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.

ROSELAND COMMUNITY HOSPITAL 45 W 111TH STREET CHICAGO, IL 60628 Nov. 8, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 2 Patient (Pt #1 & Pt #2) records reviewed for chemical restraints (sedating medication), the Hospital failed to ensure that Pt #1 & Pt #2 were free of chemical restraints.

Findings include:

1. On 11/5/18 at approximately 11:00 AM, the Hospital's policy entitled "Restraints, Seclusion and the 1 Hour Face to Face" (3/2017) policy was reviewed and required "...Drugs Used as Restraint: A drug or medication when it is used as a restriction to manage the patient's behavior..."

2. On 11/5/18 at approximately 11:30 AM, Pt #1's medical record was reviewed. Pt #1 was a [AGE] year old female admitted to the ER (emergency room ) on 6/22/18 at 1:12 AM with the diagnoses depression and suicidal ideation. Pt #1's medical record dated 6/22/18 at 3:30 AM indicated "...Pt #1 continues to be abusive to staff, screaming very loudly, using profanities and threatening to cause bodily harm to staff. Verbal order received to medicate Pt #1 with Benadryl (antihistamine - 50 mgs (milligrams) - can cause sleepiness, Haldol (antipsychotic) 5 mgs - can cause drowsiness and Ativan (antianxiety - sedative) 2 mgs. Pt #1 was medicated as ordered..." Pt #1's medical record dated 6/22/18 at 3:30 AM indicated "...MD #1 made aware of situation, need for chemical restraint per MD #1. Med [medication] administered as ordered..."

3. On 11/5/18 at approximately 11:45 AM, Pt #2's medical record was reviewed. Pt #2 was a [AGE] year old female admitted to the ER (emergency room ) on 6/7/18 at 10:13 PM with bizarre behavior, depression and homicidal ideation. Pt #2's medical record dated 6/8/18 indicated Pt #2 received "...Ativan 1 mg IM (intramuscular) injection at 12:28 AM, Ativan 2 mg IM at 10:55 AM, 6:19 PM and 9:34 PM; Benadryl 25 mg at 1:17 AM, 10:55 AM and 6:19 PM..."

4. On 11/5/18 at approximately 12:30 PM, an interview was conducted with the emergency room Manager (E #2). E #2 stated that sometimes both chemical restraints and physical restraints are used at the same time. E #2 stated that sometimes patients are fighting so you have to give them medication so staff can apply the restraints.

5. On 11/7/18 at approximately 2:00 PM, an interview was conducted with the Public Safety Officer (E #15). E #15 stated that on 6/22/18 at approximately 3:00 AM, E #15 witnessed the Registered Nurse (E #5) administer an injection to Pt #1. E #15 stated that Pt #1 stated "Don't give me that shot." E #15 stated that E #5 "jabbed" the needle into Pt #1's arm and said "You are getting it."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 2 of 2 Patient (Pt #1 & Pt #2) records reviewed for restraints, it was determined that the Hospital failed to ensure there was an ongoing assessment to determine the need for the 4 point restraint (restraint for all four limbs).

Findings include:

1. On 11/5/18 at approximately 11:30 AM, the Hospital's policy entitled, "Restraints, Seclusion and the 1 Hour Face to Face" (3/2017) was reviewed and indicated "...Initial assessment of the individual who is at risk of harming himself/herself or others including staff, identified: Techniques, methods or tools that would help the individual control his or her behavior...Rationale for restraint (observed condition or behavior) shall be assessed on an ongoing basis..."

2. On 11/5/18 at approximately 12:30 PM, Pt #1's medical record was reviewed. Pt #1 was a [AGE] year old admitted to the ER (emergency room ) on 6/22/18 at 1:12 AM with the diagnoses depression and suicidal ideation. Pt #1's medical record dated 6/22/18 indicated "Pt #1 continues to be verbally and physically abusive to staff.. "4 point restraint was ordered and applied at 1:35 AM and discontinued at 5:51 AM. There was no documentation in Pt #1's medical record on 6/22/18 that less restricted interventions were attempted prior to applying a 4 point restraint. There was no documentation in Pt #1's medical record of an ongoing assessment to determine the need to Pt #1's 4 point restraint.

3. On 11/5/18 at approximately 11:45 AM, Pt #2's medical record was reviewed. Pt #2 was a [AGE] year old female admitted to the ER (emergency room ) on 6/7/18 at 10:13 PM with bizarre behavior, depression and homicidal ideation. Pt #2's medical record indicated "...Pt #2 is very disrespectful to staff, cursing screaming and attempting to fight them...Restraint order in place at 12:38 AM..." There is no documentation that a less restricted intervention was attempted for Pt #2. Pt #2's medical record noted that the next documentation after 10:13 PM was on 6/8/18 at 10:11 AM indicated Pt #2's "...left foot restraint released, left arm and right foot intact..." There was no documentation in Pt #2's medical record of an ongoing assessment while Pt #2 was in restraints.

