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.

PRESENCE SAINT JOSEPH HOSPITAL - ELGIN 77 N AIRLITE STREET ELGIN, IL 60123 Nov. 8, 2018
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 1 of 3 patient (Pt. #4) records reviewed for restraints in the Emergency Department, the Hospital failed to ensure that patient's condition was assessed every 15 minutes while in restraints.

Findings include:

1. The Hospital's policy titled, "Utilization of Restraints and Seclusion" (dated 7/13/18) was reviewed on 11/7/18 and included, " ...C. Monitoring-Frequency and Documentation ...Patients in Restraints or Seclusion will be monitored continuously, without interruption, by an associate assigned only to that patient ...D. Condition Checks must be performed ...documented in the medical record ...every 15 minutes ..."

2. The clinical record of Pt. #4 was reviewed on 11/7/18. Pt. #4 was a [AGE] year old male, admitted on [DATE], with a diagnosis of alcohol intoxication.
- The physician order, dated 9/27/18 at 8:26 PM, included, "Belt - locked restraints, imminent harm to others ..."
- The Care Activity Assessment checklist, dated 9/27/18, indicated that while Pt. #4 was in restraints, assessments were conducted at 8:30 PM and then again at 9:15 PM (45 minutes apart).

3. On 11/07/18, at approximately 2:15 PM, an interview was conducted with E#1 (Quality and Patient Safety Specialist). E#1 stated, "Patient should have been assessed every fifteen (15) minutes when in restraints. There are a lot of things that can happen if they are not monitored." E#1 reviewed Pt. #4's record and was unable to find documentation that the patient's condition was assessed every 15 minutes while in restraints. E#1 confirmed that the 15 minute condition checks were not completed.