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 28, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A. Based on document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a medical screening exam for the patient presenting for treatment. (A 2406)
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on document review and interview, it was determined that for 1 of 20 (Pt #1) Emergency Department (ED) clinical records reviewed, the Hospital failed to ensure a medical screening examination was provided to a patient presenting for emergency treatment.

Findings include:

1. On 4/27/15 the Hospital Medical Staff by-laws was reviewed and included, "...27.2. Qualified Medical/Psychiatric Personnel...are individuals determined qualified by the medical staff to perform a medical screening....medical staff in the following positions are authorized to perform medical screening and stabilization...27.2.4. Registered Nurses..."

2. Hospital policy entitled, "Admission Procedure: Level of Care Assessment (1/13) was reviewed and required, "A. Triage: 1. Once a patient presents for assessment, they are screened by a Mental Health Counselor...B. Every patient who presents for an assessment is seen by a Registered Nurse who completes a nursing assessment..."

3. On 4/27/15 the Emergency Department record of Pt. 1 was reviewed. Pt. #1 was a [AGE] year old male who arrived at the ED on 3/26/14 at 3:06 PM with a request for assistance with methadone detoxification. Pt. #1 history was significant for Heroin addiction. Pt #1's vital signs at time of triage were: temp 98, blood pressure 108/76, pulse 81, respirations 20 oxygen saturation 97%, pain level 6 (noted area of pain knee and teeth). Triage level was green (non-urgent). After Pt. #1's triage was completed by a mental health counselor (MHC), Pt. #1's name was placed on the call board at 5:00PM for the medical screening examination (MSE) and intake assessment. The ED record lacked documentation that a MSE was provided by the RN in accordance with Hospital by-laws. On 3/26/15 at 8:15 PM (5 hours and 9 minutes after Pt. #1's arrival) a licensed professional counselor (LPC #1) performed an assessment and notified the on-call psychiatrist at 9:30 PM. Upon the on call psychiatrist's recommendation, Pt. #1 was instructed to call 911 for any emergency; follow up with the primary care physician and or call the toll free insurance hotline for guidance. Pt. #1 was discharged at 9:30 PM without an MSE or additional vital signs.

4. On 4/28/15 at approximately 12:00 PM, the Director of Admission and Referrals (E #1) and the Chief Nursing Officer (E #5) stated E #3 (Registered Nurse), was qualified to perform a medical screening examination; that the examination was performed but the document could not be located.