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.

CENTEGRA HEALTH SYSTEM - WOODSTOCK HOSPITAL 3701 DOTY ROAD WOODSTOCK, IL 60098 March 29, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 2 sampled patients (Pt. #11) placed in restraints, the Hospital failed to ensure that a restriction of rights notification was provided to the patient or representative when restraints were applied.

Findings include:

1. On 3/28/18 at 1:50 PM, the Hospital's policy titled, "Restraint/ Seclusion Policy, (revised March 2017), was reviewed. The policy required, "Notification Requirements... The patient shall be informed in writing that restraint and/or seclusion is a restriction of his/her rights..."

2. On 3/28/18 at 10:20 AM, Pt. #11's clinical record was reviewed. Pt. #11 was a [AGE] year old female, admitted on [DATE], with diagnoses of acute bipolar disorder and severe depression. A physician's order dated 3/10/18 at 10:49 AM, required "Restraint - TAT [twice as tough] Locking Limb Holder (4 Point)." However, there was no "Notice Regarding Restricted Rights of Individuals" in the clinical record.

3. On 3/28/18 at 2:15 PM, an interview was conducted with the Vice President of Operations (E #1). E #1 stated that "There should have been a restriction of rights and there's not one."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review, interview, and video review, it was determined that for 6 of 6 sampled patients (Pt #1, Pt #2, Pt #4, Pt #5, Pt #7, & Pt #9) reviewed for behavior precautions, the Hospital failed to ensure observation rounds were performed every 15 minutes as required.

Findings include:

1. On 3/26/18 at approximately 11:00 AM, the Hospital's policy entitled "Levels of Observation" (revised 3/22/18) was reviewed and included "Policy - The Inpatient Behavioral Health Unit shall take reasonable measures to minimize the risk of a patient harming self or others ...Behavioral Precautions - An Associate performs visualization/observation of the patient every 15 minutes. Monitoring documentation should be made every 15 minutes ...All admitted patients receive this level of observation unless 1:1 observation is ordered... Procedure... 7. If a patient is determined to be a suicide... risk, he/she may be placed in a patient gown and slippers until the psychiatrist writes a order that the patient may wear their own clothing..." The policy did not define "close observation."

2. On 3/26/18 at 11:15 AM, an interview was conducted with the Behavioral Health Unit Charge Nurse (E #2). E #2 stated that close observation means that a staff member must see the patient on close observation every 15 minutes.

3. On 3/26/18 at approximately 11:00 AM, the "Columbia-Suicide Severity Rating Scale (Screen Version) Level of Observation and Intervention Decision Matrix" (implemented 3/22/18), was reviewed. The Columbia Matrix provided guidance on assessment, observation, and intervention for suicidal patients, using 5 level of severity. All 5 levels required safety checks every 15 minutes.

4. On 3/26/18 at approximately 3:00 PM, videotape footage from the Behavior Health Unit (BHU) rooms 303, 304, 305 & 306 was observed from 3/23/18 (12:00 AM to 5:30 AM). The videotape footage from the BHU included that on 3/23/18, there were no patient observational rounds conducted from 4:15 AM through 5:29 AM, even though patients were in these rooms.

5. On 3/27/18 at approximately 9:00 AM, videotape footage from the BHU rooms 303, 304, 305, & 306 was observed from 3/25/18 (12:00 AM to 6:21 AM). The videotape footage from the BHU included that on 3/25/18, there were no patient observational rounds conducted from 1:29 AM to 2:21 AM, from 2:30 AM to 4:07 AM, and from 4:10 AM to 6:21 AM.

6. On 3/26/18 at 10:25 AM, the clinical record of Pt. #1 (room 304) was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with the diagnoses of bipolar with psychosis and learning disability. Pt #1's admitting physician's orders dated 11/29/17 included, "...Suicide Precautions..." Pt's suicide risk assessment dated [DATE] included, "...Potential for harm - moderate..." Pt #1's observation flow sheets dated 3/23/18 & 3/25/18 documented that Pt #1 was observed every 15 minutes in room 304. However, the videotape footage documented that Pt #1 was not observed every 15 minutes on 3/23/18 & 3/25/18.

