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.

LINDEN OAKS HOSPITAL 852 S WEST STREET NAPERVILLE, IL 60540 May 10, 2012
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined, that for 4 of 17 patients (Pts. 2 - 5) requiring safety checks every 15 minutes on the Geriatric/ Generations (Gero) Unit, the Hospital failed to ensure safety checks were completed and documented every 15 minutes.

Findings include:

1. Hospital policy No. CLIN 078, revised, 4/26/12, titled, "Safety Precautions" required, "H. Close observation ("CO") - Used when a patient requires closer supervision than General Precautions... 1. Observe every 15 minutes...

N. Suicide Precautions ("S") - Used when patient at risk for suicide... Observed every 15 minutes...."

2. An observational tour was conducted on 5/9/12 between 9:07 AM and 11:05 AM on the Geriatric/ Generations (Gero) Unit. At 9:07 AM, a Behavior Health Associate (E #1) at the far end of the Unit was completing the 15 minute safety check sheets for the unit. For 3 of the 17 patient's (Pts. 2 - 4) safety check sheets had not been completed since 8:00 AM, over 1 hour earlier. E #1 stated that he had taken a group of patients to the cafeteria for breakfast at 8:00 AM, had just returned and was completing the documentation. E #1 stated that other team members told him where the other patients were when he was downstairs.

3. Pt. #2's clinical record was reviewed on 5/9/12 at 9:45 AM. Pt. #2 was a [AGE] year old female, admitted on [DATE], with a diagnosis of Suicidal Ideation. A physician's order dated 5/1/12, required suicidal safety precautions.

4. Pt. #3's clinical record was reviewed on 5/9/12 at 10:10 AM. Pt. #3 was a [AGE] year old male, admitted on [DATE], with diagnoses of Suicidal Ideation and Depressive Disorder. A physician's order dated 5/7/12 at 8:25 PM, required suicidal safety precautions.

5. Pt. #4's clinical record was reviewed on 5/9/12 at 10:30 AM. Pt. #4 was a [AGE] year old female, admitted on [DATE], with a diagnosis of Psychosis. A physician's order dated 5/6/12, required suicidal and fall safety precautions.

6. The Director of In-Patient Services confirmed these findings during the tour and staff interview on 5/9/12 at 11:00 AM.

7. Pt. #5's physician's order dated 4/20/12 at 9:00 AM, discontinued S precautions and required "CO" (Close Observation). Pt. #5's 15 minute safety sheet was incomplete on 5/7/12 at 5:00 PM and 5:15 PM.

8. The Director of Specialty Services confirmed the finding related to Pt. #5 during the clinical record review and staff interview on 5/9/12 at 1:30 PM.