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 Nov. 6, 2015
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 in 3 of 4 (Pt #6, 8 and 9) clinical records reviewed of patients with restraint/seclusion usage, the Hospital failed to ensure the notice of restriction of rights was completed as required.


Findings include:

1. The Facility policy titled "Restriction of Rights" (rev. 4/11) required, "V. Restrictions including Medication Against Patient's Will: A. A Restriction of Rights form ... filled out by the RN."

2. The Facility policy titled "Use of Restraints and Seclusion" (rev. 2/13 required, "F. A "Notice of Restriction of Rights" form is completed: one copy goes to the patient and one copy to the chart. When Restraints/Seclusion are used, the patient shall be advised of his/her right to have any person of their choosing, including the Guardianship and Advocacy Commission notified of the restraint/Seclusion.

3. On 11/6/15 the clinical record of Pt#6 was reviewed. Pt#6 was a [AGE] year old male admitted on 8/7/15 for bipolar disorder. Pt#6's record contained a physician's order dated 9/3/15 at 10:30 AM and 1:30 PM for FVR (full Velcro restraints) with a 1:1 staff monitor. On the "Notice of Restriction of Rights" dated 9/3/15 at 10:30 AM and 1:45 PM the form failed to include Pt#6 was placed on restraints.

4. On 11/6/15, the clinical record for Pt. #8 was reviewed. Pt. #8 was a [AGE] year old female admitted on [DATE] with diagnoses of bipolar disorder and post traumatic stress disorder. The clinical record contained a physician's order dated 9/28/15 for physical restraints. The record contained documentation that Pt. #8 was placed in restraints on 9/28/15 at 11:30 AM; however the record lacked a "Notice of Restriction of Rights" for the restraints.

5. On 11/6/15, the clinical record for Pt. #9 was reviewed. Pt. #9 was a [AGE] year old female admitted on [DATE] with a diagnosis of unspecified episodic mood disorder. The clinical record contained a physician's order dated 3/27/15 for 5 point velcro restraints. The record indicated that Pt. #9 was restrained on 3/27/15 at 9:45 PM; however the Notice of Restriction of rights did not include that patient was placed in restraints.

-On 3/30/15 a physician ordered full velcro restraints on Pt. #9 at 10:30 AM, for 2 hours, and reordered the restraints at 12:30 PM. Documentation indicated that Pt. #9 was restrained from 10:30 AM to 1:15 PM; however the record did not contain a "Notice of Restriction of Rights" for the restraints.

6. The above findings were discussed with the Interim Chief Nursing Officer (CNO) during an interview on 11/6/15 at approximately 12:30 PM. The CNO stated that the restriction of rights notice should be completed for all restraint/seclusion use and the notice should indicate the type of restriction used.
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 that for 3 of 9 (Pt#1, #2, and #3) reviewed for psychotropic medications the Hospital failed to ensure informed consents were obtained as required per policy.

1. Policy entitled, "Informed Consent" (effective 10/20/15) indicated "I. Policy: AC. Informed Consent must be obtained from a patient, or the patient's legal representative, by the hospital...when it is deemed required to have formal documentation of the patient's consent for treatment. D. ...written verification of the informed consent must be on the patient's medical record prior to initiation of care, treatment services. II. 6. The following signatures are required as part of the informed consent: a.) Patient or representative/legal guardian (signature may be written or electronic) 1.) If the patient is unable to sign for the Administration of Psychotropic medication, document the verbal agreement by the patient or patient's legal representative. B. Obtaining Psychotropic Medication Informed Consent: Documentation by the performing practitioner in the medical record shall include:..b. That the informed consent was obtained...7. The original copy of the informed consent must be in the patient's medical record prior to care, treatment or services. 8. Any special circumstance(s) must be documented on the informed consent.

2. Policy entitled "Psychotropic Medication Side Effects/Patient Information/Consent Forms" (Revised 8/2012) indicated "Procedure: 6. The Physician checks the appropriate boxes, signs the consent form and has the patient/guardian sign that they have received verbally and and in writing the benefits, risks, side-effects, and alternative treatments to the medication ordered. 7. The Psychiatric Medication Informed Consent form remains in the front of the physician's orders and each new medication is added per policy. 8. Guardians of adult patients are permitted to provide written and informed consent as long as the patient agrees to the administration of psychotropic medication."

