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.

HARTGROVE HOSPITAL 5730 W ROOSEVELT ROAD CHICAGO, IL 60644 Jan. 27, 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 that for 1 (Pt. #1) of 10 clinical records reviewed, the Hospital failed to ensure the patient received care in a safe setting.

Findings include:

1. Hospital policy number PC 413-1 titled, "Suicide Prevention Plan," (reviewed 12/15) required, "Suicide Precaution: 1. Staff will closely observe and make rounds on the patient at least every 15 minutes or more as often as MD orders."

2. Hospital policy number PC 424 titled, "Patient Monitoring/Observation Rounds," (reviewed 12/15) required, "Responsibility: ... 2.0 Observation will be documented on Observation Sheet."

3. On 1/22/16 at approximately 4:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of unspecified mood disorder. Pt. #1 was placed on suicidal precaution that required monitoring every 15 minutes. However the Observation Round/Precautions sheet dated 1/14/16 lacked documentation of monitoring for 30 minutes between 7:45 AM and 8:15 AM.

4. On 1/27/16 at approximately 12:05 PM, an interview was conducted with the Director of Nursing (DON) who stated that every 15 minutes rounding should be documented on the monitoring sheet. The DON added that, "if monitoring was not documented, it means it was not done."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview, it was determined that the Hospital failed to ensure adequate staffing was provided to deliver safe patient care. This potentially affected 63 patient on census for 2 North and 2 South on 1/8/16; and 39 patients on 2 North on 1/11/16.

Findings include:

1. Hospital policy NR 223 titled, "Staffing Plan/Patient Acuity," reviewed 12/15 required, "Policy Statement: Nurse executive team actively maintains on-going processes to assure that sufficient number and mix of staff are provided on a 24 hours a day based on census and patient care needs... Daily Staffing Plan: ...Staffing coordinator prepares daily schedule and assess staffing needs based on census and acuity of patient needs on each unit... DON/Nurse Manager/House Supervisor... assess any additional staffing needs in coordination with unit RN based on verbal discussion focusing on safety issues on the unit...precautions such as 1:1... The Nurse Manager/DON are responsible for assuring appropriate staffing 24 hours a day.

2. On 1/26/16 at approximately 11:00 AM, staffing grid titled, "24 Hour Nursing Administration," revised 9/14/15 was reviewed and required... Staffing for night shift on all units... 25+ patients required 4 staff (1 Registered Nurse, 3 Mental Health Staff). The DON also stated that additional staff, Registered Nurse (RN) or Mental Health Specialist (MHS) will be provided for each unit with patients requiring 1:1 monitoring.

3. On 1/26/16, staffing schedules of all units (2 North, 2 South, 3 North, and 3 South) from 1/8/16 to 1/21/16 were reviewed. Staffing for the night shift examples were as follows:

- 1/8/16 census of 2 North was 35 with 2 patients requiring 1:1 monitoring. There were 6 staff (2 RNs and 4 MHS). However, 1 of the 2 RNs was assigned to cover another staff in a different unit. As a result, the unit was short of 1 staff from 3:00 AM to 3:30 AM.

- 1/8/16 census of 2 South was 28. There were 3 staff (1 RN and 2 MHS) scheduled for the entire shift. The unit was short of 1 staff from 11:00 PM - 7:00 AM.

- 1/11/16, census of 2 North was 39 with 2 patients who required 1:1 monitoring. There were 5 staff (2 RNs and 3 MHS) scheduled. 2 South had 28 with 1 patient requiring 1:1 monitoring. There were 3 staff (1 RN and 3 MHS) scheduled. Both units were short of 1 staff for the shift.

4. On 1/26/16 and 1/27/16 between 11 AM and 12:00 PM, an interview was conducted with the Director of Nursing (DON). Examples of the staffing schedule for the night shift was also reviewed. The DON stated that: "Ideally, the staffing grid should be followed." Further, the DON concurred that the patient care units were short-staffed on the examples provided by the surveyor.