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.

NORTHWESTERN MEMORIAL HOSPITAL 251 E HURON ST CHICAGO, IL 60611 June 13, 2014
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview, it was determined that for 3 of 10 (Pt #1, 6, and 9) Emergency Department (ED) records reviewed, the Hospital failed to ensure all patients presenting to the Hospital receive a complete nursing assessment to include skin.

Findings include:

1. Hospital policy subject and title, "Emergency and Trauma Services, Nursing Documentation Standards," (Effective date 11/01/09) required, "III Procedure: 2...The primary nurse is accountable for the provision of nursing care...B. This assessment will encompass an evaluation of the following physiologic systems:7. Skin Integrity."

2. Pt #1 was a [AGE] year old female that presented to the Hospital's ED by Chicago Fire Department Emergency Medical Service (EMS) with a chief complaint of crisis. Pt #1 was triaged at 11:48 AM as a level 2 (emergent) on a 1 - 5. Pt #1's initial nursing assessment at 11:50 AM failed to include assessment of Pt #1's skin integrity as required.

3. The clinical record of Pt #6 was reviewed on 6/12/14 at approximately 11:00 AM. Pt $+#6 was a [AGE] year old female that presented to the Hospital's ED on 6//4/14 with a complaint of Nausea/Vomiting. Pt #6 was triaged as a level 2 (emergent) on a 1 - 5 level. Pt #6's initial nursing assessment dated [DATE] at 12:46 PM lacked an assessment of Pt #6's skin integrity as required.

4. The clinical record of Pt #9 was reviewed on 6/12/14 at approximately 11:00 AM. Pt #9 was a [AGE] year old female that presented to the Hospital's ED on 5/19/14 wit chief complaint of dehydration. Pt #9 was triaged as a level 3 (urgent) on a 1 - 5 level. Pt #9's initial nursing assessment on 5/19/14 at 9:29 7 PM failed to include an assessment of Pt #9's skin integrity as required.

5. The findings were verified by the Manager of Emergency Services during interviews on 6/12/14 at approximately 11:00 AM and 6/13/14 at approximately 9:15 AM. During the interview, the Manager stated that the patients' should have had their skin assessed as required.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed with a diagnosis of drug abuse, the Hospital failed to ensure reasons for incomplete tests were documented.

Findings include:

1. Hospital policy subject and title, "Emergency and Trauma Services, Nursing Documentation Standards," (Effective date 11/01/09) required, "III. Procedure: E. Miscellaneous: 1. Any non-pharmacological treatment/interventions rendered in the ED..."

2. Pt #1 was a [AGE] year old female that presented to the Hospital's ED by Chicago Fire Department Emergency Medical Service (EMS) with a chief complaint of crisis. Pt #1's clinical record contained a physician's order dated 4/28/14 at 11:56 AM that required a urine drug screen. On 4/29/14 at 8:20 PM the order was canceled. Pt #1's clinical record lacked documentation as to the reason the test had not been completed.

3. The Manager of Accreditation, Clinical Compliance and Policy Management stated during an interview on 6/13/14 at approximately 12:00 PM that the cliniocal record lacked documentation of why the patient's urine drug screen was not collected.