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.

LITTLE COMPANY OF MARY HOSPITAL 2800 W 95TH ST EVERGREEN PARK, IL 60805 Nov. 14, 2014
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 that for 1 of 12 records reviewed (Pt. #1) for belongings checks the Hospital failed to ensure a belongings check was completed on admission as required by policy.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 11/13/14. Pt. #1 was a [AGE] year old male admitted on [DATE] at 4:00 PM on the secured behavioral unit with diagnoses of depression and alcohol detoxification. Pt. #1's admitting order on 9/26/14 at 4:00 PM included precautions for safety. Nursing documentation on 9/26/14 at 4:16 PM, indicated Pt. #1 was admitted from the Emergency Department (ED) with a strong smell of alcohol and indicated that Pt. #1 was uncooperative with the admit process due to "I'm sick." At 6:00 PM (2 hours after admission), documentation by nursing indicated, "heard a thud against bathroom door, Pt was found on the bathroom floor with bleeding from left ear..., sweatshirt string tight around his neck...told writer 'nobody cares'...." The "Psych belongings checklist" which indicated ..."gray hoodie with red strings (discarded)..." was documented as done on 9/26/14 at 8:15 PM, 4 hours after Pt. #1 was admitted to the unit and 2 hours after finding Pt. #1 with a string around his neck.

2. The Hospital policy titled, "Admission Within the Behavioral Health Continuum" (revised 5/1/14), required, "Inpatient Admission Procedure: Patients are escorted to the Inpatient Behavioral Health unit. ...The nurse will interview the patient, complete the Nursing assessment.... The nurse will further assess risk potential and initiate appropriate precaution. ...Belongings: The nurse or designee will conduct a belongings search in the presence of the patient...."

3. The Hospital policy titled, "Contraband and Restricted Articles" (revised 5/6/14), required, "Purpose: To assure the provision of safe environment. Policy: items which are considered a danger or potential danger to patients and others will be considered contraband...items considered to be restricted...cords of any kind..., also considered contraband, clothing items deemed potentially dangerous..."

4. On 11/14/14 at approximately 9:40AM the Assistant Unit Supervisor (E#5) was interviewed. E #5 stated belongings are reviewed by the nurse or care partner with the patient during the admission process. Any item that is considered contraband the patient is notified that it will be removed and secured. A form is signed by the patient and staff member.
5. The above was discussed with the Manager of Behavioral Health Unit during an interview on 11/14/14 at 10:25 AM, who stated that patients' belongings are checked on admission. E #4 stated that the string Pt. #1 used to wrap around his neck came from the patient's sweatshirt.





B. Based on review of documents, observations, and interview, it was determined that for 8 of 9 patients (Pts. 3-8, 10 and 11), on the 5 North psychiatric unit, the Hospital failed to ensure patient safety checks were conducted every 15 minutes as required.

Findings include:

1. Hospital policy entitled, "Safety Round & Safety Checks - Inpatient Secured Unit," (review date July 24 2013) required, "Policy:...Safety Checks are conducted for patients admitted to the secured unit every 15 minutes and their safety and whereabouts is documented on the individual's 'Behavioral Health Department, Inpatient Secured Unit Safety Check' sheet."

2. An observational tour was conducted on the Hospital's inpatient psychiatric unit on 11/13/14 at approximately 9:45 AM. During the tour it was discovered that the last documented 15 minute patient safety checks for the 8 patients (Pts 3, 4, 5, 6, 7, 8,10 and 11) on the unit were conducted at 8:30 AM. Safety rounds had not been conducted between 8:45 AM and 9:30 AM.

3. The 8 patients (all placed on safety precautions) on the psychiatric unit were:

- Pt #3, [AGE] year old female, admitted on [DATE], diagnoses schizophrenia and attempted over dose;

- Pt #4, [AGE] year old male, admitted [DATE], diagnosis major depression, acute episode;

- Pt #5, [AGE] year old female, admitted [DATE], diagnosis major depression;

- Pt #6, [AGE] year old female, admitted [DATE], diagnoses bipolar disease and opiate dependence;

- Pt #7, [AGE] year old male, admitted [DATE], diagnoses major depression and generalized anxiety;

- Pt #8, [AGE] year old male admitted [DATE], diagnosis alcohol dependence;

- Pt #10, [AGE] year old female, admitted [DATE], diagnosis major depression; and

- Pt #11, [AGE] year old female, admitted [DATE], with diagnoses major depression and suicide ideation.

4. The Care Partner performing patient safety checks (E #6) was interviewed on 11/13/14 at approximately 10:15 AM. E #6 stated, "When we were made aware that you (IDPH) was in the Hospital we stopped everything and started cleaning to make sure the unit was clean. I put the check sheets down but always knew where they were (patients)."

5. The Manager of the Behavioral Health Unit stated during an interview on 11/14/14 at approximately 10:15 AM that the patients' safety checks are to be completed and documented every 15 minutes.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, interviews, and observations, it was determined that for: 4 of 5 (Pt. #s 6-9) clinical records reviewed for psychotropic medication consent; 1 of 12 (Pt. #1) clinical records reviewed for belongings checks; and 8 of 9 (Pt. #s 3-8, 10 and 11) patients observed on the 5 North psychiatric unit, the Hospital failed to consistently promote and protect patients' right to make informed decisions and right to care in a safe environment. The cumulative effects of these systemic practices resulted in the Hospital's failure to comply with the Condition of Patient Rights.

Findings include:

1. The Hospital failed to ensure patients were informed of information related to psychotropic medications prior to administration. (See deficiency at A 131).

2. The Hospital failed to ensure a belongings check was completed on admission as required by policy. (See deficiency at A 144A).

