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.

NORWEGIAN-AMERICAN HOSPITAL 1044 N FRANCISCO AVE CHICAGO, IL 60622 June 9, 2017
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined for 3 of 5 psychotropic drug records reviewed (Pt. #2, #3, and #4), the Hospital failed to ensure that the consents for psychotropic medications were completed as required.

Findings include:

1. On 6/6/17 at approximately 10:15 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizophrenia Disorder. Pt. #2 had a physician's order for Prolixin (antipsychotic) as needed on 6/2/17. Pt. #2 received Prolixin on 6/3/16, 6/4/17, and 6/5/17. However, Pt. #2's Psychotropic Medication Consent Form did not include Prolixin.

2. On 6/6/17 at approximately 10:20 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old female admitted on [DATE] with a diagnosis of Bipolar Disorder. Pt. #3 had a physician's order for Risperidone (antipsychotic) on 6/4/17. Pt. #3 received Risperidone on 6/4/17, 6/5/17, and 6/6/17. However, Pt. #3's Psychotropic Medication Consent Form did not include Risperidone.

3. On 6/6/17 at approximately 10:25 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder. Pt. #4 had a physician's order for Depakote (mood stabilizer) and Seroquel (antipsychotic) on 6/4/17. Pt. #4 received Depakote and Seroquel on 6/4/17, 6/5/17, and 6/6/17. However, Pt. #4's Psychotropic Medication Consent Form did not include Depakote and Seroquel.

4. On 6/6/17 at approximately 12:00 PM, the Hospital's policy titled, "Psychotropic Medications" (effective 5/14) was reviewed and required, "...When psychotropic medication is prescribed in the course of the patient's treatment, the patient shall be informed verbally and in writing of the name and purpose of the medication ordered...Procedure:...3. The Registered Nurse administering medication checks that the Medication Consent Form is completed prior to giving the medication."

5. On 6/6/17 at approximately 10:30 AM, findings were discussed with E #6 (Manager, Behavioral Unit), who stated that the Psychotropic Medication Consent should have been completed to reflect the medications given.

B. Based on document review and interview, it was determined for 1 of 2 clinical records reviewed (Pt. #1) for involuntary admission, the Hospital failed to ensure a second Inpatient Certificate was completed as required.

Findings include:

1.On 6/7/17 at approximately 9:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizophrenia, Paranoid. The clinical record of Pt. #1 included the Petition for Involuntary Admission and Inpatient Certificate dated 4/28/17. However, a second Inpatient Certificate was not completed 24 hours from the time of Pt. #1's admission.

2. On 6/7/17 at approximately 9:30 AM, the Hospital's policy titled "Admission: Involuntary" (reviewed 5/17) was reviewed and required, "...Definition:... Certificate: A legal document substantiating the immediate need for hospitalization ... The second certificate must be completed by a psychiatrist... Within 24 hours of admission... a second certificate completed..."

3. On 6/7/17 at approximately 12:38 PM, an interview was conducted with MD #2 (Psychiatrist). MD #2 stated that, "It was a mistake on my part... A second Inpatient Certificate should have been completed..."

C. Based on document review and interview, it was determined for 1 of 2 clinical records reviewed (Pt. #11) for involuntary admission, the Hospital failed to ensure the Inpatient Certificate was completed as required.

Findings include:

1. On 6/8/17 at approximately 9:15 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a [AGE] year old male who came to the Hospital's emergency room on [DATE] for Acute Psychosis. The clinical record of Pt. #11 included a Petition for Involuntary admitted d 6/3/17. However, the Inpatient Certificate for involuntary admission was not completed.

2. On 6/8/17 at approximately 10:30 AM, the Hospital's policy titled "Admission Procedures" (reviewed 5/17) was reviewed and required, "To provide guidelines for admission...Procedure: I. emergency room Admission:... 2. Intake Staff completes admission paperwork with the patient: a. Legal documents:... ii. Reviews the Petition and Certificate for Involuntary Admission for completion."

3. On 6/7/17 at approximately 10:35 AM, an interview was conducted with E #7 (Senior Intake Specialist). E #7 stated that the Inpatient Certificate for admission should have been completed.