7. On 3/28/18, the clinical record of Pt. #2 was reviewed. Pt #2 (room 303-1) was a [AGE] year old female, admitted on [DATE] with the diagnosis of bipolar disorder with suicide attempt. Pt #2's admitting physician's orders dated 3/24/18 included " ...close observation ..." Pt #2's observation flow sheet dated 3/25/18 documented that Pt #2 was observed every 15 minutes on 3/25/18. The videotape footage documented that Pt #2 was not observed every 15 minutes on 3/25/18.

8. On 3/28/18, Pt. #4's clinical record was reviewed. Pt #4 (room 306-1) was a [AGE] year old male, admitted on [DATE] at 3:05 AM with a diagnosis of major depression with suicidal ideation/ alcohol abuse. Pt #4's admitting physician's orders included " ...Suicide Precautions ..." Pt #4's Suicide Risk assessment dated [DATE] included " ...Potential risk for harm - high. Pt #4's observation flow sheet dated 3/23/18 documented that Pt #4 was observed every 15 minutes starting at admission (3:05 AM), and every 15 minutes on 3/25/18. The videotape footage documented that Pt #4 was not observed every 15 minutes on 3/23/18 & 3/25/18.

9. On 3/28/18, Pt. #5's clinical record was reviewed. Pt #5 (room 303-2) was a [AGE] year old female, admitted on [DATE] with the diagnosis schizophrenia. Pt #5's admitting physician's orders dated 3/17/18 included suicide precautions. Pt #5's observation flow sheet dated 3/23/18 documented that Pt #5 was observed every 15 minutes on 3/23/18. The videotape footage documented that Pt #5 was not observed every 15 minutes on 3/23/18.

10. On 3/28/18, Pt. #7's clinical record was reviewed. Pt #7 (room 305-1) was a [AGE] year old male, admitted on [DATE] with the diagnosis opiate dependence. Pt #7's psychiatric history & physical dated 3/21/18 included, " ...Pt #7 had thoughts of killing himself by overdosing on heroin ..." Pt #7's Suicide Risk assessment dated [DATE] included " ...Suicidal ideation - continuous, plan - specific.." Pt #7's observation flow sheet dated 3/23/18 documented that Pt #7 was observed every 15 minutes. The videotape footage documented that Pt #7 was not observed every 15 minutes on 3/23/18.

11. On 3/28/18, Pt. #9's clinical record was reviewed. Pt #9 (room 305-1) was a [AGE] year old male, admitted on [DATE] at 7:42 PM with the diagnoses of bipolar and suicidal ideation. Pt #9's psychiatric history & physical dated 3/24/18 included, "...Pt #9 stated that he wants to hurt himself and wants to kill himself..." Pt #9's admitting physician's orders dated 3/24/18 included "...Suicide Precautions..." Pt #9's Suicide Risk assessment dated [DATE] included "...Potential risk for self harm- moderate.." Pt #9's observation flow sheet dated 3/25/18 documented that Pt #9 was observed every 15 minutes. The videotape footage documented that Pt #9 was not observed every 15 minutes on 3/25/18.

12. On 3/27/18 at approximately 10:10 AM, an interview was conducted with the Psychiatric Medical Director (MD #1). MD #1 stated that it is an expectation that patient observation rounds should be conducted every 15 minutes for every patient on the BHU. MD #1 stated that she was not aware that patient observational rounds were not being conducted every 15 minutes on 3/23/18 from 12:00 AM to 5:30 AM and on 3/25/18 from 12:00 AM to 6:21 AM. MD #1 stated that the failure to do observational rounds every 15 minutes is an immediate, serious concern because of the potential for harm that could occur such as patients harming themselves. MD #1 stated that the Hospital needs an immediate plan to ensure that patients are monitored every 15 minutes.