4. On 11/5/18 at approximately 1:00 PM, an interview was conducted with the Manager of the emergency room (E #2). E #2 stated that nurses should do an ongoing assessment and document in the patient's medical record when a patient is in restraints to determine the need for the restraint. E #2 verbalized that there was no documentation of assessments while Pt. #2 was in restraints.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, it was determined that the Hospital failed to ensure that a thorough abuse investigation was conducted, failed to protect a patient who made an abuse allegation, and failed to ensure that staff was educated on the different types of abuse and how to protect the patient from abuse. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that a thorough abuse investigation was conducted to determine if the allegations were unfounded (A145-A).

2. The Hospital failed to ensure protection of a patient after making an abuse allegation against a staff nurse (A145-B).

3. The Hospital failed to ensure that staff was educated on the different types of abuse and how to protect the patient from abuse (A145 -C).

4. The Hospital failed to develop and implement an abuse policy with the required components of abuse (A145 - D).

An Immediate Jeopardy (IJ) began on 6/22/18, where Pt. #1 alleged that Pt. #1 was slapped by a Registered Nurse (E #5). The Hospital failed to thoroughly investigat Pt. #1's abuse allegation. This failure potentially placed all current and future emergency room patients at risk for serious harm.

The IJ was identified and announced on 11/8/18 at 8:50 AM, during a meeting with Administrative Director of Accreditation and Regulatory Complaince/Interim Chief Nursing Officer, The Director of Hospital Operations and the Vice President/Chief Information Officer. The IJ was not removed by the survey exit date of 11/8/18.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that the Hospital failed to ensure a thorough investigation for an allegation of abuse was conducted. This failure potentially placed the average daily census of 80 - 90 emergency room patients at risk for serious harm.

Findings include:

1. On 11/8/18 at approximately 10:30 AM, the Hospital's policy titled, "Abuse and Neglect" (reviewed December 2016) was reviewed and included, "...B. Reporting 1. a. All cases suspected of abuse/neglect shall be seen by the CNO (Chief Nursing Officer and Risk Management. If no evidence of abuse/neglect, the physician shall document the findings in the patient's medical record..."

2. On 11/7/18, the Hospital's Policy titled, "Reporting Fraud and Abuse Complaints (Reviewed 03/17) was reviewed and included, "...The Compliance Officer is responsible for investigating and reviewing all allegations of non-compliance with laws of policies for reporting hospital fraud and abuse complaints..."

3. On 11/5/18 Pt. #1's medical record was reviewed. Pt. #1 was [AGE] year old female who was seen in the emergency room on [DATE] for Alcohol abuse, cannabis (marijuana) use, major depressive disorder, and suicidal ideations. Pt. #1 complained of suicidal ideations with a plan to shoot herself. Pt. #1's emergency room nursing note dated 6/22/18 at 3:30 AM included, " ...Pt. [Pt. #1] became physically aggressive towards staff, kicking and spitting at staff. Staff nurse [E #5] turned Pt's [Pt. #1] to the side, face mask applied ..."

4. On 11/5/18, a Patient Advocate/Navigator Complaint log tool dated 6/23/18 at 10:30 AM was reviewed. The complaint tool included, "Patient [Pt. #1] stated that several nurses tried to give her an injection and she refused it which caused other staff to come into the room to restrain the patient [Pt. #1]. Patient [Pt. #1] stated that while they were trying to place her in restraints a nurse [E #5] slapped her [Pt. #1] and she [Pt. #1] asked why did she [E #5] slap her [Pt. #1] and the nurse [E #5] stated that she [E #5] did not. Resolution: CNO (Chief Nursing Officer) approached me [author unidentified] with the complaint from the patient while I was at the Men's Health seminar. Documents from my interview with the patient and statements from security were turned over to the Risk Manager. June 25.2018 - complaint of employee behavior forwarded to HR (Human Resources) and CNO to investigate. 7/25/18 Letter sent to patient regarding customer service. HR follow-up - Statement of nurse slapping patient unfounded."

5. On 11/7/18 at approximately 9:59 AM, an interview was conducted with the Risk Manager (E #9). E #9 stated that she was not involved in the complaint investigation. E #9 stated that she was notified of the abuse allegation on 6/25/18 in an incident report. E #9 stated that normally Risk Management handles allegations of abuse but she was instructed by the Chief of Human Resources (E #8) to turn the investigation over to Human Resources.

