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 Sept. 8, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation, and interview, the Hospital failed to ensure contraband checks were completed as required to prevent patients from obtaining items which could be used for self injury and failed to ensure the precautions were maintained as ordered.

Findings include:

The Hospital failed to ensure the accurate completion of room checks and preventing the availability of contraband on the unit. (see tag A-144)

The Hospital failed to ensure precautions were maintained as ordered. (see tag A-144)

The cumulative effect of these deficiencies resulted in an IJ potentially affecting all 13 patients on the adolescent girl's unit during the survey.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 3 of 6 (Pt. #5, 6, & 7) records reviewed, the Hospital failed to ensure psychotropic consent forms were completed as required by policy.

Findings include:

1. The Hospital policy titled, "Psychotropic Medication Informed Consent" required, "The physician shall determine and state in writing whether the recipient (patient) has the capacity to make a reasoned decision regarding their treatment/medication. For each medication ordered for administration to the patient, the physician or physician's designee advises the recipient (patient), in writing....Procedure: Adult Units: 3. The Psychotropic Medication Informed Consent form is placed in the front of the Physicians Orders for the physician to sign after reviewing with the patient."

2. The clinical record for Pt #5 was reviewed on 9/7/16 and included Pt #5 was a [AGE] year old male admitted on [DATE] with a diagnosis of suicidal thoughts. There were physician orders for Wellbutrin XL 300 mg (anti-depressant), Prozac 60 mg (anti-psychotic), and Seroquel (anti-psychotic). The medication administration record indicated that Pt #5 received these medications as ordered. However, the clinical record lacked consent for psychotropic medications.

3. The clinical record for Pt #6 was reviewed on 9/7/16 and included Pt #6 was a [AGE] year old male admitted on [DATE] with diagnoses of psychotic behavior and schizoaffective disorder. Physician's orders, dated 9/1/16, included Lithium 450 mg (anti-manic) twice a day and Risperdal 1 mg (anti-psychotic) twice a day. The medication administration record indicated that Pt #6 received these medications as ordered. However, the clinical record lacked consent for psychotropic medications.

4. The clinical record for Pt #7 was reviewed on 9/7/16 and included Pt #7 was a [AGE] year old male admitted on [DATE] with a diagnosis of paranoid schizophrenia. Physician's orders, dated 8/31/16, included Geodon 40 mg (anti-psychotic) three times a day. The medication administration record indicated that Pt #7 received these medications as ordered. However, the clinical record lacked consent for psychotropic medications.

5. The above findings were discussed with the Clinical Nurse Manger, during an interview on 9/7/16 at approximately 3:00 PM, stated that the psychotropic consent forms should be completed by the ordering physicians once the medication is reviewed with the patient.
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, observation, and interview, it was determined for 2 of 2 patients (Pt #1 and Pt #2) who were at risk for self-injury, the Hospital failed to ensure prevention of patients from obtaining sharp instruments, which could be used to inflict self-harm.

Finding include:

1. The Hospital policy entitled, "Contraband" (revised 10/2015) was reviewed on 9/6/16 and included, "In order to provide a safe and therapeutic environment all hospitalized patients are allowed personal items with the exception of those deemed high risk based on unit contraband list...If any of the listed contraband items appear on the unit, it is the responsibility of Nursing Staff to immediately remove them...sharp instruments..."

2. The clinical record for Pt #1 was reviewed on 9/6/16 at approximately 11:00 AM. Pt #1 was a [AGE] year old female admitted to the Hospital's adolescent girls psychiatric unit under the care of MD #1 on 3/30/16 with diagnoses of post traumatic stress disorder (PTSD), bipolar disorder, and borderline personality disorder. Pt #1 was on assault and suicide precautions with 15 minute checks. All checks were documented every 15 minutes from 12:00 AM-11:45 PM on the rounding sheet. On 4/1/16 at 7:30 PM, an occurrence report documented that Pt #1 came out of her room with her left arm covered in superficial cuts. Staff checked Pt #1's bathroom and found that she had broken the porcelain toilet tank and also found sharp pieces of the porcelain with blood on the ends.

MD #1's orders required Pt #1 to be on assault and suicide precautions with 15 minute checks from 7/25/16-8/1/16. On 8/1/16, Pt #1 broke the porcelain toilet tank while in the community bathroom. Pt #1 used the broken porcelain to cut her left forearm requiring emergency medical treatment at another hospital and 18 stitches. Per the 8/1/16 progress note dated and timed 8/1/16 at 3:45 PM, Pt #1 was transferred to Weiss Hospital. All checks were documented every 15 minutes from 7:30 AM-4:00 PM on the 8/1/16 rounding sheet.

3. On 9/6/16 at approximately 12:00 PM, an interview was conducted with Pt #1. Pt #1 stated that she had broken at least 6 toilet tanks during her admission. Pt #1 stated that there is only one screw securing the lid to the tank. Pt #1 stated that she just lifts the lid until it cracks or lifts the lid and slams it down to break it. Pt #1 stated no one is watching when she is in the bathroom when she is on 15 minute checks. No further details of dates or times of the 6 broken toilets were provided in the record or other documentation, except 4/1/16 and 8/1/16.

4. The clinical record for Pt #2 was reviewed on 9/7/16 at approximately 10:00 AM. Pt #2 was a [AGE] year old female admitted to the Hospital's adolescent girl's psychiatric unit on 8/11/16 with diagnoses of PTSD, major depressive disorder, and mild mental retardation. Pt #2 was admitted following a suicidal attempt of swallowing broken glass. Pt #2 was on 1:1 precautions on 8/24 and 8/25/2016. The 1:1 precautions were discontinued at 3:00 PM on 8/25/16, and Pt #2 was on suicide precautions requiring 15 minute checks.

