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.
| ADVOCATE GOOD SAMARITAN HOSPITAL | 3815 HIGHLAND AVENUE DOWNERS GROVE, IL 60515 | Sept. 15, 2017 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on document review, observation and interview, it was determined for 1 of 1 inpatient psychiatric unit and 2 of 13 (Pts #7 and 8) clinical records reviewed, the Hospital failed to ensure patients' rights were protected. As a result, the Condition of Participation for Patient Rights 42 CFR 482.13, was not met. Findings include: 1. The Hospital failed to ensure that the consent for psychotropic medication were completed as required. See deficiency at A 131. 2. The Hospital failed to ensure patient's privacy was protected. See deficiency at A-143. 3. The Hospital failed to ensure that the unit contraband checks were completed as required. See deficiency at A-144A. 4. The Hospital failed to ensure that the patients on suicide precautions were monitored as required. See deficiency at A-144B. 5. The Hospital failed to ensure patient was restrained for the appropriate length of time. See deficiency at A-171. 6. The Hospital failed to ensure the patient received a face-to-face evaluation with each new restraint event. See deficiency at A-179. |
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| VIOLATION: PATIENT RIGHTS: INFORMED CONSENT | Tag No: A0131 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined for 2 of 5 psychotropic drug record reviewed (Pt #'s 1 and 2), the Hospital failed to ensure that the consent for psychotropic medication was completed as required. Findings include: 1. On 9/14/17 at approximately 11:00 AM, the Hospital Policy titled, "Psychotropic Medication Treatment" (reviewed 3/17) was reviewed and required, "... IV. Procedure A... 1. Except in emergencies, psychotropic medication will be administered with the informed consent of the patient or legal representative. The physician or the physician's designee shall advise the recipient in writing of side effects, risks, and benefits of treatment..." 2. On 9/14/17 at approximately 11:30 AM, the Hospital Form "Patient Consent/Notification for Psychotropic Medications" was reviewed and indicated, "Patient/Guardian: By signing below, for each psychotropic medication prescribed, I acknowledge that my physician advised me in writing of the side effects, risks, benefits of the medication..." 3. On 9/14/17 at approximately 12:00 PM, the Hospital's listing of psychotropic medications requiring patient consent form was reviewed. On the list, Haldol (antipsychotic), Ativan (antianxiety), and Sertraline (antidepressant) were included. 4. On 9/14/17 at approximately 9:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar with psychosis. Pt. #1 had a physician's order of Haldol and Ativan on 9/12/17. Pt. #1 received Haldol on 9/13/17 at 9:10 PM and Ativan on 9/13/17 at 10:09 PM. The "Patient Consent/Notification for Psychotropic Medication" form was not signed by Pt. #1 or by her legal guardian. 5. On 9/14/17 at approximately 10:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old female admitted on [DATE] with a diagnosis of major depressive disorder. Pt. #2 had a physician order of Sertraline (Zoloft) on 9/12/17. Pt. #2 received the Zoloft on 9/12/17 at 2:35 PM; 9/13/17 at 8:43 AM; and 9/14/17 at 8:29 AM. Pt. #2's clinical record did not include the "Patient Consent/Notification for Psychotropic Medication" Form. 6. On 9/14/17 at approximately 9:45 AM, findings were discussed with E #2 (Charge Nurse, Behavioral Unit). E #2 stated that the Patient Consent to Psychotropic Medication form should have been signed by Pt. #1. On 9/14/17 at approximately 10:45 AM, findings were also discussed with E #1 (Manager, Inpatient Behavioral Health) who stated that there should be a psychotropic medication consent form completed for Pt. #2. |
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| VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY | Tag No: A0143 | |