6. On 11/7/18 at approximately 1:11 PM, an interview was conducted with the Director of Accreditation Regulatory Compliance/Interim Chief Nursing Officer (E #1). E #1 stated that Pt. #1's abuse allegation was considered a grievance, should have been investigated by the Risk Manager, and a root cause should have been identified. E #1 stated, "The Risk Manager should have received all investigation interviews and called a root cause meeting, which did not happen."

7. On 11/8/18 at approximately 8:21 AM, an interview was conducted with the House Supervisor (E #7). E #7 stated that he was notified of Pt. #1's abuse allegation against E #5 by the Public Safety Officer II (PSO II) (E #15) and by the nurse (E #5). E #7 stated that he requested the staff involved with the allegation to provide a written statement about the incident. MD #2 refused to provide a written statement because he would put all necessary documentation in Pt. #1's medical record. E #7 stated that he tried twice to interview Pt. #1 but she (Pt. #1) was sedated and did not respond. E #7 stated that he collected the written statements and submitted them to the Chief Nursing Officer (who no longer works for the Hospital). E #7 stated that he interviewed E #6 (Registered Nurse/RN), E #11 (RN) and MD #2, but did not conduct an interview with E #15 who initiated the complaint. E #7 stated that E #5 remained on duty providing patient care. E #7 saw no reason to remove E #5 from patient care because she [E #5] was not providing direct patient care to Pt. #1. E #7 stated that discipline is not part of his (E #7) job. E #7 stated that the investigation was not complete on 6/22/18 because the abuse allegation would be investigated by the Chief Nursing Officer the following day.


B. Based on document review and interview, it was determined that the Hospital failed to ensure the protection of a patient (Pt. #1) who made an abuse allegation against a Registered Nurse-RN (E #5), until a thorough investigation was conducted. This failure potentially places the average daily census of 80 - 90 emergency room (ER) patients at risk for serious harm.

Findings include:

1. On 11/7/18, the Hospital's policy titled, "Patient Rights/Grievance Process" (revised 03/17) was reviewed and included, "...Exercise Patient Rights...F. The right to receive care in a safe setting...G. The right to be free from all forms of abuse or harrassment..."

2. On 11/5/18 Pt. #1's medical record was reviewed. Pt. #1 was [AGE] year old female who was seen in the emergency room on [DATE] for Alcohol abuse, cannabis (marijuana) use, major depressive disorder, and suicidal ideations. Pt. #1 complained of suicidal ideations with a plan to shoot herself. Pt. #1's emergency room nursing note dated 6/22/18 at 3:30 AM included, " ...Pt. [Pt. #1] became physically aggressive towards staff, kicking and spitting at staff. Staff nurse [E #5] turned Pt's [Pt. #1] to the side, face mask applied ..."

3. On 11/7/18 at approximately 10:40 AM, an interview was conducted with a Registered Nurse (E #5). E #5 stated that on 6/22/18, Pt. #1 was spitting and she (E #5) used a sheet to cover Pt. #1's face and then put a face mask on Pt. #1. E #5 stated that Pt. #1 was screaming that she (E #5) slapped her. E #5 stated that all of the staff in the room heard Pt. #1 accusing her (E #5) of slapping Pt. #1. E #5 stated that E #6 and E #11 were in the room when Pt. #1 made the allegation. E #5 stated that the House Supervisor (E#7) was notified of Pt. #1's allegation of abuse. E #5 stated that she was not Pt. #1's assigned nurse and was helping another nurse. E #5 stated that she remained on duty providing patient care after the allegation of abuse was made against her.

4. On 11/7/18 at approximately 2:07 PM, an interview was conducted with a Public Safety Officer II (PSO II) (E #15). E #15 stated that she (E #15) was called to Pt. #1's bedside for aggressive behaviors. Pt. #1 was trying to leave the hospital and E #5 and E #6 (RN's) put Pt. #1 back in the bed because Pt. #1 was threatening suicide. E #5 went to get medication for Pt. #1 and when she [E #5] returned Pt. #1 stated that she [Pt #1] did not want the medication. E #5 jabbed the needle with the medication into Pt. #1's arm and Pt. #1 spit at E #5, but the spit landed on Pt. #1's gown. E #5 immediately slapped Pt. #1 hard across the face. Pt. #1's face was red after the slap and Pt. #1 yelled that E #5 had slapped her and requested to make a call to her daughter. E #15 asked to speak to E #5 after Pt. #1 was restrained and told E #5 that it was wrong to slap a patient. E #5 laughed and said it was just a reflex. E #15 reported the incident to her supervisor (E #10) and the House supervisor (E #7). Pt. #1 requested to speak to E #15 later that morning and stated that she would be reporting E #5 for slapping her. E #5 came to the security desk later that morning and asked E #15 not to report the incident. E #5 stated that it does not matter if she (E #15) reports it because we (ER staff) will all stick together and say it did not happen. MD #2 called E #15 on the security telephone after E #15 left the security desk and asked E #15 not to report the incident because Pt. #1 should not have spit at E #5.

