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.

INGALLS MEMORIAL HOSPITAL 1 INGALLS DRIVE HARVEY, IL 60426 Feb. 7, 2018
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed for Advanced Directives, the Hospital failed to ensure information was provided.

Findings include:

1. On 2/6/18 at approximately 3:00 PM, the Hospital's policy titled, "Advance Directives" (reviewed 2/15) was reviewed and required, "... B. All inpatients, their agents or surrogates, as applicable, are given written information on advance directives..."

2. On 2/6/18 at approximately 11:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old female admitted on [DATE] with a diagnosis of psychosis. The clinical record of Pt. #3 did not indicate that information on advance directives was provided.

3. On 2/6/18 at approximately 11:35 AM and on 2/7/18 at approximately 8:45 AM, findings were discussed with E #3. E #3 stated that the area where advance directive was normally documented indicated that information was not provided.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed regarding notification of inpatient admission, the Hospital failed to ensure patient's designated individual was notified of the admission.

Findings include:

1. On 2/6/18 at approximately 3:15 PM, the Hospital's policy titled "Patient's Rights and Responsibilities" (revised 2/15/) was reviewed and required, "... The patient and, when appropriate, his or her surrogate have the right to be informed... of their care..."

2. On 2/6/18 at approximately 11:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old female admitted on [DATE] with a diagnosis of psychosis. The clinical record of Pt. #3 indicated that a designated person be notified of the admission. However, the clinical record lacked documentation that the designated person was notified of the admission to the Hospital.

3. On 2/6/18 at approximately 11:35 AM and on 2/7/18 at approximately 8:45 AM, findings were discussed with E #3. E #3 stated that the clinical record did not include notification of Pt. #3's designated person.
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 1 of 4 (Pt. #2) records reviewed for psychotropic drugs use, the Hospital failed to ensure the psychotropic education form was completed, to indicate that Pt. #2 was informed and consented to the treatment plan.

Findings include:

1. On 2/7/18 at approximately 11:00 AM, the Hospital's policy titled, "Psychotropic Medication Education" (reviewed 12/17) was reviewed and required, "... Psychotropic medication may include... mood stabilizing drugs...The patient and/or guardian... are to be informed... 1. Why the psychotropic medication is necessary... 2. The probable benefits of the treatment... Completion of Psychotropic Medication Education Form: This form is to be completed by listing the psychotropic medications, date initiated, and must be signed by both the Nurse and the Psychiatrist..."

2. On 2/7/18 at approximately 9:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old female admitted on [DATE] with a diagnosis of schizophrenia. The clinical record included a physician's order for Depakote (mood stabilizer) dated 6/23/17. The clinical record also indicated that Pt. #2 received Depakote on 6/23/17; 6/24/17; 6/25/17; 6/26/17; 6/27/17; 6/28/17; 6/29/17; and 6/30/17. However, the psychotropic education form did not include the name of the psychotropic drug (Depakote), to indicate that Pt. #2 was informed and consented to the treatment plan.

3. On 2/7/18 at approximately 9:25 AM, an interview was conducted with MD #1 (Attending Psychiatrist). MD #1 stated that, "... She (Pt. #2) was on Depakote, which was used as mood stabilizer..."

4. On 2/7/18 at approximately 9:30 AM, findings were discussed with E #3 (Unit Manager, Behavioral Unit). E #3 stated that Depakote is normally included on the Psychotropic Medication Education form to indicate that the patient was informed.