B. Based on document review and interview, it was determined that for 15 out of 15 sampled Behavior Health Unit (BHU) employees (E #5 thru E #19) reviewed for management of suicidal patients, the Hospital failed to ensure that training included: ligature risks, suicide risks, suicide levels of intervention, crisis intervention, factors that decrease suicide risk, contraband, patient belongings, and body search.

Findings include:

1. On 3/27/18, an e-mail dated 11/16/17, regarding, "Professional Education Expectations for FY18 [fiscal year 2018]," was reviewed. The plan included, "FY18 training priorities: Co-occurring alcohol and substance use disorders [and] Treating psychosis in the acute care setting". CPI (crisis prevention training and Restraints education was required, as well as a movie regarding suicide."

2. On 3/27/18 at 11:30 AM, 15 BHU employee files were reviewed (7 Registered Nurse files - E #5, E #6, E #8, E#12, E #13, E #14, E #19) and (8 Behavior Health Counselors - E #7, E #9, E#10, E #11, E #15, E#16, E #17, E#18). All 15 employee files lacked documentation of ligature risk training. Twelve out of 15 (E #5 thru E#14 and E#18 & E#19's) employee files lacked documentation of training for contraband, patient belongings, and body search.

3. Seven staff files (E# 5, #6, #7, #8, #9, #11, & #13) lacked documentation of orientation and training that included suicide risk, levels of suicide intervention, factors to decrease suicide risk, crisis intervention, contraband, patient belongings and body search.

4. On 3/27/18 at approximately 11:45 AM, an interview was conducted with the Clinical Educator (E #20). E #20 stated that the employees in the BHU should have ligature risk training, management of suicide patient training, factors that decrease suicide risk training, level of suicide intervention training, contraband training, body search training, and crisis intervention.

C. Based on document review and interview, it was determined that for 6 of 6 sampled Behavioral Health Unit (BHU) patients (Pt #1, Pt #2, Pt #4, Pt #5, Pt #7, Pt #9) reviewed for Suicide Risk Assessments, the Hospital failed to ensure that a Suicide Risk Assessment included factors that increase or decrease the risk of suicide.

Findings include:

1. On 3/28/18 at approximately 1:00 PM, the Hospital's policy entitled, "Levels of Observation" (revision date 3/22/18) was reviewed and included "...Immediately after admission, an RN shall assess the patient, including an assessment of Risk Behaviors... The assessment will include the use of the standardized assessment tool of suicide or self-harm risk..."

2. Pt #1's clinical record was reviewed on 3/26/18. Pt. #1 was a [AGE] year old male, admitted on [DATE] with diagnoses of Bipolar with Psychosis and learning disability. Pt #1's admitting physician's order dated 11/29/17 included, "...Suicide Precautions..." Pt. #1's Suicide Risk assessment dated [DATE] included "...Potential for harm - moderate ..." Pt #1's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risk of suicide.

3. Pt. #2's clinical record was reviewed on 3/28/18. Pt #2 was a [AGE] year old female, admitted on [DATE] with diagnoses of bipolar disorder with suicide attempt. Pt. #2's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risks of suicide.

4. Pt. #4's clinical record was reviewed on 3/28/18. Pt. #4 was a [AGE] year old male, admitted on [DATE] at 3:05 AM with diagnoses of major depression with suicidal ideation/ alcohol abuse. Pt #4's Suicide Risk assessment dated [DATE] included "...Potential risk for harm - high..." Pt #4's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risks of suicide.

5. Pt. #5's clinical record was reviewed on 3/28/18. Pt #5 was a [AGE] year old female, admitted on [DATE] with a diagnosis of schizophrenia. Pt #5's admitting physician's orders dated 3/17/18, included "...Suicide Precautions..." Pt #5's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risks of suicide.

