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.

WESTLAKE COMMUNITY HOSPITAL 1225 LAKE ST MELROSE PARK, IL 60160 Sept. 4, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, observational tour, and staff interview, it was determined for 3 of 13 patients (Pt. #4, 5, & 6) on the 4 West male psychiatric unit, the Hospital failed to ensure psychiatric patients were monitored for safety every 15 minutes, as required by physician's order.

Findings include:

1. On 9/4/13 at 7:20 AM, Hospital policy number 1308.75, titled, "Patient Rounds", revised May 2013, was reviewed. The policy required, "Monitor all patients for: 1. Alterations in physical or cognitive functioning that may lead to unsafe behavior. 2. Unsafe behaviors that may require a higher level of precaution. Warning signs... Poor impulse control. Verbal or physical abuse. Early warning signs of: a. Escalation, b. Elopement attempt, c. Suicidal preoccupation or gestures...
The caregiver assigned to rounds: a. Locates each patient, observes his/her activity and physiology and respiratory effort when in bed and documents location and behavior on the rounds every 15 minutes..."

2. On 9/4/13 at 6:25 AM, an observational tour was conducted on the 4 West male psychiatric unit. A Mental Health Counselor (E #1) was completing fifteen minute precautions observation records for 13 of 13 patients while sitting at a table and not locating and observing each patient.

3. At 6:30 AM, the Surveyor asked E #1 permission to examine the fifteen minute precautions observation records he was completing. E #1 had just completed 10 records, 1 record (Pt. #6) partially complete (up to 5:45 AM), and 2 records (Pt. #4 & 5) had no 15 minute safety precaution entries since 3:30 AM, 3 hours earlier.

- The clinical record of Pt. #4 was reviewed on 9/2/13 at 11:20 AM. Pt. #4 was a [AGE] year old male, admitted on [DATE], with a diagnosis of bipolar disorder. Pt. #4's physician's orders dated 9/2/13 at 5:15 PM for suicide, assault, and close observation precautions, required patient monitoring every 15 minutes.

- The clinical record of Pt. #5 was reviewed on 9/2/13 at 11:25 AM. Pt. #5 was a [AGE] year old male, admitted on [DATE], with diagnoses of HIV and Schizophrenia. Pt. #5's physician's orders dated 8/14/13 at 2:00 PM for assault precautions, required patient monitoring every 15 minutes.

- The clinical record of Pt. #6 was reviewed on 9/2/13 at 11:30 AM. Pt. #6 was a [AGE] year old male, admitted on [DATE], with a diagnosis of bipolar disorder. Pt. #6's physician's orders dated 8/26/13 at 8:45 PM, for suicide precautions required patient monitoring every 15 minutes.

4. An interview was conducted with E #1 on 9/4/13 at 6:30 AM. E #1 stated he had completed the hourly rounds, not the 15 minute rounds and did not explain why the 15 rounds were not completed.

5. On 9/4/13 at 6:30 AM, the Psychiatric Unit Nurse Manager / Director of Risk Management (E #2) accompanied the Surveyor on the observational tour of 4 West and observed the deficient practice. On 9/4/13 at 1:50 PM, E #2 stated, during an interview, fifteen minutes precaution observation rounds were to be completed every 15 minutes.