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||Oct. 17, 2014|
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, it was determined for 3 of 3 patients (Pt#7, Pt#8 and Pt#9) reviewed for enuresis (uncontrolled urination), the Hospital failed to ensure the patients were assessed, plans of care developed and interventions monitored.
1. Policy entitled, "Multidisciplinary Treatment Plan (Revised 9/13) indicated "Procedure I B. Identification of Problems: 1. All problems are documented even if they are not the cause for the patient's admission, including medical issues. L. Multidisciplinary Treatment Interventions: 1. Each discipline treatment interventions are documented describing what the clinician will do to assist the patient in achieving his short or long term goal. Interventions are documented defining the purpose and frequency. 2. Each discipline interventions will include identifying the problems being addressed."
2. Policy entitled, "Documentation: Daily Flowsheet" (Revised 1/13) indicated "Patients are continually re-assessed throughout their hospitalization . Ongoing assessments are documented each shift on the Daily flow sheet, in addition to the progress notes in the patients' medical records.
3. Policy entitled "Documentation: Daily RN Assessment" (Revised 1/13) indicated " Procedure: B 2. After conducting a face-to face patient assessment, the RN documents ....physical status on the RN assessment form.
4. Pt.#7 was a [AGE] year old male admitted on [DATE] with a diagnosis of Impulse Control Disorder. Pt#7's physician's orders, history and physical, initial nurse's assessment and Multidisciplinary Plan (MDTP) were reviewed. These documents did not reflect if the patient had an issue with enuresis. However the nurse's report sheet and communication board reflected Pt. #7 had enuresis.
On 10/15/14 at approximately 11:00AM the Assistant Director of Nursing stated Pt#7 has been assessed and found to have enuresis. However, the patient's clinical record does not reflect this finding.
5. Pt#8 was a [AGE] year old male admitted on [DATE] with a diagnosis of Episodic Mood Disorder. Patient Nursing assessment dated [DATE] indicated in review of systems the genitourinary system was within normal limits, however the patient had episodes of "bed wetting."The MDTP did not reflect the patient had enuresis. No interventions were documented. The clinical record lacked documentation of interventions for enuresis.
On 10/15/14 at approximately 11:45AM the Registered Nurse (E#2) stated Pt#8 did not have episodes of enuresis. However the MDTP was not updated and Pt. #8 had been endorsed in report as a patient with enuresis.
6. Pt#9 was a 7 year old female admitted on [DATE] with a diagnosis of Impulsive Control Disorder. The medical history and physical exam dated 9/27/14 indicated, "Problem List/Assessment Enuresis. Plan 2. Currently on enuretic protocol. Asked staff to let us know if having any enuresis outside protocol." Pt#9's MDTP dated 9/26/14-9/29/14 indicated the patient had a diagnosis of enuresis. However the MDTP lacked documentation of any interventions for the enuresis.
On 10/16/14 at approximately 11:15AM the Assistant Director of Nursing, (E#7) stated the patient's clinical record may contain an order for "enuresis protocol". However, the Hospital does not have an enuresis protocol. E#7 stated it is our practice for the night staff to frequently round and assist the patient at 1:00AM and at 4:00AM to prevent enuresis. E#7 stated if the doctor does not document the patient has enuresis/incontinence it is not addressed in the patient multi-disciplinary plan (MDTP). E#7 stated if the nurses observe after initial assessment patient has enuresis episode, it is not reflected in the patient's clinical chart.