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.

PRESENCE SAINT JOSEPH HOSPITAL - ELGIN 77 N AIRLITE STREET ELGIN, IL 60123 July 13, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed for violent restraints, the Hospital failed to ensure a physician order was obtained.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of autism. The clinical record indicated that Pt. #1 was in restraints on 6/26/17 from 1:30PM to 5:30 PM. However, the clinical record lacked a physician's order for the restraints.

2. The Hospital's policy titled "Utilization of Restraints & Seclusion" (revised 6/13) was reviewed and indicated, "... Procedure... 2. Orders for all restraint use should be as follows:a. Each episode of restraint or seclusion must be initiated in accordance with the order of a physician..."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 who agreed that there was no order for Pt. #1's restraint.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 3 (Pt. #4) clinical records reviewed for suicide assessment, the Hospital failed to ensure a suicide assessment was completed for each shift, as required.

Findings include:

1. On 7/11/17 at approximately 10:30 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old male admitted on [DATE] with a diagnosis of suicidal ideation. The clinical record lacked documentation of a suicide assessment for the 3-11 shift on 7/10/17.

2. On 7/12/17 at approximately 2:00 PM, the Hospital's document titled, "Suicide Assessment: Proper documentation for suicide assessments" (undated) was reviewed and required, "...The suicide assessment is a crucial part of assessing the patient for safety... This assessment is completed... every shift..."

3. On 7/11/17 at approximately 10:35 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that documentation of a suicide assessment for the 3-11 shift on 7/10/17 should have been completed.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) clinical records reviewed for restriction of privileges, the Hospital failed to ensure a physician order was obtained.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of autism. The clinical record of Pt. #1 indicated that visitation privilege was restricted on 6/28/17. However, the record lacked a physician's order for the restriction of privileges.

2. On 7/12/17 at approximately 1:30 PM, the Hospital's policy titled, "Restriction of Privileges" (revised 2/17) was reviewed and required, "The following privileges/activities may be temporarily restricted by staff when there is a genuine concern for a patient and/or unit safety and welfare: visitors...C. Physician... orders obtained regarding duration of restriction."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that, "There should have been an order for the restriction for visitation."

B. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) clinical record reviewed for restriction of privileges, the Hospital failed to ensure guardian was notified as required.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of autism. The clinical record of Pt. #1 indicated that visitation privilege was restricted on 6/28/17. The clinical record lacked documentation that Pt. #1's guardian (mother) was notified.

2. On 7/12/17 at approximately 1:30 PM, the Hospital's policy titled, "Restriction of Privileges" (revised 2/17) was reviewed and required, "...E. Patient, family members, (in case of... guardian...) will be notified of restriction."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 who stated that there was no documentation that guardian was notified.
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 3 psychotropic drug record reviewed (Pt #3), the Hospital failed to ensure that consent to psychotropic medication was completed as required.

Findings include:

1. On 7/11/17 at approximately 10:40 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old male admitted on [DATE] with a diagnosis of depression. Pt. #3 had a physician's order of Wellbutrin (antidepressant) on 7/8/17. Pt. #3 received Wellbutrin on 7/8/17; 7/9/17; and 7/10/17. However, Pt. #3's clinical record did not include the Psychotropic Counseling Medication form to indicate informed consent was provided.

2. On 7/12/17 at approximately 3:00 PM, the Hospital's policy titled, "Psychotropic Medications" (revise 2/17) was reviewed and indicated, "...Purpose: To facilitate the patient's informed consent and cooperation... Procedure:... B. The patient and psychiatrist or other Behavioral Health Member giving the explanation will sign the Psychotropic Counseling Medication form..."

3. On 7/11/17 at approximately 10:45 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that there was no consent form for the Wellbutrin.