6. Pt. #7's clinical record was reviewed on 3/28/18. Pt #7 was a [AGE] year old male, admitted on [DATE] with a diagnosis of opiate dependence. Pt #7's psychiatric history & physical dated 3/21/18 included "...Pt #7 had thoughts of killing himself by overdosing on heroin..." Pt #7's Suicide Risk assessment dated [DATE] included "...Suicidal ideation - continuous, plan - specific..." Pt #7's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risks of suicide.

7. Pt. #9's clinical record was reviewed on 3/28/18. Pt #9 was a [AGE] year old male, admitted on [DATE] at 7:42 PM with diagnoses of bipolar & suicidal ideation. Pt #9's Psychiatric history & physical dated 3/24/18 included "...Pt #9 stated that he wants to hurt himself and wants to kill himself..." Pt #9's Suicide Risk assessment dated [DATE] included "...Potential risk for self harm- moderate.." Pt #9's Suicide Risk assessment dated [DATE] did not include factors that increase or decrease risks of suicide.

8. On 3/28/18 at 11:45 AM, an interview was conducted with the Behavioral Unit Charge Nurse (E#2). E#2 stated that the patient's Suicide Risk Assessments do not include factors that increase or decrease suicide risks.





D. Based on document review, observation and interview it was determined that the Hospital failed to ensure the Behavioral Health Unit (BHU) had no ligature and environmental risks. These risks potentially could cause injury or death to 11 patients on the BHU on census on 3/26/18.

Findings Include:

1. The Hospital's policy titled, "Inpatient Behavioral Health - Contraband: Room, Personal Belongings,and Personal Body Check" (reviewed 9/17) was reviewed on 3/27/18 at 10:00 AM. The policy included, "To ensure the safety of everyone on the Behavioral Health Unit, certain items are considered contraband. Use of contraband will be restricted and/or monitored by a BH (Behavioral Health) Associate... Contraband is defined as any item that is considered potentially dangerous..."

2. On 3/26/18 from approximately 9:35 AM - 11:45 AM, an observational tour of the BHU was conducted. Ten of 11 patients were on Suicide Precautions. The following ligature risks and environmental hazards were observed:

- 20 patient room doors (rooms #: 301 - 320) have 3 hinges and pinch points at the top of the door;
- 20 bathroom doors (rooms #: 301 - 320) have 3 hinges and pinch points at the top of the door;
- 15 corridor doors are equipped with lever handles;
- 12 corridor doors have door [extended] closing devices on the corridor side;
- 4 entrance/ cross corridor doors have exposed vertical panic hardware rods;
- 2 unlocked medical gas valve box in the corridor;
- An interior bathroom door inside a quiet room on the acute side;
- All smoke doors have exposed panic rods;
- 3 unlocked cabinets are in the day room and 4 cabinets have door [handles];
- 2 wall mounted phone with approximately 2 foot cords; and
- An unsupervised housekeeping cart was in the corridor containing unsecured plastic bags.

3. On 3/27/18 at 10:10 AM, an interview was conducted with the Medical Director of the Psychiatric Department (MD #1). MD #1 stated that she is aware of the ligature risks that exist on the Behavioral Health unit. MD #1 stated that some of the ligature risks have been removed and there will be a plan developed to reduce the remaining ligature risks. MD #1 stated that anything can be a ligature risk if a patient wants to commit suicide.





E. Based on document review, observation, and interview, it was determined that for 1 of 1 Housekeeper (E #4) on the Behavioral Health Unit (BHU), the Hospital failed to ensure housekeeping secured contraband items on the housekeeping cart.

Findings include:

1. On 3/28/18 at 2:50 PM, the Hospital's policy titled, "Inpatient Behavioral Health - Contraband, Room, Personal Belongings, and Personal Body Check," (reviewed 9/17), was reviewed. The policy required, "Contraband List - To ensure safety, the following items are not allowed to be in the possession of patients... plastic bags..."

