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 ST MARYS HOSPITAL 500 W COURT ST KANKAKEE, IL 60901 June 24, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of emergency department (ED) medical records, daily staffing sheet, staffing guidelines, potential transfer log, faxed referral information, and staff interview it was determined the Hospital failed to ensure compliance with CFR 489.24.
Findings include:

1. The Hospital inappropriately transferred a Psychiatric/Behavioral Health patient when the Hospital had the specialized services for treatment and the capability and capacity to provide care. See deficiency cited at A-2409.

2. The Hospital failed to ensure the acceptance of a transfer of a Psychiatric /Behavioral Health patient when the Hospital had the specialized services for treatment and the capability and capacity to provide care. See deficiency cited at A-2411.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on a review of emergency department (ED) medical records, daily staffing sheet, staffing guidelines, and staff interview it was determined in 1of 21 (Pt. #21) ED records reviewed the Hospital inappropriately transferred a Psychiatric/Behavioral Health patient when the Hospital had the specialized services for treatment and the capability and capacity to provide care.
Findings include:

1. The ED medical record for Pt. #21 was reviewed. Pt. #21 presented to the ED 4/30/2013 at 2:17PM with a chief complaint Psych Evaluation. Pt. #21 had punched another resident in face at the Nursing Home earlier. The Psych / Medical Clearance form indicated Pt. #21 was medically cleared and indicated "Explosive Disorder." The "Medical Transfer Form" indicated the transfer was Physician Request with the Benefits: Psychiatric Evaluation, Admission, Medication Adjustment. Pt #21 was transferred by ambulance in stable condition on 4/30/2013 at 11:00PM as a direct admission to another Hospital's psychiatric unit.

2. The Daily Staffing Sheet for the Behavioral Health Unit was reviewed. Documentation indicated that on 4/30/13 the Behavioral Health patient census at 2PM was 5, at 5PM and 10PM it was 3. Documentation also indicated the daily staffing for 4/30/13 indicated 1 Charge Nurse from 7AM to 7PM and a nurse's aide from 6AM to 6PM, and then a Charge Nurse and a tech from 7PM to 7AM with a Registered Nurse (RN) "LCOC" (low census on call) from 7PM to 7AM.

3. The Behavior Health Unit Staffing Guidelines was reviewed. The Staffing Guidelines indicate 1 RN and 1Tech for a census of 1 to 6.

4. A staff interview was conducted with the Director of Behavioral Health on 6/24/13 at 2:40PM. The Director of Behavioral Health indicated that according to the census and the staffing, the Hospital had the capability and the capacity to accept Pt. #21; however the Behavioral Health Unit and the Psychiatrist on call take into consideration the acuity of the patients on the unit at that time. The Director of Behavioral Health Unit stated that at the time Pt. #21 was in the ED the unit had 3 geriatric patients, 1 patient with mental retardation (MR), and 1 patient that was being sent to the medical unit and by 5PM the unit was down to 3 patients - 2 geriatric and 1 MR.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
Based on a review of potential transfer log, faxed referral information, daily staffing sheet, staffing guidelines, and staff interview it was determined in 1of 1 (Pt. #22) referral intake information reviewed, the Hospital failed to ensure the acceptance of a transfer of a Psychiatric/Behavioral Health patient when the Hospital had the specialized services for treatment and the capability and the capacity to provide care.
Findings include:

1. The Behavior Health Unit Potential Transfer Log from other facilities was reviewed. Pt. #22 was recorded on the log and indicated the psychiatrist was notified "PSMH Response - No appropriate, Disposition - Decline."

2. The Faxed Referral Information including the Behavior Health Unit Transfer Hand Off Sheet for Pt. #22 was reviewed. The Faxed Referral Information indicated that Pt. #22 presented to the referring Hospital's ED on 4/30/13 at 10:06PM with the "Stated Complaint: Eval per pt, Chief Complaint: Psychosocial Turmoil." Psychiatrist Recommendation indicated "Pt to be transferred to inpt mental health due to full occupancy at this facility." A Petition and Certificate for Involuntary Admission were completed. The Behavior Health Unit Transfer Hand Off Sheet for Pt. #22 was dated: 5/1/13 at 12AM. There was no documentation to indicate why Pt. #22 was not accepted for admission to the Behavioral Health Unit.

3. The Daily Staffing Sheet for the Behavioral Health Unit was reviewed. Documentation indicated that on 4/30/13 the Behavioral Health patient census at 10PM was 3. On 5/1/13 the census was at 3 all day. The daily staffing for 4/30/13 indicated a Charge Nurse and a tech from 7PM to 7AM with a Registered Nurse (RN) "LCOC" (low census on call) from 7PM to 7AM. The daily staffing for 5/1/13 was 1 Charge Nurse and 1 Tech for 7AM to 7PM and the same for 7PM to 7AM. There was 1 Licensed Practical Nurse (LPN) that indicated "LCOC" from 7AM to 7PM.

4. The Behavior Health Unit Staffing Guidelines was reviewed. The Staffing Guidelines indicate 1RN and 1 Tech for a census of 1 to 6.

5. A staff interview was conducted with the Director of Behavioral Health on 6/24/13 at 2:40PM. The Director of Behavioral Health indicated that according to the census and the staffing, the Hospital had the capability and the capacity to accept Pt. #22 as they only had 3 patients; however the Behavioral Health Unit and the Psychiatrist on call take into consideration the acuity of the patients on the unit at that time. The Director of Behavioral Health Unit stated that at the time Pt. #22 was referred the unit had 2 geriatric patients and 1 patient with mental retardation.