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 April 6, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 3 of 4 patients (Pts. #11 - 13) on the third floor intensive treatment psychiatric unit (ITU), the Hospital failed to ensure that psychiatric patients with physician's orders for close observation safety precautions were monitored every 15 minutes.

Findings include:

1. On 4/6/16 at 11:35 AM, Hospital policy number 200.29, titled, "Rounds for Patient Observations", effective 1/10/14, was reviewed. The policy required, "Every patient must be seen by a staff member at a minimum of every fifteen minutes... Hand off assigned patient observation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies)."

2. On 4/4/16, at 11:25 AM, an observational tour was conducted on the third floor adults intensive treatment psychiatric unit, in the company of the Director of Clinical Services (E #6). At 11:25 AM, the Patient Observation Records (15 minute safety rounding sheets) were requested. Three of 4 patients (Pts. #11 - 13) did not have rounding sheets completed for 11:00 AM and 11:15 AM.

- Pt. #11 was an [AGE] year old female, admitted on [DATE], with a diagnosis of psychosis, and a physician's order dated 3/21/16, for escape precautions (EP), assault precautions (AP), and self injury precautions (SIP).

- Pt. #12 was a [AGE] year old female, admitted on [DATE], with diagnoses of psychosis and bipolar disorder, and a physician's order dated 4/1/16 for EP, AP, and SIP.

- Pt. #13 was a [AGE] year old male, admitted on [DATE], with a diagnosis of bipolar disorder, and a physician's order dated 3/31/16 for EP, AP, and SIP.

3. On 4/4/16 at 11:30 AM, an interview was conducted with the Mental Health Counselor (E #3) who was assigned to patient observation rounding. E #3 stated he was catching up on the rounding sheets because he had been "busy with a patient".

4. These findings were discussed with the Director of Clinical Services (E #6) during the observational tour on 4/4/16 at 11:30 AM.