5. Occurrence reports involving Pt #2 were reviewed on 9/7/16 at approximately 11:30 AM and included 3 incidents (8/25/16,8/26/16, and 8/28/16) of Pt #2 reporting that she had removed screws from the wall plates and inserted them into her rectum; 3 incidents of swallowing inappropriate items/contraband: an electrocardiogram electrode patch on 8/27/16, paint dust from broken wall on 8/28/16, and a screw that she removed from the wall on 8/28/16. The occurrence report completed by E #9 (MHW-mental health worker) dated and timed 8/25/16 at 6:00 PM included, "At 5:50 PM [Pt #2] approached the nurses' station and stated she put a screw inside her rectum. Pt complained of discomfort. Pt then went into her room. She was then approached by two other pts [Pt #1 and Pt #3]. Pts were seen exiting [Pt #2's] room. [Pt #1 and Pt #3] told staff they removed the screw from [Pt #2's] rectum."

6. The Hospital initiated an RCA (Root Cause Analysis) on 8/31/16, which was reviewed on 9/7/16 at approximately 11:00 AM and included, "Detailed Event Description Including Timeline: The patient placed a screw in her rectum. She requested that she receive aid from a nurse. While the nurse was calling the Physician for an order, the MHW [E #1] handed two other patients gloves to " clean the room " . The two patients removed the screw from the patient's rectum. Past Medical/Psychiatric History: The patient has had a number of incidents related to screws during this hospitalization ...Staff failed to follow established policies/procedures ...Staff were not vigilant or mindful enough on patients entering other patient's rooms ...Risk Reduction Strategies: #1. Wall plates will be changed to unbreakable wall plates. #2. All staff on unit will be counseled and re-educated on contraband policy and patients entering room practices. " However, E #3 could not provide the surveyor with any documentation of staff counseling or re-education.

7. On 9/6/16 at approximately 12:20 PM, an interview was conducted with Pt #2. Pt #2 stated that she pulls on the wall plates until the screws are loose, and then she can remove them from the wall. When the surveyor asked why she removed the screws, Pt #2 stated "for self-injury". Pt #2 stated that she either swallows the screws or "puts them in her butt". Pt #2 stated that she pulled the screws out when staff is not looking. Pt #2 also stated the Hospital had fixed all the wall plates, so she had to pull the screws out of the air conditioner vent in her room on 9/5/16.

8. During an observational tour of the adolescent girl's unit on 9/6/16 between approximately 11:00 AM and 1:30 PM, the following was observed:
- 2 patient bathrooms (Rooms 404 and 407) and 1 unit bathroom closed for repairs/toilet replacement.
- 2 missing screws from the air conditioner vent cover in Pt #2's room.

9. The Safety Checklists (form completed every shift that indicate any contraband or damage to all rooms on the unit) dated 9/5/16 and 9/6/16 did not include the 3 bathrooms closed for maintenance or the missing screws from the vent cover.

10. On 9/7/16 at approximately 10:00 AM, an interview was conducted with the Director of Performance Improvement (E #3). E #3 stated that the Hospital did not keep a list of all the toilets and dates that Pt #1 had broken toilets. E #3 stated that the Hospital had considered purchasing stainless steel replacement toilets, but for now, the Hospital was replacing the breakable toilets with the exact same porcelain toilets. E #3 stated that all of the wall plates were replaced with nylon plates and flush screws on 9/2/16, but had not fixed any of the vents with removable screws. E #3 stated the missing screws and the closed bathrooms should have been documented on the safety checklist. E #3 stated that E #1 was put on suspension for providing gloves [contraband] to Pt #1 and Pt #3 during investigation of the occurrence on 8/25/16, and E #1 was terminated on 9/2/16.

B. Based on document review and staff interview, it was determined for 1 of 1 (Pt #2) patient on 1:1 observation, the Hospital failed to ensure 1:1 observation was maintained.

Findings include:

1. The Hospital's policy entitled, "Precautions" (revised 10/2015) was reviewed on 9/6/16 at approximately 1:30 PM and included, "Precautions are implemented to monitor and protect the patient...1:1= One to One...A single staff is assigned no other responsibilities other than 1:1 monitoring and clinical care of the patient...The 1:1 staff must be with the patient at all times. If the patient is on 1:1 due to suicidality and/or self injury, the staff must be within arms length from the patient at all times..."

2. The clinical record for Pt #2 was reviewed on 9/7/16 at approximately 10:00 AM. Pt #2 was a [AGE] year old female admitted to the Hospital's adolescent girl's psychiatric unit on 8/11/16 with diagnoses of PTSD, major depressive disorder, and mild mental retardation. Pt #2 was admitted following a suicidal attempt of swallowing broken glass. MD #6's special precautions order dated and timed 8/25/16 at 4:30 PM included, " Block patient's room, 1:1 ...Self-harming-scratching wrists with screws and then inserting them in rectum. Poor boundaries. "

3. The occurrence report completed by E #2 (MHW) dated and timed 8/25/16 at 6:00 PM included, "At 5:50 PM [Pt #2] approached the nurses' station and stated she put a screw inside her rectum. Pt complained of discomfort. Pt then went into her room. She was then approached by two other pts [Pt #1 and Pt #3]. Pts were seen exiting [Pt #2's] room. [Pt #1 and Pt #3] told staff they removed the screw from [Pt #2's] rectum."

4. During an interview with the Administrative Director of Children's Pavilion (E #4) on 9/8/16 at approximately 10:30, E #4 stated that Pt #2 had not been on 1:1 observation earlier on 8/25/16. Therefore, no one had been assigned 1:1 observation at the start of that shift (3:00 PM-11:00 PM on 8/25/16). Therefore, E #4 could not determine which staff, if any, was providing 1:1 observation at the time of the occurrence.