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.

LOYOLA UNIVERSITY MEDICAL CENTER 2160 S 1ST AVENUE MAYWOOD, IL 60153 April 8, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, and interview it was determined that for 3 of 5 (Pt #1, 9, & 10) records reviewed for restraint usage, the Hospital failed to ensure a one hour face to face evaluation was conducted on all patients placed in restraints.

Findings include:

1. The Hospital policy titled, "Restraints Use-Non-violent and no-self-Destructive Behavior, Violent and Self Destructive Behavior" (rev 1/2013), required, "Licensed Independent Practitioner (LIP) defined as an attending physician, house medical/dental staff. or Advanced Practice Nurse (APN)....c. Violent and Self-Destructive Behavior- One-Hour Rule Initiation of Restraint: A LIP must see the patient within one hour after initiation of the restraints to evaluate the patient's: immediate situation, reaction to the intervention, medical condition, including review of systems, behavioral condition, high risk medical issues and need to continue or terminate the restraints."

2. The Clinical record for Pt. #1 was reviewed on 4/7/15. Pt. #1 was a [AGE] year old female, who arrived via ambulance to the Emergency Department (ED) on 2/2/15 at 1:40 PM for psychiatric evaluation, and a primary diagnosis of episodic mood disorder. The clinical record contained a physician's order dated 2/2/15, at 4:00 PM for restraints of "all wrist and ankles", with justification of "Harmful to Self." The nursing documentation included the initiation of restraints at 4:00 PM on 2/2/15 with monitoring of every 15 minutes. However the record lacked documentation of a 1 hour face to face assessment after initiating the restraints..

3. The Clinical record for Pt. #9 was reviewed on 4/8/15. Pt. #9 was a [AGE] year old female admitted on [DATE] with a diagnoses of intoxication and hallucination. The clinical record contained a physician's order dated 2/26/15 at 11:10 PM, for restraints of "all wrist and ankles", with justification of "Harmful to others." The nursing documentation included the initiation of restraints at 11:00 PM on 2/26/15 with monitoring of every 15 minutes. However the record lacked documentation of a 1 hour face to face assessment after initiating the restraints.

4. The Clinical record for Pt. #10 was reviewed on 4/8/15. Pt. #10 was a [AGE] year old male admitted on [DATE] with a diagnosis of a fall with alcohol intoxication. The clinical record contained a physician's order dated 3/15/15 at 2:10 AM, for restraints of "all wrist and ankles", with justification of "Harmful to others." The nursing documentation included the initiation of restraints at 2:10 AM on 3/15/15 with monitoring of every 15 minutes. However the record lacked documentation of a 1 hour face to face assessment after initiating the restraints.

5. The above findings were discussed with the ED Manager on 4/8/15 at approximately 9:55 AM, who stated that patients placed in restraints are expected to be evaluated by the physician with in one hour after the restraints are initiated.