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.

AURORA CHICAGO LAKESHORE HOSPITAL 4840 N MARINE DR CHICAGO, IL June 19, 2012
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 1 patient (Pt. #1) identified as allegedly sexually abused, the Hospital failed to ensure the grievance investigation process was conducted by the governing body or an appointed grievance committee.

Findings include:

1. Hospital policy #ADM-005, revised 1/09, titled, "Patient Grievance" required, "The hospital appoints a Patient Advocate and has a procedure for receiving, investigating, and responding to complaints from patients..." Grievances are required to be investigated by the governing body or an appointed grievance committee, not only by the Patient Advocate.

2. The clinical record of Pt #1 was reviewed and included that Pt. #1 was an [AGE] year old male, admitted on [DATE], with a diagnosis of Bipolar Disorder. Pt. #1's admission orders dated 5/31/12 at 1:35 AM, included, admit to ITU (Intensive Treatment Unit) and precautions for: Escape, Assault, Self Injury, and Close Observation. A physician's order dated 6/4/12 at 5:00 PM, required "Block Room for Sexual Allegations". Pt. #1's observation record dated 6/4/12, indicated he was moved from room 320B to 319B.

3. On 6/18/12 at 10:00 AM, an interview was conducted with the Director of Performance Improvement/ Risk Management and Patient Advocate (E #1). E #1 stated that she had been informed on 6/4/12 by the Medical Director that Pt. #1's Guardian had called because Pt. #1 alleged that he was raped on 6/2/12. E #1 stated that she conducted an investigation and after interviewing Pts. # 1 & 2 and staff members, determined the allegation could not be substantiated. E #1 stated that interviews with staff were not documented and that the alleged sexual assault was a complaint, not a grievance, because it was quickly resolved.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of Hospital policy, grievance reports and staff interview, it was determined that for 1 of 1 (Pt. #1) grievance report involving an allegation of sexual abuse, the Hospital failed to respond to the complainant in writing within 7 days for a significant issue as per policy.

Findings include:

1. Hospital policy titled, "Patient Grievance" (revised 1/09) required, "The Patient Advocate will respond to the person about the action being taken on his/her grievance, verbally and in writing within 7 days of the receipt of complaint for significant issues."

2. The grievance reports from July 1, 2011 to June 18 th, 2012 were reviewed and included only one allegation of sexual abuse. The incident involved Pt. #1 on 6/2/12.

3. The Director of Performance Improvement/ Risk Management (E#1) was interviewed on 6/18/12 at 10:00 AM. E#1 was informed by the Medical Director on 6/4/12 of an allegation of rape that occurred on 6/2/12, reported by Pt. #1's Guardian. E#1 conducted an investigation and determined the allegation "unbelievable". E#1 called Pt. #1's Guardian on 6/5/12 and stated, "I completed my investigation regarding the allegation". E#1 did not follow up with a letter of the findings because, "I felt this was a complaint and not a grievance".
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 1 patient (Pt. #1) identified as allegedly sexually abused, the Hospital failed to conduct a complete investigation to ensure the patient's safety.

Findings include:

1. Hospital policy #NS-76, revised 7/09, titled, "Sexual Acting Out Behaviors" required, "5. For all alleged incidents involving sexual behavior... g. In the case of sexual behavior involving a minor, the Program Director/ Nursing Supervisor calls the DCFS [Department of Children and Family Services] hotline to report the incident and completes the DCFS reporting form... 7. b. 1. The Chicago Police Department is contacted so there is an official report of the alleged coerced sexual behavior..."

2. The clinical record of Pt #1 was reviewed and included that Pt. #1 was an [AGE] year old male, admitted on [DATE], with a diagnosis of Bipolar Disorder. Although Pt. #1 was not a minor, he was still included as a ward of DCFS. Pt. #1's physician admission orders dated 5/31/12 at 1:35 AM, included, admit to ITU and precautions for: Escape, Assault, Self Injury, and Close Observation. A physician's order dated 6/4/12 at 5:00 PM, required "Block Room for Sexual Allegations". The record contained no further documentation regarding an allegation of sexual abuse.

3. On 6/18/12 at 10:00 AM, an interview was conducted with the Director of Performance Improvement/ Risk Management and Patient Advocate (E #1). E #1 stated that she had been informed on 6/4/12 by the Medical Director that Pt. #1 ' s Guardian had called because Pt. #1 alleged that he was raped on 6/2/12. E #1 stated that she conducted an investigation and after interviewing Pts. # 1 & 2 (alleged perpetrator) and staff members, determined the allegation was unbelievable. E #1 stated that interviews with staff were not documented. "I spoke to... [the CEO] about my findings. The hospital will not report." Police, State, and DCFS were not notified of Pt. #1's alleged sexual assault.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, clinical records, and staff interview, it was determined for 1 of 2 clinical records (Pt. #1) for restrained patients, the Hospital failed to ensure the physicians' orders for restraints were clear.

