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 May 20, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on Document review and interview, it was determined in 6 of 10 (Pt #1, #2, #3, #4, #5, #10) records reviewed for patients' rights, the Hospital failed to ensure patient care was provided in a safe manner. As a Result the Condition of Particiation of Patient Rights, 42 CFR 482.13, was not met.

Findings include:

1. The Hospital failed to ensure patients received care in a safe environment, A144

2. The Hospital failed to ensure appropriate patient monitoring, A167

3. The Hospital failed to ensure restraints were initiated in accordance with physician orders, A168

4. The Hospital failed to ensure renewal restraint order was obtained within the required time frame, A171
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined for 1 of 6 (Pt # 5) patient placed in a violent restraint, the Hospital failed to ensure renewal restraint order was obtained within the required time frame. This has the potential to affect all patients that receive care at the Hosptial, an average daily census of 67 patients.

2. The clinical record for Pt #5 was reviewed on 5/17/16 at approximately 1:00 PM. Pt #5 was admitted on [DATE] with a diagnosis of pneumonia and agitation. Pt #5 was placed in violent restraints on 4/30/16 at 10:35 AM. A physicians order was obtained 4/30/16 at 10:59 AM and then at 4:19 PM, greater than the 4 hours requirement.

3. During an interview on 5/19/16 at approximately 10:15 AM, E#6 (Nurse Educator) verbally agreed the above order was not obtained in the required time frame and should have been.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined for 3 of 6 (Pt #1, #2, #5) patients with violent behavior restraints, the facility failed to ensure the patients received care in a safe environment. This has the potential to affect all patients that receive care at the Hospital, an average daily census of 67 patients.

Findings include:

1. The policy titled "Contraband Policy" (reviewed 11/9/15) was reviewed on 5/17/16. The policy required patients who present in the emergency department (ED) with behavior or a history that creates a concern the patient is likely to be a danger to himself or herself or to others will have a belongings search conducted. The policy required patients to be placed in a gown, all belongings in the patients possession to be collected and stored in a secure area.

2. The clinical record of Pt #1 was reviewed on 5/17/16 at approximately 11:00 AM. Pt #1 (MDS) dated [DATE] at 11:55 PM with a diagnosis of intoxication and possible head trauma after a fall. The record noted Pt #1 was a danger to self and others and was placed in 4 point restraints at approximately 1:20 AM on 4/18/16. The record noted at approximately 3:15 AM, Pt # 1 was yelling the bed was on fire. Staff entered Pt #1's room and put the fire out with fire extinguishers. Pt #1 was immediately transferred to another room and assessed to have a small burn to left wrist and forearm. No other injuries noted. The record noted appropriate monitoring and medical treatment for possible smoke inhalation and wound mangement. The record noted Pt #1 had a lighter in his/her pants pocket and set fire to the bed sheets. The record lacked documentation that Pt #1 was changed into a gown and checked for contraband per facility policy.

3. The clinical record of Pt #2 was reviewed on 5/17/16 at approximately 2:00 PM. Pt #2 (MDS) dated [DATE] at 5:00 AM with a diagnosis of intoxication. The record noted Pt #2 was a danger to self and others and was placed in 4 point restraints at 5:05 PM. The record lacked documentation Pt #2 was put into a gown and had a belongings search.

4. The clinical record of Pt #5 was reviewed on 5/17/16 at approximately 3:00 PM. Pt #5 (MDS) dated [DATE] at 10:35 AM with a diagnosis of Pneumonia and Agitation. The record noted Pt #5 was a danger to self and others and was placed in 4 point restraints at 5:05 PM. The record lacked documentation Pt #5 had a belongings search.

5. During an interview on 5/17/16 at 3:30 PM, E#6 (Nurse Educator) verbally agreed that Pt #1, #2 and #5 did not have a belongings search conducted.

B. Based on document review and interview, it was determined in 2 of 6 (Pt #1, #3) patients, the Hospital failed to ensure items collected from patients during a belongings search were documented to ensure belongings were properly secured and accounted for. This has the potential to affect all patients that receive care at the Hospital, an average daily census of 67 patients.

Findings include:

1. The policy titled "Contraband Policy" (reviewed 11/9/15) was reviewed on 5/17/16. The policy required patients who present in the emergency department (ED) with behavior or a history that creates a concern the patient is likely to be a danger to himself or herself or to others and any patient for whom Security is required will have a belongings search conducted. The policy required all belongings in the patients possession to be collected, inspected and valuables and auxiliary aides are documented then stored in a secure area except for illegal contraband which will go to Security.

2. The clinical record of Pt #1 was reviewed on 5/17/16 at approximately 11:00 AM. Pt #1 (MDS) dated [DATE] at 11:55 PM with a diagnosis of intoxication and possible head trauma after a fall. The record noted Pt #1 was a danger to self and others and was placed in 4 point restraints at approximately 1:20 AM on 4/18/16. The record noted Pt #1 had a lighter in his/her pants pocket and set fire to the bed sheets. The record lacked documentation the lighter was collected and the disposition of the lighter.

3. During an interview on 5/19/16 at approximately 10:30 AM, E#7 (Manager of Safety and Security) stated the police took Pt #1's lighter as evidence and any other belongings the patient had.