5. On 11/8/18 at approximately 8:21 AM, an interview was conducted with the House Supervisor (E #7). E #7 stated that he was notified of Pt. #1's abuse allegation against E #5 by the PSO II (E #15) and by the Registered Nurse (E #5). E #7 stated that he tried twice to interview Pt. #1 but she (Pt. #1) was sedated and did not respond. E #7 stated that E #5 remained on duty providing patient care. (E #7) saw no reason to remove E #5 from patient care because she was not providing direct patient care to Pt. #1. E #7 stated that discipline is not part of his (E #7) job. E #7 stated that the investigation was not complete on 6/22/18 because the abuse allegation would be investigated by the Chief Nursing Officer the following day.

C. Based on document review and interview it was determined that the Hospital failed to ensure that staff received abuse training on types of abuse and staff to patient abuse. This failure potentially places the average daily census of 80 - 90 emergency room patients at risk for serious harm.

Findings include:

1. On 11/8/18 the Hospital's policy titled, "Competency Assessment" (reviewed September 2018) was reviewed and lacked annual mandatory abuse/neglect training.

2. On 11/7/18 at approximately 1:24 PM, a telephone interview was conducted with a Registered Nurse (E #11). E #11 stated that she has not received training on what actions to take if there is an allegation of staff to patient abuse.

3.On 11/7/18 at approximately 1:30 PM - 1:50 PM, interviews were conducted with 4 emergency room Registered Nurses (E #17, E #18, E #19 and E #20). The Registered Nurses were not aware of the different types of abuse. E #17, E #18, E #19, E #20 stated that abuse is reported to the Department of Children and Family Services, Elder Abuse hotline and the Managers.

D. Based on document review and interview, it was determined that the Hospital failed to develop and implement an abuse policy that addresses all components of abuse/neglect. This failure potentially places the average daily census of 80 -90 emergency room patients at risk for serious harm.

Findings include:

1. On 11/8/18, the Hospital's policy titled, "Abuse and Neglect' (reviewed December 2016) was reviewed. The policy lacked details for the required components of prevention, screening, training, protection, investigation and report/respond.

2. On 11/8/18 at approximately 10:30 AM, an interview was conducted with the Director of Accreditation and Regulatory Compliance/Interim Chief Nursing Officer (E #1). E #1 stated that the abuse policy needs to be revised to include all of the required components and the current policy lacked the required components.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 2 of 2 Patient (Pt #1 & Pt #2) records reviewed for restraints, the Hospital failed to determine that a less restricted intervention was attempted on Pt #1 or Pt #2 prior to applying a 4 point restraint (restraint for all four limbs).

Findings include:

1. On 11/5/18 at approximately 11:00 AM, the Hospital's policy entitled "Restraints, Seclusion and the 1 Hour Face to Face"(3/2017) was reviewed and indicated "...Restraint and/or seclusion are high risk, potentially harmful procedures that are intended to be used only when less restrictive measures have been attempted and have not succeeded...Every effort is made to avoid the most restrictive treatment measures through the use of de-escalation techniques and alternative treatment measures aimed at controlling behavior without physical restraint..."

2. On 11/5/18 at approximately 11:30 AM, Pt #1's medical record dated 6/22/18 was reviewed. Pt #1 was a [AGE] year old female admitted to the ER (emergency room ) on 6/22/18 at 1:12 AM with the diagnoses depression and suicidal ideation. Pt #1's medical record dated 6/22/18 indicated, "Pt #1 continues to be verbally and physically abusive to staff.. "4 point restraint was ordered and applied." There was no documentation in Pt #1's medical record on 6/22/18 that less restricted interventions were attempted prior to applying a 4 point restraint.

3. On 11/5/18 at approximately 11:45 AM, Pt #2's medical record was reviewed. Pt #2 was a [AGE] year old female admitted to the ER (emergency room ) on 6/7/18 at 10:13 PM with bizarre behavior, depression and homicidal ideation. Pt #2's medical record indicated, "...Pt #2 is very disrespectful to staff, cursing screaming and attempting to fight them...Restraint order in place at 12:38 AM..." There was no documentation that a less restricted intervention was attempted for Pt #2. Pt #2's medical record noted that the next documentation after 10:13 PM was on 6/8/18 at 10:11 AM indicated Pt #2's "...left foot restraint released, left arm and right foot intact..." There was no documentation in Pt #2's medical record that a less restricted intervention was attempted prior to applying a 4 point restraint.