Findings include:

1. Hospital policy #NS-65, revised 3/10, titled, "Use of Restraint/Seclusion" required, "C. 'Restraint/Seclusion Order Sheet' shall contain... 3. Type: seclusion or full restraints..."

2. The clinical record of Pt #1 was reviewed and included that Pt. #1 was an [AGE] year old male, admitted on [DATE], with a diagnosis of Bipolar Disorder. Pt. #1's admission orders dated 5/31/12 at 1:35 AM, included, admit to ITU (Intensive Treatment Unit) and precautions for: Escape, Assault, Self Injury, and Close Observation. A physician's order dated 6/1/12 at 1:10 PM, was checked "restraint" and "seclusion" and the type was identified as "seclusion" not "full restraints". On 6/1/12 at 1:15 PM, Pt. #1 was placed in 5 point restraints (legs, arms, & chest) because he "became increasingly angry and aggressively posturing" during a session with the Social Worker. Pt. #1 was released from restraints at 2:00 PM.

3. On 6/18/12 at 12:20 PM, an interview was conducted with the Manager of Clinical Services who stated that "seclusion" was a "mistake" on the restraint/seclusion order sheet and should have been "full restraints".
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, clinical record review and staff interview, it was determined that for 5 of 10 (Pt. #'s 1, 2, 3, 6 and 9) clinical records reviewed, the Hospital failed to ensure an assessment was documented on the Daily Flow Sheets every shift.

Findings include:

1. Hospital policy titled, "Documentation:Nursing Daily Flowsheet" (revised 10/09) required, "Nursing personnel are assigned to collect and record on the Daily Flow-Sheet for each patient every 8 hours".

2. The clinical record of Pt. #1 included that the Pt. was an [AGE] year old male admitted on [DATE] with the diagnosis of Bipolar Disorder. The Daily Flow Sheet lacked documentation of an assessment for the following shifts:

7:00 AM - 3:00 PM on 6/5/12
3:00 PM - 11:00 PM on 6/6/12

3. The clinical record of Pt. #2 included that the Pt. was a [AGE] year old male admitted on [DATE] with the diagnosis of Schizo-Affective Disorder. The Daily Flow Sheet lacked documentation of an assessment for the 7:00 AM - 3:00 PM shift on 6/3/12.

4. The clinical record of Pt. #3 included that the Pt. was a [AGE] year old male admitted on [DATE] with the diagnosis of Psychosis. The Daily Flow Sheet lacked documentation of an assessment for the following shifts:

- 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on 6/3/12
- 3:00 PM - 11:00 PM on 6/8/12
- 3:00 PM - 11:00 PM on 6/11/12
- 7:00 AM - 3:00 PM on 6/14/12
- 3:00 PM - 11:00 PM on 6/15/12
- 7:00 AM - 3:00 PM on 6/17/12

5. The clinical record of Pt. #6 included that the Pt. was a [AGE] year old male admitted on [DATE] with the diagnosis of Depressive Disorder. The Daily Flow Sheet lacked documentation of an assessment for the 3:00 PM - 11:00 PM shift on 6/13/12.

6. The clinical record of Pt. #9 included that the Pt. was a [AGE] year old male admitted on [DATE] with the diagnoses of Bipolar Disorder and Intermittent Explosive Disorder. The Daily Flow Sheet lacked documentation of an assessment for the 7:00 AM - 3:00 PM on 6/13/12.

7. The Director of Clinical Services was interviewed on 6/19/12 at 8:30 AM and stated that she, "reviewed the charts and found several shifts of documentation missing, but the expectation is that an entry is made each shift on the Daily Flow Sheet for all patients".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policies, clinical records and staff interview, it was determined that for 1 of 3 (Pt. #2) clinical records reviewed of patients with a length of stay over seven days, the Hospital failed to ensure the patients received an updated treatment plan.

Findings include:

1. Hospital policy titled, "Multidisciplinary Treatment Plan/Integrated Summary" (revised 9/10) required, "Each patient's treatment plan is updated minimally every 7 days".

2. The clinical record of Pt. #2 included that the Pt. was a [AGE] year old male admitted on [DATE] with the diagnosis of Schizo-Affective Disorder. The initial treatment plan was dated 5/25/12. The clinical record lacked an updated treatment plan as of discharge date of [DATE].

3. The Manager of Clinical Services was interviewed on 6/18/12 at 12:45 PM and stated that she reviewed Pt. #2's clinical record and was unable to find an updated treatment plan.