| Based on observation and document review, it was determined that for 1 of 3 inpatient hallways (3 North, Intensive Treatment Unit/ITU) on the Behavioral Health Unit, the Hospital failed to ensure patient's privacy was protected. This potentially affected 6 patients (maximum capacity) in the ITU. Findings include: 1. On 9/15/17 at approximately 8:45 AM, an observational tour of the ITU was conducted. During the tour, 6 cameras were observed in all 6 patient rooms numbered 320, 321, 322, 323, 324, and 325. A monitor was observed at the nurses station showing visual images from the patients' room such as patients sleeping while in bed. 2. On 9/15/17 at approximately 10:20 AM, the Hospital's policy titled "Admission Criteria Inpatient Behavioral Health" (reviewed 12/16) was reviewed and required, "... E. Patient requirements for intensive treatment setting will include one or more of the following needs: 1. Continuous observation. 2. Limited observation area..." The policy did not include requirements regarding use of cameras. 3. On 9/14/17 at approximately 12:00 PM, the Hospital policy regarding use of surveillance camera on the behavioral unit was requested from E #4 (Director of Quality). E #4 stated that use of cameras on the behavioral unit were not stated in the Hospital policy. 4. On 9/15/17 at approximately 9:00 AM, interviews were conducted with E #1 (Manager, Inpatient Behavioral Unit) and E #5 (Registered Nurse). E #1 stated that the cameras were used to monitor patients. E #1 added that the cameras on the ITU were directed to the patient's bed. E #5 stated that, "The hope is to see the whole room." |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on document review and interview, it was determined that the Hospital failed in 10 of 74 (7/7/17; 7/8/17; 7/21/17; 7/22/17; 8/1/17; 8/6/17; 8/11/17; 9/3/17; 9/4/17; and 9/10/17) days from July 2017 to September 2017, the Hospital failed to ensure that the unit contraband checks were completed as required. This potentially affected all patients (maximum census of 36) admitted to the Psychiatric unit. Findings include: 1. The Hospital policy entitled, "Contraband/Personal Belongings Security Searches," (revised 3/13/2017) required, "...IV Procedure... F. Room searches are performed on day and PM shift...G. Searches of Common Areas: 1. Common areas such as day/group rooms, bathrooms, and patient kitchens will be searched at least daily and without restrictions..." 2. On 9/14/17 at approximately 9:30 AM, the Psychiatric Unit Contraband checks for the Psychiatric Units (3 West, 3 East and 3 North ITU) were reviewed. The following were noted: - Missing contraband checks either on the day or evening shift on: 7/7/17; 8/6/17; and 9/10/2017 on 3 East; and 7/8/17, 7/21/17, 7/22/2017; and 9/3/2017 on 3 North. - Missing contraband check on the following days: 8/1/17; 8/11/17; and 9/4/2017 on 3 North and 9/10/2017 on 3 East. 3. On 9/14/17 at approximately 10:00 AM the Manager of Inpatient Behavioral Health (E #1) was interviewed. E #1 stated that the contraband checks are to be completed 2 times a day. B. Based on document review and interview, it was determined for 4 of 4 (Pt. #1, #3, #4, and #5) clinical records reviewed on the Intensive Treatment Unit (ITU), the Hospital failed to ensure that the patients on suicide precautions were monitored as required. Findings include: 1. On 9/14/17 at approximately 12:00 PM, the Hospital's policy titled, "Suicide Risk Assessment and Precautions in Behavioral Health Department Only" (review date 3/17) was reviewed and required, "... E. Suicide Precautions (SP) are methods for supervising and monitoring the inpatient... G. Levels of suicide precaution... 2. SP II: The patient is monitored for location and behavior every 15 minutes, and this is documented... B... 4. Monitoring the inpatient on Suicide Precautions mean that the individual is visually observed by the staff person doing the monitoring and documentation of monitoring..." 2. On 9/14/17 at approximately 9:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar with psychosis. Pt. #1 had a physician's order of Suicide Precautions, Level II/sp 2 (monitored for location and behavior every 15 minutes, and documented) on 9/2/17, which has not been discontinued as of survey date 9/14/17. Pt. #1's every 15 minute monitoring sheets (Psychiatry and Substance Abuse Services Precaution Monitoring Sheet) dated 9/11/1, 9/12/17, and 9/13/17 did not indicate that Pt. #1 was on suicide precautions. 3. On 9/14/17 at approximately 9:55 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old male admitted on [DATE] with a diagnosis of depression. Pt. #3 had a physician's order of Suicide Precautions, Level II (monitored for location and behavior every 15 minutes, and documented) on 9/10/17, which has not been discontinued as of survey date 9/14/17. Pt. #3's every 15 minute monitoring sheets dated 9/11/17, 9/12/17, and 9/13/17 did not indicate that Pt. #1 was on suicide precautions. 