4. The clinical record of Pt #3 was reviewed on 5/17/16 at approximately 2:30 PM. Pt #2 (MDS) dated [DATE] at 11:44 AM with a diagnosis of Acute Psychosis. The record noted Pt #3 was screaming and security was called. The ED note dated 5/5/16 at 11:44 AM noted "placed in gown clothes and belongings secured..." The record lacked documentation of what belongings were obtained. A Nurse note dated 5/15/16 at 7:00 PM noted Pt #3 stated a cell phone and wallet were stolen but family identified the items were not brought to the hospital.

5. During an interview on 5/19/16 at approximately 12:00 PM, E#6 (Nurse Educator) stated personal items collected during a belongings search are not documented in the record. E#6 verbally agreed Pt #3 did not have any items obtained during the belongings search and the documentation was incorrect. Pt #3 verbally agreed the Hospital was unable to identify if contraband was secured and accounted for.

6. During an interview on 5/19/16 at approximately 10:30 AM, E#1 (Director of Risk Management) verbally agreed the record should reflect what items are collected from the patient, especially since they have an altered mental status.
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 6 (Pt #1) patient restrained for violent behavior, the Facility failed to ensure the patient was appropriately monitored per policy. This has the potential to affect all patients that receive care at the facility, an average daily census of 67 patients.

Findings include:

1. The policy titled "Utilization of Restraints & Seclusion" (effective 7/1/13) was reviewed on 5/17/16. The policy required "Patients in Seclusion or being restrained for violent or self destructive behavior will be monitored continuously via the assignment of a 1:1 staff member assigned only to that patient and assessed with documentation every 15 minutes."

2. The clinical record of Pt #1 was reviewed on 5/17/16 at approximately 11:00 AM. Pt #1 (MDS) dated [DATE] at 11:55 PM with a diagnosis of intoxication and possible head trauma after a fall. The record noted Pt #1 was a danger to self and others and was placed in 4 point restraints at approximately 1:20 AM on 4/18/16. The record lacked documentation Pt #1 was continuously monitored. The clinical record noted only 11 of the 26 (1:30 AM applied restraints - 8:00 AM left the ED) required 15 minute assessments were documented.

3. During an interview on 5/17/16 at approximately 11:15 AM, E#1 (Director of Risk Management) verbally agreed Pt #1 did not have a sitter and was not continuously monitored and should have been. E#1 verbally agreed Pt #1 did not have 15 minute checks performed and there should have been.
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 3 of 10 (pt #3, #4, #10) patients with restraints, the Hospital failed to ensure restraints were initiated in accordance with physician orders. This has the potential to affect all patients that receive care at the Hospital, an average daily census of 67 patients.

Findings include:

Facility Policy Utilization of Restraints & Seclusion dated 06/27/13 under VI Procedure A. Licensed Independent Practioner (LIP)/Physician Responsibilities 2. Orders for all restraint use should be as follows: a. Each episode of restraint or seclusion must be initiated in accordance with the order of a physician or other LIP (Licensed Independent Practioner).
B. Registered Nurse Responsibilities 1. In an emergency situation to protect the patient and/or others from imminent injury, restraint may be initiated by a trained RN,....not feasible. C. Violent and Self-Destructive Behavior Restraint 1. Orders for violent and self-destruct behavior/imminent risk restraint or seclusion are limited to: g. The Registered nurse will contact the LIP to request an in-person evaluation and a written order within one (1) hour of initiation of restraint for a patient in violent restraints.


1. The clinical record for Pt #3 was reviewed on 5/17/16 at approximately 2:30 PM. Pt #3 was admitted on [DATE] with the diagnosis of acute psychosis. Pt #3 was placed in violent restraints on 5/15/16 at 12:15 PM. A physician's order was obtained on 5/15/16 at 5:02 PM, 4 hours and 47 minutes after the violent restraint application.

2. The clinical record of Pt #4 was reviewed on 5/19/16 at approximately 10:00 AM. Pt #4 was admitted on [DATE] with a diagnosis of schizophrenia. A physicians order for Violent restraints was written on 5/5/16 at 7:06 AM. Violent Restraints were placed on 5/5/16 at 9:45 PM.
Pt #4 was placed in violent restraints on 5/8/16 at 9:45 PM. A physicians order was put into writing on 5/17/16 at 12:06 PM, 9 days after the application of restraints.

3. The clinical record of Pt #10 was reviewed on 5/19/16 at approximately 2:15 PM. Pt #10 was admitted on [DATE] with a diagnosis of Septic Shock. A physician's order for the application of non-violent restraints was obtained on 5/9/16 at 4:55 PM. The nurses note/interventions noted non-violent restraints were applied on 5/9/16 at 6:44 PM, 1 hour 51 minutes later.

4. During an interview on 5/19/16 at approximately 10:15 AM, E#6 (Nurse Educator) verbally agreed that Pt #4's Violent Behavior Restraints were ordered 14 hours prior to the event and should not have been. E#6 verbally agreed restraints were not initiated on Pt #10 upon obtaining the order and should have been. E#6 verbally agreed the above orders were not obtained in the required time frame and should have been.