3. The Hospital failed to ensure patient safety rounds were conducted every 15 minutes as required. (See deficiency at A 144B).
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 4 of 5 (Pt. #s 6-9) clinical records reviewed for psychotropic medication consent, the Hospital failed to ensure patients were informed of information related to psychotropic medications prior to administration.

Findings include:

1. Hospital policy entitled, "Psychotropic Medication Consent - Patient Education," (reviewed May 1, 2013) required, "Procedure: The attending physician will: Complete Psychotropic Medication Consent form to include, patient/guardian name, medication(s) to be given, date discussed as evidenced by physician signature."

2. The clinical records of Pts #6-9 were reviewed on survey date 11/13/14. The records contained documentation of Psychotropic Medication Consent forms that lacked some prescribed psychotropic medications.

Examples include:

- Pt. #6 was a [AGE]-year-old female, admitted [DATE] for detoxification with diagnoses of bipolar disorder and opiate dependence. The clinical record included physicians' orders for the following psychotropic medications, or medications used for psychotropic issues: Clonidine (antihypertensive used to treat anxiety, withdrawals), Lamictal (anticonvulsant used to treat bipolar disorder and clinical depression), Abilify (antipsychotic), Lithium (mood stabilizer). The Psychotropic Medication Consent form date 11/11/14 lacked Clonidine, to indicate Pt #6 had been informed about the benefits, risks, side effects and alternative treatment options for this medication.





- Pt #7 was a [AGE] year old male admitted on [DATE] with a diagnosis of suicidal ideation. Pt #7's clinical record contained a Psychotropic Medication Consent dated 11/11/14 that included Cymbalta (antidepressant), Ambien (sedative, hypnotic), Klonopin (sedative, anticonvulsant, muscle relaxant properties), and Seroquel (antipsychotic). Pt #7's clinical record contained a physician's order dated 11/8/14 that required Trazodone 50 mg (antidepressant) every night. Pt #7's Psychotropic Medication Consent lacked Trazodone to indicate Pt #7 had been instructed about the medication as required.






- Pt. #8 was a [AGE] year old male admitted on [DATE] with a diagnosis of alcohol dependence. Pt #8's clinical record contained a physician's order dated 11/12/14 for Zolpidem (Ambien) 5 milligram (mg) orally as needed at night time and an order for Lorazepam (Ativan) (antianxiety agent)1 mg every hour as needed. Pt #8's electronic medication administration record (eMAR) indicated on 11/12/14 at 8:53 PM the patient received a dose of Ambien 5 mg. Pt#8 was administered a total of 7 doses of Ativan 1 mg tablets from 11/12/14-11/13/14. The clinical record lacked an Psychotropic Medication Consent indicating that Pt #8 had been instructed about these medications as required.

- Pt #9 was a [AGE] year old male admitted on [DATE] with diagnoses of major depression and ETOH (alcohol) dependence. Pt #9's clinical record contained a physician's order dated 11/12/14 for Venlafaxine 75 mg (antidepressant) twice a day. The form entitled "Psychotropic Medication Consent" dated 11/12/14 did not include Venlafaxine to indicate benefits, risks, side effects and alternative treatment options were explained prior to administration.

3. The Manager of the Behavioral Health Unit stated during an interview on 11/13/14 at approximately 10:15 AM that the medication consent forms were not complete to include all medications.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review, observation, and interview, it was determined that for 1 of 1 patient nourishment freezers on the psychiatric unit, the Hospital failed to ensure proper monitoring of the freezer.

Findings include:

1. Hospital policy entitled, "Floor Stock Program," (revised February 2013) required, "Floor Stock Program: 4. Nursing is responsible for logging the temperatures of the refrigerators/freezers and maintaining documentation of such. Nursing is responsible for discarding any outdated food items. Freezer temperatures = 0 or below."

2. On 11/13/14 at approximately 9:45 AM an observational tour was conducted on the Hospital's inpatient psychiatric unit. During the tour, the patient nourishment refrigerator/freezer was observed. The freezer section was observed to be full of nourishment items however, the temperature of the freezer was not being monitored to ensure the correct temperature.

3. On 11/13/14 at approximately 2:30 PM the Manager of the Behavioral Health Unit stated the freezer is not monitored by the nursing staff only the refrigerator.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview and document review, it was determined in 1 of 1 (5 North) narcotic storage areas, the Hospital failed to ensure controlled substances were secured as per the Hospital policy.

Findings include:

1. On 11/13/14 at approximately 9:45 AM a tour of the 5 North behavioral health unit was conducted. In the medication storage room, the following were found in an unlocked cabinet: Percocet (controlled substance, narcotic pain reliever) 5/325 milligram (mg) (10 individual packed tablets) and Tramadol 50 mg (controlled substance, narcotic analgesic) (3 individual packed tablets).

2. On 11/13/14 at approximately 9:50 AM, the Assistant Unit Manager (E#5) stated when the pharmacy delivers narcotic medications that are not routinely administered on this unit, they are kept in the cabinet and counted each shift. E#5 also stated, there is a lock and the nurses have the key, but the cabinet is not locked.

3. Policy entitled, "Medication Administration: Narcotics and Controlled Substances (Revised 8/31/14) indicated, "C. 1. Controlled substances stored outside the automated distribution cabinet should be counted at the end of each shift against the accounting sheet by two nurses. These narcotics should be in a locked cabinet. Information/ Procedure: I. E. The nurse should check all controlled drug deliveries... and then put the drugs in the patient specific narcotic drawer in the Automated Distribution Machine (ADM)."

4. On 11/13/14 at approximately 11:35 AM E #5 stated, the medication should have been in the Pyxis machine (ADM).