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 March 30, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview, it was determined for 3 of 4 (2 North, 2 South, and 3 South ) nursing units, the Hospital failed to ensure adequate staffing was provided. This potentially affected an average daily census between 30 to 38 patients admitted to each unit.

Findings include:

1. On 3/28/17 at approximately 11:00 AM, the Hospital's policy titled "Staffing Plan/Patient Acuity" (reviewed 12/16) was reviewed and required, "Daily Staffing Plan: Nurse manager works collaboratively with staffing coordinator in maintaining a schedule system that provides appropriate skilled personnel, twenty four a day seven days a week... Nurse Manager/Staffing Coordinator/House Supervisor adheres to staffing guidelines as outlined in the grid..."

2. On 3/28/17 at approximately 11:30 AM, the Hospital's "Staffing Guidelines" for all units were reviewed. The staffing guidelines indicated that on the day and evening shifts for 2 North, 9 staff (3 Registered Nurses [RN]/Licensed Practical Nurses [LPN] and 6 Mental Health Specialists [MHS]) was required for 35 to 39+ patients); for 2 South, 7 staff (2 RNs/LPNs and 5 MHS) was required for 32 to 36 patients; and for 3 South, 8 staff (2 RNs and 6 MHS) was required for 31 to 36 patients.

3. On 3/29/17 at approximately 11:00 AM, the staffing assignment sheets for all units (2 North, 2 South, 3 North, and 3 South) for 3/2/17, 3/4/17, and 3/5/17 were reviewed and included the following staff shortages per the unit staffing grid:

- 3/4/17, 3 South evening shift's census was 34 (with 2 patients requiring 1:1 monitoring). There were 9 staff (2 RN and 7 MHS) scheduled. The unit was short of 1 MHS for the shift.

- 3/5/17, 2 North day and evening shift's census was 40 and 41 respectively (each shift with 1 patient requiring 1:1 monitoring). There were 9 staff (3 RNs and 6 MHS) scheduled for each shift. The unit was short of 1 MHS on both day and evening shifts.

- 3/5/17, 2 South day and evening shift's census was 35. There were 6 staff scheduled (2 RNs and 4 MHS) for each shift. The unit was short of 1 MHS on both day and evening shifts.

- 3/5/17, 3 South evening shift's census was 34 (with 2 patients requiring 1:1 monitoring). There were 9 staff (2 RNs and 7 MHS) scheduled. The unit was short of 1 MHS for the shift.

4. On 3/29/17 at approximately 1:00 PM, findings were discussed with E #2 (Director of Nursing), who stated, "Ideally, staffing is based on the grid." E #2 agreed that the units were short staffed on 3/4/17 and 3/5/17.