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 60640 Jan. 30, 2013
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, that for 1 of 5 clinical records reviewed (Pt. #1), the Hospital failed to ensure the parent of a minor was promptly informed when the minor's rights were restricted.

Findings include:

1. The Hospital's "Restriction of Rights" policy, revised 4/11, was reviewed and required,
" V. Restrictions including Medication Against Patient's Will: A Restriction of Rights form... is filled out by the R.N... C. If patient is a minor, and a non-DCFS Ward, the parent/guardian must receive prompt notification by telephone. Documentation in the medical record indicates if staff are unable to contact directly the parent/guardian..."

2. Pt #1's clinical record was reviewed and included that Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of Suicidal Ideation and Major Depressive Disorder. Pt. #1's "Notice of Restriction of Rights" dated 10/23/12 at 1:10 PM, completed by an RN (E #4), included, that Pt. #1 was placed in restraints and was medicated with Thorazine 50 mg and Benadryl 50 mg, intramuscularly, due to "increase agitation, unable to follow directions, and threatening to elope". However, the Notice did not indicate that Pt. #1's Mother or Father was notified of the restriction of rights by telephone or that Pt. #1's Mother or Father was unable to be contacted by phone, but rather that the Notice was mailed to Pt. #1's Mother.

3. An interview was conducted with the Director of Clinical Services on 1/29/12 at 3:15 PM. The Director stated that Pt. #1's Mother came to the Hospital approximately 5 hours after the incident and was informed of the restriction of rights by the Social Worker. The Director stated that the Hospital used to mail the restrictions of rights notice to parents, but have changed the policy to utilize phone contact, to provide more rapid communication.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, that for 1 of 5 clinical records reviewed for patients placed in restraints (Pt. #1), the Hospital failed to ensure the patient's respirations were monitored every 15 minutes, as required by policy.

Finding include:

1. The Hospital's "Use of Restraint/Seclusion" policy, revised 11/12, was reviewed and required, "A. Care of Patient while in Restraint/Seclusion... 7. TPR [temperature, pulse, respiration] and blood pressure are monitored every 15 minutes, if possible. Respiratory status must be assessed and documented on patients in restraints, if unable to conduct all vital signs."

2. Pt #1's clinical record was reviewed and included that Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of Suicidal Ideation and Major Depressive Disorder. Pt. #1's "Notice of Restriction of Rights" dated 10/23/12, included, that Pt. #1 was placed in restraints due to "increase agitation, unable to follow directions, and threatening to elope". Pt. #1's "Restraint/Seclusion Record" dated 10/23/12, included Pt. #1 was placed in restraints at 1:10 PM and released at 2:10 PM. However, Pt. #1's vital signs, including respirations, were not recorded every 15 minutes, by the Mental Health Counselor (E #7) who was monitoring Pt. #1.

3. On 1/29/13 at 2:05 PM, an interview was conducted with E #7. E #7 reviewed Pt. #1's "Restraint/Seclusion Record" and stated that Pt. #1 was crying and talking while in restraints, but did not explain why Pt. #1's vital signs were not documented.

4. These findings were discussed with the Director of Performance Improvement and Risk Management on 1/29/13 at 4:55 PM.