2. On 3/26/18 at 9:35 AM, an observational tour was conducted in the BHU. At 9:50 AM, a Housekeeper (E #4) was in the washroom of patient room 302 and E #4's housekeeping cart was in the corridor, out of E #4's sight. In an unlocked drawer on the housekeeping cart were rolls of plastic bags.

3. On 3/26/18 at 9:50 AM, an interview was conducted with E #4. E #4 stated the plastic bags were not to be used in patient rooms and the cart could not be locked.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, videotape review, observations, and interviews it was determined, that for 1 of 1 Behavioral Health Unit (BHU), the Hospital failed to ensure that staff performed safety monitoring rounds every 15 minutes on all patients on suicide precautions; the BHU was free from ligature risks; and BHU staff received training related to suicidal issues. These deficient practices placed current and future patients at risk for serious harm. As a result, the Condition of Participation (42 CFR 482.13) Patient Rights was not in compliance. The Immediate Jeopardy (IJ) was not removed by the survey exit dated on 3/29/18.

Findings Include:

1. The Hospital failed to ensure that a restriction of rights notification was provided to the patient or representative when restraints were applied. (A-117)

2. The Hospital failed to ensure observation rounds were performed every 15 minutes. (A-144 A)

3. The Hospital failed to ensure that training included: ligature risk, suicide risk, suicide level of intervention, factors that decrease suicide risk, contraband, patient belongings, and body search. (A-144 B)

4. The Hospital failed to ensure that a Suicide Risk Assessment included factors that increase or decrease the risk of suicide. (A-144 C)

5. The Hospital failed to ensure ligature risks were removed from the BHU. (A-144 D)

6. The Hospital failed to ensure housekeeping secured contraband items on the housekeeping cart. (A-144 E)

7. The Hospital failed to ensure that a physician's order was written for restraints. (A-171)

8. The Hospital failed to ensure that patients in restraints were assessed every 15 minutes. (A-175)

An immediate jeopardy began on March 27, 2018, for the Hospital's failure to conduct safety rounds every 15 minutes for patients requiring suicide precautions, as seen on video tape of safety rounds on March 27, 2018.

An immediate jeopardy was identified during video tape monitoring on March 27, 2018, for the Hospital's failure to conduct safety rounds every 15 minutes for patients requiring suicide precautions, thus placing all of these patients at potential risk for serious harm.

An immediate jeopardy was announced on March 27, 2018 at 3:20 PM, during a meeting with the Hospital President (E #21), and Vice President of Operations (E #1). The IJ was not removed by the exit date of March 29, 2018.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 2 sampled patients (Pt. #11) placed in restraints, the Hospital failed to ensure that a physician's order was written for restraints.

Findings include:

1. On 3/28/18 at 1:50 PM, the Hospital's policy titled, "Restraint/ Seclusion Policy, (revised March 2017), was reviewed. The policy required, "Orders for Restraint and/or Seclusion: Restraint/ seclusion shall be applied only upon the written order of a physician... In an emergency... a Qualified Supervisory RN may initiate physical restraint/ seclusion... In this event... obtain a telephone order for the restraint/ seclusion from the attending physician/ designee within one hour of the initiation of restraint/ seclusion.... The order shall state... Maximum length of time restraint and/or seclusion is to be used based on the patient's age..."

2. On 3/28/18 at 10:20 AM, Pt. #11's clinical record was reviewed. Pt. #11 was a [AGE] year old female, admitted twice, on 2/11/18 and on 3/20/18, with diagnoses of acute bipolar disorder and severe depression. On the first admission, a physician's order dated 3/10/18 at 10:49 AM, required "Restraint - TAT [twice as tough] Locking Limb Holder (4 Point)." However, there was no restraint time restriction included in the order.

3. On 3/28/18 at 11:05 AM, an interview was conducted with a Behavioral Health Unit Charge Nurse (E #2). E #2 stated that the Nurse Practitioner who wrote the order on 3/10/18 choose the incorrect box on the computer screen for restraints and did not include a time duration.

