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 SAINTS MARY AND ELIZABETH MEDICAL CENTER 2233 W DIVISION ST CHICAGO, IL 60622 Feb. 1, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review and interview, the Hospital failed to ensure that an agitated patient was de-escalated appropriately. The Hospital failed to do a root cause analysis for the incident. This has the potential to affect all patients on the Behavioral Health Unit. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure that the Mental Health Counselor (E #1), handled an agitated patient appropriately. See deficiency at A 145.

2. The Hospital failed to ensure the Mental Health Counselor (E #1) used alternative de-escalation interventions as per policy. See deficiency at A 144- A.

3. The Hospital failed to ensure the required procedure for root cause analysis was done for an inappropriate behavior by Mental Health Counselor (E #1) during patient care. See deficiency at A 144- B.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A. Based on observation, document review and interview, it was determined that for one of one patient (Pt #1) who was agitated, the Mental Health Counselor (E #1) failed to use alternative de-escalation interventions as per policy. This has the potential to affect all patients on the Behavioral Health Unit.

Findings include:

1. On 01/31/19 at approximately 9:00 AM, the document titled, "Mental Health Counselor Progress Notes" dated 01/22/19 at 11:48 PM included, "...during meal time patient (Pt #1) became violent, and started acting out, patient was encouraged to relax..."

2. On 02/01/19 at approximately 9:40 AM, the 15th Floor - Female Behavioral Unit - video surveillance dated 01/23/19 from 12:13:11 PM - 12:16:46 was reviewed. At 12:16:40 - Pt #1 swings hands at the MHC (E #1), 12:16:41 - E #1 is seen standing at the end of the hallway and Pt #1 moving closer to E #1 at approximately 2- 3 feet apart, 12:16:42 - E #1 moves quickly towards Pt #1 and taking Pt #1 towards the wall, with E #1's right hand on the left side of Pt #1's neck and E #1's left forearm placed above chest, 12:16:43 - Pt #1 was seen with Pt #1's back touching the wall, and E #4 was seen coming out a patient room across from the wall, 12:16:44 - E #1 was seen releasing his hands off from Pt #1's neck and more staff approaching the scene from the nurses station, 12:16:45 - E #1 and Pt #1 are out of view of camera and staff following both of them. The video surveillance did not show, the Mental Health Counselor (E #1) using the panic alarm.

3. The Patient Psychiatric Progress Notes dated 1/24/19 at 1:06 PM, was reviewed and included, " ...Today, the patient (Pt #1) presents with; Restless and anxious ...requires frequent redirection and reminders of unit rules ...often does not respond to redirection ...Mood is irritable and labile, easily agitated ...becomes verbally abusive/aggressive if needs and requests not immediately met ...threatening to hit someone ...Patient (Pt #1) has been taking scheduled medication, given PRN medication yesterday ...after attempting to hit a staff member ..."

4. The Hospital policy titled, "Management of Violent/Self Destructive Behavior" (revised 1/1/16) was reviewed and included, "Outbursts of violent and aggressive behavior on the part of a patient must be dealt with calmly and effectively ...Utilize alternatives and de-escalation interventions whenever possible ..."

5. On 01/31/19 at approximately 9:38 AM, an interview was conducted with the Mental Health Counselor (E #10) doing her rounding. Upon asking, what steps will be taken if she notices any patient becoming agitated, E #10 stated, "I immediately press the panic alarm and call for help, I do this even when I am unable to redirect any patient on the unit ..."

6. On 1/31/19 at approximately 12:48 PM, an interview was conducted with an RN (E #4). E #4 stated that a panic alarm went off, E #4 stated that when a patient becomes upset or threatening staff initiates the panic alarm. E #4 stated that it is best to get help if you are the one that the patient is focusing on to prevent further escalation.

7. On 02/01/19 at approximately 9:50 AM, an interview was conducted with the Regional Director of Quality (E #12). E #12 stated, "...we will review the video...yes our expectation is for the staff to use the panic alarm if the environment is not safe, try to de-escalate the situation that is what we teach them...I will look into their competencies and see if they require any more training...We do not know who exactly initiated the panic alarm, we are getting mixed communications..."

B. Based on observation, document review and interview, the Hospital failed to ensure the root cause analysis to implement interventions was done for an inappropriate behavior by Mental Health Counselor (E #1) when a patient (Pt #1) was agitated. This has the potential to affect all patients on the Behavioral Health Unit.

Findings include:

1. On 02/01/19 at approximately 9:40 AM, the 15th Floor - Female Behavioral Unit - video surveillance dated 01/23/19 from 12:13:11 PM - 12:16:46 was reviewed. E #1 is observed placing his right hand on Pt #1's neck inappropriately.

2. The Hospital policy titled, "Root Cause Analysis Process" dated 04/06/17 included, " ...III. Required Procedure ...B. Root Cause Analysis Process ...2. Continually probing deeper into the root of the event at each level of causes and effect ...3. Identifies changes that need to be made to system and work processes ...4. Includes A series of meetings or interviews that are as impartial ..."

