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 19, 2016
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 2 (Pt #9) clinical records reviewed of a patient with restraint devices, the Hospital failed to ensure the patient was monitored every 15 minutes as required.

Findings include:

1. Hospital policy entitled, "Use of Restraint & Seclusion," (revised 6/15) required, "...II. Procedure...C. Restraint Monitoring...2. The staff member will document observations every (15) minutes...indicating that continuous monitoring is maintained..."

2. The clinical record of Pt #9 was reviewed on 4/19/16. Pt #9 was a [AGE] year old female admitted on [DATE] with a diagnosis of major depression. Pt #9's clinical record contained documentation of restraint usage on 3/22/16. The clinical record lacked documentation of observation checks being performed every 15 minutes as required.

3. The Nursing Supervisor stated during an interview on 4/19/16 at approximately 11:20 AM that the patient's record lacked documentation of the checks being completed.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 3 of 6 (Pt #2, 5, and 6) clinical records reviewed for advance directives, the Hospital failed to ensure all patients were allowed to formulate advance directives.

Findings include:

1. Hospital policy entitled, "Patient Rights/Restriction of Rights," (revised 10/15) required, "I. Policy: On admission to the Facility and during the patient's hospitalization , the patient will be informed of his/her rights according to federal and state rules and regulations."

2. Hospital policy entitled, "Advanced Directives," (effective 12/15) required, "...II: Procedure: A. The Assessment and Referral Department will inquire of all patients...whether they have a medical Advance Directive or want information...B. The Hospital's advance directive policy respects the right of the patient to make their own health care decisions..."

3. The clinical record of Pt #2 was reviewed on 4/19/16. Pt #2 was a 31 year male admitted on [DATE] with a diagnosis of psychosis. Pt #2's clinical record lacked documentation as to whether he had an advance directive or wanted information regarding an advance directive.

4. The clinical record of Pt #5 was reviewed on 4/19/16. Pt #5 was a 29 year female admitted on [DATE] with a diagnosis of psychosis. Pt #5's clinical record lacked documentation as to whether she had an advance directive or wanted information regarding an advance directive.

5. The clinical record of Pt #6 was reviewed on 4/19/16. Pt #6 was a 32 year female admitted on [DATE] with a diagnosis of psychosis. Pt #6's clinical record lacked documentation as to whether she had an advance directive or wanted information regarding an advance directive.

6. The Nursing Supervisor (E #8) stated during an interview on 4/19/16 at approximately 9:35 AM that the patients did not have documentation of advance directive information as required.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview, it was determined that for 4 of 5 days (4/15, 4/16, 4/17 and 4/18/16) reviewed the Hospital failed to ensure safety checks were completed every shift as required. This potentially affected a maximum of 36 patients on the 3rd floor Intensive Treatment Unit (ITU).

Findings include:

1. Hospital policy entitled, "Safety Rounds," (revised 10/15) required, "...II. Procedure: A. During each shift, a staff member will survey the unit using the safety checklist for their unit...."

2. On 4/19/16 at approximately 11:30 AM the 3rd floor ITU Safety Checklists were reviewed. The Checklists failed to include safety checks being conducted every shifty as required; 4/14/16 lacked day shift (7:00 AM - 3:30 PM); 4/16/16 lacked night shift (11:00 PM to 7:30 AM); 4/17/16 lacked day shift (7:00 AM to 3:30 PM); and 4/18/16 lacked day shift (7:00 AM to 3:30 PM and night shift 11:00 PM to 7:30 AM).

3. The Nursing Supervisor stated during an interview on 4/19/16 at approximately 11:20 AM that the safety checks were not completed every shift.