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 July 2, 2015
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. #3) patients requiring one on one observation (sitter), the hospital failed to ensure that a sitter was provided for patient safety in accordance with a physician order.

Findings include:

1. Hospital policy titled, "One on One Observation for: Patient with Suicidal Ideation (revised July 2013)" required, "Suicidal Ideation: ... This patient requires a continuous One on One Observer. ... Responsibility: ... B. The One on One Observer will directly visualize (without distraction) the patient at all times. ... Documentation: 1. The nurse will document in the electronic medical record that a One on One Observer is present."

2. The clinical record of Pt. #1 was reviewed on 7/1/15. Pt. #3 was [AGE] year old female who presented to the emergency department (ED) on 6/30/15 at 1:05 PM with the diagnoses of depression and anxiety. An ED physician order was written on 6/30/15 at 10:45 PM for "one on one observer for suicidal ideation". The order was discontinued on 7/1/15 at 9:38 AM The documentation lacked inclusion of a one on one observer being present at bedside.

3. During the record review of Pt. #3 (approximately 9:40 AM) the charge nurse (E#2) stated, "Our staff (the nurse) would have been the 1:1 sitter." The nurse had 3 patients and would not have been able to continuously monitor the patient.

4. During an interview on 7/1/15 at 11:30 AM, the Regulatory and Policy Manager stated, "We are unable to find documentation of the sitter being present; however, assessments were completed every 2 hours by staff as required."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined for 2 of 7 (Pt. #1 and Pt. #4) patients with orders for restraints, the hospital failed to ensure orders were renewed every four hours as required.

Findings include:

1. Hospital policy titled, "Restraint use: *Non-Violent and Non-Self Destructive Behavior, *Violent and Self Destructive Behavior (reviewed January 2013)" required, "...B. Obtaining a Restraint order ... Violent and Self-Destructive Behavior - time limited order applies and may not exceed 4 hours for adults ages 18 years and older."

2. The clinical record of Pt. #1 was reviewed on 7/1/15. Pt. #1 was a [AGE] year old male who (MDS) dated [DATE] at 11:27 AM with the diagnosis of psychosis. The clinical record included a physician's order written on 6/1/15 at 11:45 AM for restraints due to "harmful to others". Pt. #1 remained in restraints until 11:53 PM with no restraint order renewal (8 hours late).

3. The clinical record of Pt. #4 was reviewed on 7/1/15. Pt. #4 was a [AGE] year old female admitted on [DATE] with the diagnosis of chest pain. The clinical record included an order for restraints on 5/13/15 at 11:30 PM due to "harmful to other" and the next order was on 5/14/15 at 5:50 AM (2 hours and 20 minutes late). Pt. #4 remained in restraints the entire time with no restraint order renewal.

4. During an interview on 7/1/15 at 2:30 PM, the Regulatory and Policy Manager stated they were unable to find additional restraint orders to comply with policy.