failed to ensure that the Hospital's Medical Staff Bylaws of the University of Illinois Hospital and Health Sciences System Hospital and the Medical Staff Rules and Regulations of the University of Illinois Hospital and Health Sciences System included the responsible person to perform a medical screening exam.

Findings include:

1. On 9/5/17 at approximately 11:30 AM, the Hospital's Medical Staff Bylaws of the University of Illinois Hospital and Health Sciences System Hospital dated July 21, 2016 and the Medical Staff Rules and Regulations of the University of Illinois Hospital and Health Sciences System dated December 5, 2015 were reviewed. The Bylaws failed to include who had been deemed appropriate to perform medical screening exams in the Emergency Department.

2. On 9/5/17 at approximately 1:40 PM, the Director of Accreditation (E #1) was interviewed. E #1 stated that the Hospital has the person allowed to perform medical screening exams outlined in a policy and not in the bylaws.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 9 (Pt. #1) Emergency Department (ED)clinical records reviewed of patients transferred to another Hospital, the Hospital failed to ensure an appropriate transfer was provided, as required.

Findings include:

1. On 9/5/17 at approximately 9:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female that presented to the Hospital's ED via CFD paramedic (Chicago Fire Department) on 8/17/17 with a complaint of sexual assault, "violated in her mouth twice yesterday". Pt. #1 was triaged with a Level 2 with admitting vital signs: pulse 104, blood pressure 125/74, respiration 18, temperature 37.2 and received a medical screening exam that included completion of sexual assault kit, urine pregnancy test, and blood test. The clinical record indicated that Pt. #1 was given discharge instructions on 8/17/17 at 6:30 PM that included educational materials and a follow-up appointment with (Clinic Office).

2. On 9/5/17 at approximately 10:00 AM, the State Police Incident Report to the Hospital dated 8/17/17 at 10:26 PM was reviewed and indicated, "R/O (Responding Officer) was dispatched to a call of a disturbance with a discharged patient in the ER... R/O then asked her if she wished to seek treatment at (Hospital #2), to which she agreed. Medical staff gave R/O all of subject's personal belongings, which consisted of her discharge papers... provided a courtesy escort to (Hospital #2) without further incident."

The clinical record of Pt. #1 lacked certifying documentation of the need to transfer Pt #1, the acceptance of the receiving Hospital, that the required documents were sent with patient #1, and that Pt #1 was transferred by appropriate personnel.

3. On 9/5/17 at approximately 2:14 PM, an interview was conducted with E#2 (State Police Officer) who stated that he remembers telling the Hospital staff that he will be taking Pt. #1 to (Hospital #2's ER). E #2 then stated that he escorted Pt. #1 to (Hospital #2's ER) with the assistance of another officer.

4. On 9/5/17 at approximately 10:00 AM, the clinical record at (Hospital #2's ED) of Pt. #1 was reviewed.

The ED RN (Registered Nurse) Triage Note on 8/17/17 at 9:51 PM was reviewed and indicated, " ... Triage Adult, Accompanied by: Self ... Mode of Arrival: Walked ... Chief Complaint Additional Info (information): Pain all over per patient, s/p (status post) rape; departed (Hospital #1) and escorted to (Hospital #2) by (Hospital #1's) police staff under order of (Hospital #1's) P.D. (police department) superior ..."

The ED Physician's Note on 8/17/17 at 11:38 PM was reviewed and indicated, " ... History of Present Illness: The patient presents with a psychiatric problem, suicidal ideation, Pt (Pt. #1) presented to ED after being brought here by (Hospital #1's) police for unknown reason. As per paperwork, pt. was treated for 'alleged sexual assault' at (Hospital #1) and was discharged . Nursing coordinator verified information with (transferring Hospital) staff who also confirmed that (Pt. #1) was evaluated by psychiatry. (Pt. #1) c/o (complained of) feeling depressed and 'no one care, I don't want to live; I'm tired,' stating 'I don't know why cars don't run over me.' When specifically asked, (Pt. #1) admits to SI (suicidal ideation), tearful and denying any physical complaints ... Medical Decision Making: Differential Diagnosis: Anxiety, depression, suicide risk. Plan: threshold evaluation ..."

The ED Physician Notes on 8/18/17 at 3:23 AM was reviewed and indicated, " ... Discussed with threshold, will plan to admit patient for SI (suicidal ideation) to inpatient psych (psychiatric) facility ... Impression and Plan: Diagnosis: Suicidal thoughts ... Disposition: awaiting transfer to inpatient psychiatric facility ..."

The (Hospital #2's) RN Discharge Note on 8/18/17 at 6:19 PM was reviewed and indicated, " ... (Pt. #1) transferred to (Hospital #3) in care of (paramedic) ambulance staff."

5. On 9/6/17 at approximately 8:30 AM, an interview was conducted with E #1 (Director of Accreditation). E #1 stated that the State police respond to (Hospital #1's) calls.