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.

MERCY HOSPITAL AND MEDICAL CENTER 2525 S MICHIGAN AVE CHICAGO, IL 60616 Sept. 1, 2016
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview and document review it was determined that the Emergency Department (ED) did not have adequate nurse staffing on 7 of 7 days reviewed. Potentially affecting all patients entering the ED for treatment.

Findings include:

1. During an interview on 8/31/16 at 10:40 AM, the ED Manger (E#2) stated, "We have a 22% vacancy rate in the ED. The staffing pattern in place is: 7 AM = 8 nurses, 9 AM = 10 Nurses, 11 AM - 11 PM = 11 nurses, 11 PM = 9 nurses and 3 AM = 7 nurses.

2. The daily staffing sheets for 7/17/16 - 7/23/16 were reviewed on 8/31/16. The following days and times were short nurses based on manager interview (no written staffing guidelines available) :

7/17/16 - 1 nurse at 7 AM; 2 nurses at 9 AM, 11 AM and 3 PM; 3 nurses at 7 PM; 2 nurses at 11 PM, and 1 nurse at 3 AM
7/18/16 - 1 nurse at 3 PM and 7 PM
7/19/16 - 3 nurses at 7 PM and 11 PM, and 1 nurse at 3 AM
7/20/16 - 1 nurse at 9 AM; 2 nurses at 11 AM and 3 PM; 3 nurses at 7 PM and 11 PM, and 2 nurses at 3 AM
7/21/16 - 1 nurse at 9 AM, 11 AM and 3 PM; 2 nurses at 7 PM, and 1 nurse at 11 PM
7/22/16 - 1 nurse at 7 AM; 2 nurses at 9 AM; 2 nurses at 11 AM; 1 nurse at 3 PM; 2 nurses at 7 PM, and 1 nurse at 3 AM.
7/23/16 - 1 nurse at 9 AM and 11 AM; 3 nurses at 3 PM; 4 nurses at 7 PM; 3 nurses at 11 PM, and 1 nurse at 3 AM

3. During an interview on 8/31/16 at approximately 1:30 PM, the ED Manager (E#2) stated, "I know we are short staffed, but I am trying to get the nurses we need. It has been a long process. As we hire, people leave". E#2 stated this does have a direct impact on wait times because they try to keep the 4 to 1 patient to staff ratio for safety.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined for 3 of 7 (Pt.s # 3, #4, and #6) Emergency Department patient records reviewed, it was determined the hospital failed to ensure patient reassessments were completed as per policy.

Findings include:

1. The Hospital policy titled, "Assessment & Reassessment of Patients (reviewed 11/14)" was reviewed on 8/31/16. The policy required, "Reassessment includes vital signs... Reassessment schedule: Every 4 hours on stable category III patients..."

2. The clinical record of Pt. #3 was reviewed on 9/1/16. Pt. #3 was a [AGE] year old male who presented to the emergency department (ED) on 7/20/16 at 12:32 PM with complaints of diarrhea and vomiting. Pt. #3 was a category III (stable). Pt. #3 had vital signs (blood pressure, temperature, pulse) taken at 12:52 PM and again at 8:54 PM (8 hours later).

3. The clinical record of Pt. #4 was reviewed on 9/1/16. Pt. #4 was a [AGE] year old female who (MDS) dated [DATE] at 1:06 PM with the complaint of chest pain. Pt. #4 was a category III. Pt. #4 had vital signs taken at 1:31 PM and again at 7:41 PM (6 hours later).

4. The clinical record of Pt. #6 was reviewed on 9/1/16. Pt. #6 was a [AGE] year old female who (MDS) dated [DATE] at 1:29 PM with the complaint of headache. Pt. #6 was a category III. Pt. #4 had vital signs taken at 1:43 PM and again at 9:25 PM (approximately 8 hours later).

5. During an interview on 8/31/16 at approximately 1:30 PM, the ED Manager (E#2) stated, "We don't require a reassessment of patients waiting in the waiting room, but we do have reassessment guidelines for ED patients".