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.

ELMHURST MEMORIAL HOSPITAL 155 EAST BRUSH HILL ROAD ELMHURST, IL 60126 Oct. 6, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for pain, the Hospital failed to document interventions to address Pt.#1 being uncomfortable and shaking.

Findings include:

1. On 10/5/16 at approximately 2:00 PM, the Hospital's policy titled, "Pain Assessment and Management," (revised 9/15) indicated, "... Procedure:...4. If pain ... is unacceptable to the patient, or if non-verbal cues are noted, there will be an intervention intended to reduce the pain..."

2. On 10/4/16 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female patient admitted on [DATE] with the diagnosis of Oligohydramnios (a condition that can develop during pregnancy when not enough amniotic fluid, which surrounds the fetus, is produced) and term pregnancy. On 7/21/16 at about 8:20 PM, a pain assessment was conducted as patient was experiencing rectal and pelvic pressure. At 8:21 PM, Pt. #1's behavior was noted as shaking and more uncomfortable. However, Pt. #1's clinical record lacked documentation that an intervention was provided to address the pain.

3. On 10/05/16 at approximately 4:00 PM, finding was discussed with E #1 (Director of Women's and Children's Services) who agreed that there was no documentation of an intervention provided to Pt. #1.

B. Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for pain, the Hospital failed to document an hourly evaluation and assessment of pain.

Findings include:

1. On 10/5/16 at approximately 3:00 PM, the Hospital's policy titled, "Nursing Assessment and Management of the Woman Receiving Regional Analgesia in Labor," (reviewed 10/15) indicated, "... Post-Procedure Maternal and Fetal Assessment: ... 5. Evaluate and document maternal pain levels, using the pain scale 30-60 minutes post-procedure and hourly thereafter. Notify the anesthesiologist if adequate pain relief is not obtained."

2. On 10/5/16 at approximately 3:15 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female patient admitted on [DATE] with a diagnosis of Oligohydramnios and term pregnancy. Pt. #1 had an epidural (a regional anesthesia used to block pain) procedure completed on 7/21/16 at 6:12 PM. However, the following were noted between 7/21/16 to 7/22/16:

- Hourly pain assessment was not done from 6:36 PM to 8:19 PM (total of 1 hour and
43 minutes)
- Hourly pain assessment was not done from 8:21 PM to 1:30 AM
(total of 5 hours and 9 minutes)
- Hourly pain assessment was not done from 2:30 AM to 3:59 AM (total of 1 hour and
29 minutes)
- Hourly pain assessment was not done from 4:46 AM to 6:23 AM (total of 1 hour and 37
minutes)

3. On 10/05/16 at approximately 4:00 PM, findings were discussed with E #1 who acknowledged that there were periods of time between 7/21/16 to 7/22/16 in the clinical record of Pt. #1 when hourly pain assessments were not documented.