3. On 02/01/19 at approximately 9:50 AM, an interview was conducted with the Regional Director of Quality (E #12). E #12 stated, "The actual event allegation was made by the patient (Pt #1). We initiated our quality team discussion ...definitely will look into the root cause analysis (RCA) ...we will review the video ...yes our expectation is for the staff to use ...RCA the second part is next week ...We will look at cause and effect on our next meeting ...We did phone interviews for preliminary facts."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review and interview it was determined that for one of one patient (Pt #1) the Mental Health Counselor (E #1), was observed putting his hand on the patient's (Pt #1's) neck inappropriately. This potentially affected Pt #1 and has the potential to affect all patients on the Behavioral Health Unit.

Findings include:

1. The clinical record for Pt #1 was reviewed on 1/31/19. Pt # 1 was a [AGE] year old female admitted to the Hospital's 15-BH (15-Behavioral Health) unit on 1/20/19 through 1/27/19 with the diagnoses of [DIAGNOSES REDACTED]

2. On 02/01/19 at approximately 9:40 AM, the 15th Floor - Female Behavioral Unit - video surveillance dated 01/23/19 from 12:13:11 PM - 12:16:46 was reviewed. At 12:16:40 - Pt #1 swings hands at the MHC (E #1), 12:16:41 - E #1 is seen standing at the end of the hallway and Pt #1 moving closer to E #1 at approximately 2- 3 feet apart, 12:16:42 - E #1 moves quickly towards Pt #1 and taking Pt #1 towards the wall, with E #1's right hand on the left side of Pt #1's neck and E #1's left forearm placed above chest, 12:16:43 - Pt #1 was seen with Pt #1's back touching the wall, and E #4 was seen coming out a patient room across from the wall, 12:16:44 - E #1 was seen releasing his hands off from Pt #1's neck and more staff approaching the scene from the nurses station, 12:16:45 - E #1 and Pt #1 are out of view of camera and staff following both of them.

3.,,The Hospital policy titled, "Management of Violent/Self Destructive Behavior" (revised 1/1/16) was reviewed and included, "Outbursts of violent and aggressive behavior on the part of a patient must be dealt with calmly and effectively...Utilize alternatives and de-escalation interventions whenever possible ..."

4. The Hospital's "Job Description for Mental Health Counselor" (revised 11/13/14) was reviewed and included, " ...Essential Duties and Responsibilities: 2. Monitors patient condition and response to treatment and reports changes to Registered Nurse ...to assure optimal patient outcomes...5. Performs patient rounds to assess status of patients and overall safety of the unit ..."

5. The Hospital's policy titled, "Allegations of Patient Abuse in Hospitals" (revised 10/31/16) was reviewed and included, "...A. Abuse or Abused-means any physical or Mental Injury...inflicted on a patient...B. Associate-means a ...Health employee..."

6. The Hospital provided a "2019 Timeline and Information for Quality Investigation" and included, "Event Location: 15th Floor ...Other Departments/Units involved: Security, Risk Management, HR (Human Resources), Quality and Nurse Leaders ...When did this event occur? 1/23/2019 Time 12:16 PM ...Situation: 1. Patient reported that the staff grabbed her neck ...2. RN (E #4) ...escorted to Pt #1's room right away ...4. Patient was examined by Medical Provider ... (Some visible marks noted around neck ...). 5. Staff was taken out of service; supervisor provided support and service recovery to the patient ... 6 Reported to IDPH (Illinois Department of Public Health)."

7. A Progress Note documented by MD (Medical Doctor-MD #1) dated 1/23/19 at 5:16 PM, was reviewed and included, "Per report, she (Pt #1) was held by the neck by staff member (E #1). Patient (Pt #1) was assessed in her room at this time ...On lateral aspect of neck, area of [DIAGNOSES REDACTED] (abnormal redness and inflammation of the skin) in form of 4 horizontal lines. Mild excoriation (scraped) on central area of these well-delimitated (boundaries) lines. Tenderness to palpation (touch) ..."

8. On 1/31/19 at approximately 12:48 PM, an interview was conducted with an RN (E #4). E #4 stated that a panic alarm went off, E #4 ran out to see what was happening. And E #4 saw E #1 with hand on Pt #1's neck and other arm across chest. E #4 stated that she was able to separate Pt #1 from E #1 and escort to Pt #1 to her room.

9. On 2/1/19 at approximately 9:05 AM, and interview was conducted with a Medical Doctor (MD #1). MD #1 stated that a call came in to evaluate a patient (Pt #1) on the 15th Floor who was involved in an altercation with staff. MD #1 stated that Pt #1 was seen within an hour of being notified at approximately 5 PM. MD #1 stated that Pt #1 had a superficial abrasion on the left scapular (shoulder) area, and 3-4 linear [DIAGNOSES REDACTED] on right side of the neck. MD #1 stated that the marks clearly looked like a hand. MD #1 stated that at that time Pt #1 was sleeping and refused to be further evaluated. MD #1 stated that Pt #1 never told MD #1 that Pt #1 was choked, but this statement was in the incident report.

10. On 02/01/19 at approximately 9:50 AM, an interview was conducted with the Regional Director of Quality (E #12). E #12 stated, " ...I am not sure if they did the right thing at that time ...It is definitely not necessary to touch the patient around her (Pt #1's) neck ...I will look into their competencies and see if they require any more training..."