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.

VISTA MEDICAL CENTER EAST 1324 NORTH SHERIDAN ROAD WAUKEGAN, IL 60085 Sept. 27, 2018
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 and interview, it was determined that for 1 of 1 (Pt. #2) clinical record reviewed for a patient on suicide precaution (every 15 minute observation), the Hospital failed to ensure precaution rounds were completed as required.

Findings include:

1. On 9/25/18 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old male admitted on [DATE] with diagnoses of toxic encepalopathy (neurologic disorder caused by exposure to toxins) and suicidal ideation. The clinical record included a physician's order for suicide precaution on 9/24/18 at 1:53 AM. However, the "Patient Observation" sheet dated 9/24/18, did not include the initial of the nurse from 7:45 AM to 11:45 AM (4 hours), to indicate that the suicide precaution rounds were conducted every 15 minutes.

2. On 9/25/18 at approximately 2:30 PM, the Hospital's policy titled, "Suicide Risk Assessment and Interventions in an Acute Care Setting" (revised 6/2017) was reviewed and included, "... C. Physician orders for the level of suicide precautions will be initiated immediately... Suicide precautions can be initated by nursing staff... F... Clinical status and patient safety documented every 15 minutes."

3. On 9/25/18 at approximately 11:10 AM, findings were discussed with E #3 (Quality Coordinator) and E #4 (Unit Manager, 5 West). E #3 and E #4 stated that the "Patient Observation" sheet should have been initialed by the staff who conducted the rounds, to indicate that the suicide precaution rounds were conducted.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #2) clinical records reviewed for a patient with suicidal ideation, the Hospital failed to complete an inventory of patient's personal belongings were conducted, to ensure that potentially harmful items were removed.

Findings include:

1. On 9/25/18 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old male admitted on [DATE] with diagnoses of toxic encepalopathy and suicidal ideation. Pt. #2's clinical record did not include documentation that an inventory of patient's personal belongings was completed.

2. On 9/25/18 at approximately 2:30 PM, the Hospital's policy titled, " "Suicide Risk Assessment and Interventions in an Acute Care Setting" (revised 6/2017) was reviewed and included, "Policy: All patients who present for evaluation and treatment with... complaint of an emotional or behavioral disorder... Based on the level of suicide risk, interventions will be implemented... F...Inventory and secure patient personal items and remove potentially harmful items."

3. On 9/25/18 at approximately 11:10 AM, findings were discussed with E #3 (Quality Coordinator) and E #4 (Unit Manager, 5 West). E #3 and E #4 could not provide documentation that an inventory of Pt. #2's personal belongings was conducted.

4. On 9/25/18 at approximately 3:00 PM, E #1 (Chief Quality Officer) stated that, "It (Inventory of Pt. #2's personal items) was just completed this afternoon."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 2 of 2 (Pt. #5 and #6) clinical records reviewed for restraints usage due to violent/self-destructive behavior, the Hospital failed to conduct a debriefing, to ensure appropriate use of a restraint.

Findings include:

1. On 9/26/18 at approximately 10:30 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a [AGE] year old male who came to the ED (Emergency Department) on 8/12/18 due to alcohol abuse and suicidal ideation. The clinical record indicated that Pt. #5 was in locked restraints on 8/12/18 from 4:59 AM until 11:59 AM (7 hours). However, the clinical record did not include documentation that a debriefing was conducted regarding the use of restraints on Pt. #5.

2. On 9/26/18 at approximately 10:45 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a [AGE] year old female admitted on [DATE] with a diagnosis of altered mental status. The clinical record indicated that Pt. #6 was placed in locked restraints on 8/13/18 from 11:59 PM until 8/14/18 at 8:15 AM (approximately 8 hours). However, the clinical record did not include documentation that a debriefing was conducted regarding the use of restraints on Pt. #6.

3. On 9/26/18 at approximately 11:30 AM, the Hospital's policy titled, "Restraint and Seclusion" (revision date 3/2018) was reviewed and included, "...V...B...At (the Hospital), for Restraints and Seclusion used for Violent/Self-destructive behavior... it is recommended that each episode will include a debriefing... The debriefing will include staff, patient, and family if appropriate, to identify the incident that lead to the restraint, alternatives, patient's well-being during a restraint... The debriefing should be documented in the medical record.

4. On 9/26/18 at approximately 11:00 AM, findings were discussed with E #3 (Quality Coordinator). E #3 stated that there was no documentation for Pt. #5 and #6 to indicate that a debriefing was conducted regarding the use of restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 2 (Pt. #5 and #6) clinical records reviewed for restraint usage due to violent/self-destructive behavior, the Hospital failed to ensure physician's order was obtained for the application of restraints, as required.

Findings include:

1. On 9/26/18 at approximately 10:30 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a [AGE] year old male who came to the ED (Emergency Department) on 8/12/18 due to alcohol abuse and suicidal ideation. Pt. #5's clinical record included a physician's order, dated 8/12/18 at 4:48 AM, for mechanical 4 point restraints (locked restraints) for 4 hours. The clinical record indicated that Pt. #5 was in locked restraints on 8/12/18 from 4:59 AM until 11:59 AM (7 hours). However, the clinical record did not include a renewal order for the locked restraint use from 8:48 AM until 11:59 AM (approximately 3 hours and 11 minutes).

2. On 9/26/18 at approximately 10:45 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a [AGE] year old female admitted on [DATE] with a diagnosis of altered mental status. The clinical record indicated that Pt. #6 was placed in locked restraints on 8/13/18 from 11:59 PM until 8/14/18 at 8:15 AM (approximately 8 hours). However, the clinical record did not include a physician's order for the use of restraints.

3. On 9/26/18 at approximately 11:30 AM, the Hospital's policy titled, "Restraint and Seclusion" (revision date 3/2018) was reviewed and included, "...E. Orders for Restraint i) The physician or Licensed Independent Practitioner (LIP)... is authorized to order restraint... Orders should: a. Be for each use of the restraint... G. Violent or Self-Destructive Restraint or Seclusion Orders: 1. Orders for restraint... used for the management of violent or self-destructive behavior... may be renewed in accordance with the following limits... 4 hours for adults 18 years or older... 2. As the time frame is about to expire (4 hours...), the RN must contact the LIP as soon as possible... and request that the order be renewed."

4. On 9/26/18 at approximately 11:00 AM, findings were discussed with E #3 (Quality Coordinator). E #3 stated that there should be a restraint renewal order for Pt. #5, and that a physician's order for Pt. #6's restraint use was missing.