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.

OSF SAINT ANTHONY MEDICAL CENTER 5666 EAST STATE STREET ROCKFORD, IL 61108 April 21, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 3 of 3 patients in restraints (Pt's. #5, 6, & 9), the Hospital failed to ensure restrained patients were monitored and care provided every 2 hours, as required by policy.

Findings include:

1. On 4/21/15 at 9:00 AM, Hospital policy # 8, titled, "Restraint and Seclusion Management", effective 7/5/11, was reviewed. The policy required, "Process... 7. Nursing monitors and documents the following: Non-Violent / Non-Self-Destructive Behavior - Every 2 hours or more often as needed - Visual check of patient... circulation and skin integrity... range of motion to extremities in restraints...fluids and foods...elimination needs."

2. On 4/20/15 at 1:10 PM, Pt. #5's clinical record was reviewed. Pt. #5 was a [AGE] year old female, admitted on [DATE], with diagnoses of [DIAGNOSES REDACTED]#5's restraint monitoring flow sheet lacked documentation of range of motion exercise from 4/17/15 at 8:00 PM to 4/18/15 at 8:00 AM, for 12 hours, instead of every 2 hours, as required. Pt. #5 was released from restraints on 4/18/15 at 8:00 AM.
3. On 4/20/15 at 1:50 PM, Pt. #6's clinical record was reviewed. Pt. #6 was a [AGE] year old female, admitted on [DATE], with diagnoses of [DIAGNOSES REDACTED]. Pt. #6's restraint monitoring flow sheet included monitoring and care on 4/14/15 at 8:45 AM and 10:45 AM, but lacked subsequent documentation on 4/14/15 or 4/15/15. There was no documentation when Pt. #6's was released from restraints.
4. On 4/21/15 at 8:30 AM, Pt. #9's clinical record was reviewed. Pt. #9 was a [AGE] year old male, admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#9's restraint monitoring flow sheet lacked monitoring and care offered between 4/4/15 at 8:52 AM to 12:45 PM, for almost 4 hours, instead of every 2 hours as required. Pt. #9 was released from restraints on 4/4/15 at 2:00 PM.
5. On 4/21/15 at 8:45 AM, an interview was conducted with the Accreditation Coordinator/ Risk Management (E #3). E#3 stated she did not know why the 2 hour documentation was not done.