4. On 11/5/18 at approximately 1:25 PM, an interview was conducted with the Manager of the emergency room (E #2). E #2 stated that nurses should document that a less restricted intervention was attempted. E #2 stated that examples of less restricted interventions include talking softly or listening to the patients. E #2 stated that less restrictive interventions were not found in Pt. #2's medical record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 2 Patient (Pt #1) records reviewed for restraints, the Hospital failed to ensure that Pt #1's response and reason for continued use of the 4 point restraint (restraints for all limbs) was documented.

Findings include:

1. On 11/5/18 at approximately 10:30 AM, the Hospital's policy entitled, "Restraints, Seclusion and the 1 Hour Face to Face" (3/2017) was reviewed and indicated, "...Staff must document observations at least every 15 minutes...Signs of injury associated with applying restraints...Physical and psychological status and comfort...Readiness for discontinuation of restraint..."

2. On 11/5/18 at approximately 11:30 AM, Pt #1's medical record dated 6/22/18 was reviewed. Pt #1 was a [AGE] year old admitted to the ER (emergency room ) on 6/22/18 at 1:12 AM with the diagnoses of depression and suicidal ideation. Pt #1's medical record dated 6/22/18 indicated "Pt #1 continues to be verbally and physically abusive to staff.. "4 point restraint was ordered and applied at 1:35 AM and discontinued at 5:51 AM. There was no documentation in Pt #1's medical record. There was no documentation in Pt #1's medical record on 6/22/18 regarding response to the 4 point restraint or the reason for contiuned use of the 4 point restraint.

3. On 11/5/18 at approximately 1:30 PM, an interview was conducted with the Manager of the emergency room (E #2). E #2 stated that nurses need to contiually reassess the patient's condition so a restraint can be discontinued as soon as possible.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on document review and interview, it was determined that for 8 of 8 ER (emergency room ) Registered Nurses (E #2, E #5, E #6, E #11, E #12, E #13, E #14 & E #16) reviewed for restraint training, the Hospital failed to ensure restraint training was conducted as part of orientation. This has the potential to affect a daily average of 80 to 90 patients in the emergency room (ER).

Findings include:

1. On 11/7/18 at approximately 11:00 AM, the Hospital's policy entitled "New Employee Orientation" (1/2008) was reviewed and required "...Each employee will receive orientation/training specific to his/her job..."

2. On 11/7/18 at approximately 11:30 AM, the ER Registered Nurses' (E #2, E #5, E #6, E #11, E #12, E #13, E #14 and E #16) employees files were reviewed for orientation training. There was no documentation of restraint training during orientation in the employee files.

3. On 11/7/18 at approximately 11:45 AM, an interview was conducted with the Director of Regulatory Compliance/Interim Director of Nursing (E #1). E #1 stated that all employee orientation information is in the employee file. E #1 stated that if the orientation information is not in the personnel file, then it was not done.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 4 of 8 ER (emergency room ) Registered Nurses (E #2, E #6, E #14 & E #16), the Hospital failed to ensure that nonviolent crisis intervention training was up to date. This has the potential to affect a daily average of 80 to 90 patients in the ER.

Findings include:

1. On 11/7/18 at approximately 11:20 AM, the Hospital's policy entitled, "Competency Assessment" (8/2018) was reviewed and required "...All Nursing Department personnel are required to attend...mandatory training annually...CPI (Crisis Prevention Intervention) if applicable..."

2. On 11/7/18 at approximately 11:45 AM, the Registered Nurses' (E #2, E #6, E #12, E #14 & E #16) nonviolent crisis intervention training (CPI) documentation was reviewed. The CPI training for E #2 expired on ,d+[DATE]. E #6's CPI training expired on ,d+[DATE]. E #14 had no documentation of any CPI training, and E #16's CPI training expired 8/2018.

3. On 11/7/18 at approximately 1:00 PM, an interview was conducted with the Manager of the ER ( E#2). E #2 stated that all ER nurses are trained in CPI. E #2 stated that her CPI is not current.

4. On 11/7/18 at approximately 1:30 PM, an interview was conducted with the Director of Regulatory Compliance ( E #1). E #1 stated that all the CPI training documentation is in the employee files and the information is up to date. E #1 stated that if the employee had the CPI training, the documentation is in the file.