4. On 9/14/17 at approximately 10:05 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old male admitted on [DATE] with a diagnosis of psychosis. Pt. #4 had a physician's order of Suicide Precautions, Level II/sp2 (monitored for location and behavior every 15 minutes, and documented) on 8/31/17, which has not been discontinued as of survey date 9/14/17. Pt. #4's every 15 minute monitoring sheets dated 9/11/17, 9/12/17, and 9/13/17 did not indicate that Pt. #1 was on suicide precautions. 5. On 9/14/17 at approximately 10:15 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a [AGE] year old male admitted on [DATE] with a diagnosis of bipolar disorder. Pt. #5 had a physician's order of Suicide Precautions, Level II, (monitored for location and behavior every 15 minutes, and documented) which has not been discontinued as of survey date 9/14/17. Pt. #4's every 15 minute monitoring sheets dated 9/11/17, 9/12/17, and 9/13/17 did not indicate that Pt. #5 was on suicide precautions. 6. On 9/14/17 between 9:45 AM and 10:15 AM, findings were discussed with E #2 (Charge Nurse) and E #3 (Registered Nurse ITU). E #2 and E #3 stated that the15 minute monitoring sheets should indicate that patients were monitored for suicide precautions. |
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| 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 that for 1 of 8 (Pt #7) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure the patient was restrained for the appropriate length of time. Findings include: 1. The Hospital policy entitled, "Utilization of Restraint and Seclusion," (last review date 9/6/17) required, " ...1. Physician Orders and Physician Assessment ...c) As soon as possible (within 30 minutes) after the inition of the restraint or seclusion, the RN will consult a responsible physician about the patient's condition, and obtain an order...f) The original order may be renewed as follows, but not to exceed 16 hours: (1) 4 hours for patients 18 and older ..." 2. On 9/15/17 at approximately 9:50 AM, the clinical record of Pt #7 was reviewed. Pt #7 was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizophrenia. Pt #7's clinical record contained a physician's order dated 6/14/17 at 6:23 PM (after the initiation of the restraints) that required restraints to both wrists and ankles with justification of "Immediate danger to others." Nursing documentation included that Pt #7 was restrained from 6:00 PM to 11:00 PM (5 hours). 3. On 9/15/17 at approximately 9:50 AM, the Manager of the Inpatient Behavioral Health (E #1) was interviewed. E #1 stated that the patient was restrained for 5 hours without an additional order. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0179 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 8 (Pt #8) clinical records reviewed for restraint usage, the Hospital failed to ensure the patient received a face-to-face evaluation with each new restraint event. Findings include: 1. The Hospital policy entitled, "Utilization of Restraint and Seclusion," (last review date 9/6/17) required, " ...IV. Procedure ...1. Physician Orders and Physician Assessment ...d) The original order is based on a face to face assessment of the patient by a physician or appropriately trained RN, to occur within one hour after the initiation of restraint or seclusion. The results of the assessment will be documentaed, and will include the: (1) patient's immediate situation; (2) patient's reaction to the intervention; (3) patient's medical and behavioral condition; (4) need to continue or discontinue restraint or seclusion..." 2. On 9/15/17 at approximately 10:20 AM, the clinical record of Pt #8 was reviewed. Pt #8 was a [AGE] year old male admitted on [DATE] with a diagnosis of psychosis. Pt #8's clinical record contained physicians' orders for restraint usage on 7/29/17 at 6:25 AM, 9:45 AM, 1:45 PM, and 5:45 PM. The clinical record lacked a one hour face-to-face evaluation for the usage of the restraints. 3. On 9/15/17 at approximately 10:20 AM, the Manager of Inpatient Behavioral Health (E #1) was interviewed. E #1 stated that the patient's clinical record lacks documentation of the face to face evaluation. |
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