3. On 11/4/15 Pt#1's clinical record was reviewed. Pt#1 was admitted on [DATE] with a diagnosis of Schizophrenia. Pt#1's clinical record contained a physician's order dated 1/29/15 at 3:30 PM for Navane (antipsychotic medication) 10 mg orally twice a day. Pt#1's Psychotropic Medication Informed Consent" was not updated to include that this medication was added to the Pt#1's treatment. The Medication Administration Record (MAR) was reviewed from 1/22/15 to 2/4/15. Pt#1 received a total of 9 doses.

4. On 11/5/15 at 10:00 AM the clinical record of Pt#2 was reviewed. Pt#2 was a [AGE] year old male admitted on [DATE] with a diagnosis of schizophrenia. Pt#2's clinical record contained a physician's order for Haldol (antipsychotic medication) 5 mg orally or intramuscularly every 6 hours as needed. Ativan (antianxiety medication) 2 mg by mouth or intramuscularly every 6 hours as needed. Pt#2's Psychotropic Medication Informed Consent did not contain a signature of Pt#2, or the attending physician. The consent did not indicate that Pt#2 was unable to sign. Pt#2's "PRN" (as needed medication) MAR from 10/26/15-11/4/15 was reviewed. Pt#2 received several doses of Haldol and Ativan. Examples include: Haldol 5 mg orally was administered on 10/26/15 at 9:20 PM; 10/27/15 at 5:00 PM; 10/28/15 at 5:00 AM. Ativan 2 mg intramuscularly was administered on 10/26/15 at 10:30 AM; 10/27/15 at 4:30 AM; 10/27/15 at 11:00 PM.

5. On 11/4/15 the clinical record of Pt#3 was reviewed. Pt#3 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar disorder. Pt#3's physician's order dated 10/26/15 included Ativan 2 mg orally or intramuscularly every six hours as needed for anxiety. This medication was not included in the "Psychotropic Medication Informed Consent." The consent form did not indicate Pt#3 was unable to sign the consent for these medications. The "PRN MAR" was reviewed from 10/26/15 to 11/3/15. Pt#3 received Ativan 2 mg orally on 10/29/15 at 11:00 PM; 10/31/15 at 10:00 PM; 11/2/15 at 4:00 PM.

6. On 11/6/15 at approximately 11:15 AM the Interim Chief Nurse Officer (CNO) was interviewed. The Interim CNO stated patients shouldn't receive medication without the patient providing consent first.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview it was determined that for 1 of 9 (Pt#4) clinical records reviewed, the Hospital failed to ensure the physician's orders were implemented.

1. Policy entitled "HCG/UCG" (Revised 3/2015) "Procedure: 1. At the time of admission a serum HCG is ordered by the attending Physician for all female patients or any menstruating female...3. Results of UCG or HCG are required prior to administering medication unless otherwise indicated by physician order. 4. If a Physician orders a urine pregnancy test on admission, the Nurse uses the 'Aimstick PBD HCG...Documentation: The Urine Pregnancy test (Aim Stick) will be documented on the Medication Administration Record (MAR)."

2. On 11/4/15 at approximately 11:00 AM Pt#4's clinical chart was reviewed. Pt#4 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar manic disorder. Pt.#4's clinical record contained a physician's order dated 10/18/15 at 12:20 PM for a Serum Pregnancy, HCG and Urine pregnancy (Aim stick). Pt#4's laboratory results from 10/18/15 to 11/4/15 were reviewed. No results were found in Pt#4's clinical record for the serum pregnancy. Pt#4's MAR (Medication Administration) did not contain the urine pregnancy test result as required by Hospital policy.

3. On 11/4/15 at approximately 11:15 AM the findings were discussed with the Nurse Manager of the Intensive treatment Unit located on the 3rd floor. The Nurse Manager stated when a physician orders a pregnancy test, the nurses are responsible to obtain a urine sample, perform the test, and per policy, document the result in the MAR.

4. On 11/6/15 at 11:15 AM the Interim Chief of Nursing (CNO) was interviewed. She stated orders can be missed due to it being written and not in an electronic version. She also stated staff did not document per policy.