4. During Pt #11's second admission, "restraint flowsheet" notes dated 3/19/18 at 8:58 AM, included, "She has demonstrated non-violent behavior including imminent risk of harm to self, agitation and inability to follow directions that requires restraints... Alternatives to restraints failed... Applied right and left wrist restraints and right and left ankle restraints..." There was no physician's order for restraints.

5. On 3/28/18 at 1:55 PM, an interview was conducted with the Vice President of Operations (E #1). E #1 stated that there was no physician's order for restraints on 3/19/18.
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 2 of 2 sampled patients (Pts. #11 & #14) placed in restraints, the Hospital failed to ensure the patients were assessed every 15 minutes.

Findings include:

1. On 3/28/18 at 1:50 PM, the Hospital's policy titled, "Restraint/ Seclusion Policy, (revised March 2017), was reviewed. The policy required, "Monitoring and care activities are implemented and recorded on the Restraint/ Seclusion Flow Sheet... at the initiation of restraint/ seclusion and every 15 minutes thereafter. These include the following: 1. Adequate respiration and circulation. 2. Any signs of injury. 3. Nutrition/hydration. 4. Range of motion in the extremities. 5. Vital signs. 6. Hygiene and elimination. 7. Physical and psychological status and conduct...

2. On 3/28/18 at 10:20 AM, Pt. #11's clinical record was reviewed. Pt. #11 was a [AGE] year old female, admitted on [DATE], with diagnoses of acute bipolar disorder and severe depression. A physician's order dated 3/10/18 at 10:49 AM, required "Restraint - TAT [twice as tough] Locking Limb Holder (4 Point)." Restraints were applied. The restraint flowsheet dated 3/19/18 included restraints were applied at 8:58 AM and removed at 12:43 PM, almost 4 hours. However, monitoring and care activities were only noted at 9:15 AM.

3. On 3/28/18 at 10:35 AM, an interview was conducted with a Behavioral Health Counselor (E #22). E #22 stated that there was someone in the room with Pt. #11 throughout the restraint period, but didn't document the circulation and care being offered every 15 minutes.

4. On 3/28/18 at 10:55 AM, Pt. #14's clinical record was reviewed. Pt. #14 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder. A physician's order dated 3/14/18 at 2:40 AM, required behavioral restraints for up to 4 hours. Pt. #14 was in restraints from 1:10 AM until 3:11 AM. There was no documentation of monitoring and care activities every 15 minutes.

5. On 3/28/18 at 11:25 AM, an interview was conducted with a Behavioral Health Unit Charge Nurse (E #2). E #2 stated that he is confident 15 minute monitoring and care activities were completed for Pt. #14, but it was not documented.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on document review and interview, it was determined that the Hospital failed to ensure restraint information was integrated into the Quality Assurance and Performance Improvement (QAPI) Program. This potentially affected the safety of approximately 40 patients restrained each year on the Behavioral Health Unit (BHU).

Findings include:

1. On 3/28/18 at 1:50 PM, the Hospital's policy titled, "Restraint/ Seclusion Policy, (revised March 2017), was reviewed. The policy required, "Performance Improvement: Data is collected by the Program in order to monitor the use of restraint/ seclusion and to improve the performance of processes that involve risks."

2. On 3/27/18 at 11:15 AM, the Restraint Logs for 2017 and 2018 were reviewed. On the BHU, there were 39 patients restrained in 2017 and 7 in 2018.

3. On 3/27/18 at 11:30 AM, the Organizational Outcomes (QAPI) Meeting Minutes for 2017 and 2018 were reviewed. The minutes did not include restraint discussion or information.

4. On 3/27/18 at 1:20 PM, an interview was conducted with the Vice President of Operations (E #1). E #1 stated that restraint information is discussed in BHU staff meetings, but not in QAPI meetings.