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 Nov. 7, 2017
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 1 of 4 (Pt. #4) records reviewed for psychotropic drug use, the Hospital failed to ensure the psychotropic consent form was completed as required, to indicate the patient made an informed decision regarding the medication.

Findings include:

1. On 11/7/17 at approximately 12:35 PM, the Hospital's policy titled "Psychotropic Medication Informed Consent" (revised 11/16) was reviewed and required, "... A psychotropic medication is defined as medication used for antipsychotic... behavior management purposes... Procedure...1... When an order is written for routine medication, the Physician will check this box stating they have provided this information to the patient/guardian... 6. The patient will initial the checked routine medications that are ordered by the Psychiatrist on the same sheet... 8. If the patient is willing to take the routine medication, but refuses to sign, the nurse will initial that the medication was administered but the patient refused to sign on the Informed Consent Form."

2. On 11/7/17 at approximately 10:30 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar disorder. The clinical record included a physician's order dated 11/3/17 for Zyprexa (antipsychotic medication) at bedtime. The record also indicated that Pt. #4 received Zyprexa on 11/3/17 and 11/5/17. However, the psychotropic drug consent did not include the name of the psychotropic drug (Zyprexa), and whether Pt. #4 consented to use Zyprexa or verbally agreed to take the medication, but refused to sign the form.

3. On 11/7/17 at approximately 10:35 AM, findings were discussed with E #3 (Director of Clinical Services). E #3 stated that the name of the medication should have been checked on the psychotropic drug consent form. E #3 added that the form should have indicated if the patient gave consent to use the medication or verbally agreed to take the medication but refused to sign.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, it was determined that for 1 of 1 (Pt. #2) patients who exhibited sexually inappropriate behavior prior to admission, the Hospital failed to ensure the patient was placed on SAO (sexually acting out) precautions, thus putting all other patients at a severe safety risk. Refer to deficiencies at A-144 A and B. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1. The Hospital failed to ensure the patient was placed on SAO precautions to protect the safety of the other patients on the unit. A-144-A.

2. The Hospital failed to document the type of precautions to indicate that the patients were appropriately monitored. A-144-B.

The immediate jeopardy (IJ) began on 10/17/17 when Pt. #2 was admitted with a prior history of sexually inappropriate behavior, followed by the Hospital's failure to place Pt. #2 on SAO precautions. An allegation of rape followed.

An IJ was identified and announced on 11/7/17 at 2:15 PM, during a meeting, to the CEO (Chief Executive Officer) and the Director of Performance improvement and Risk. The immediate jeopardy was not removed by the survey exit date of 11/7/17. No corrective actions were taken.
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 for 1 of 1 (Pt. #2) patients who exhibited SAO (sexually acting out) behavior prior to admission, the Hospital failed to ensure the patient was placed on SAO precautions to protect the safety of the other patients on the unit. An allegation of rape followed.

Findings include:

1. The clinical record of Pt. #2 was reviewed on 11/6/17. Pt. #2 was a [AGE] year old male admitted on [DATE] with the diagnosis of schizophrenia. The initial petition for psychiatric admitted d 10/16/17 included, "Presented to the emergency department for the second time in two weeks with a chief complaint of agitation. ... He reportedly exposed himself to children two weeks ago and has not been taking his medication because he lost it." Pt. #2 was never placed on SAO precautions.

2. The clinical record of Pt. #1 was reviewed on 11/6/17. A nurse's note dated 10/22/17 (Sunday) at 9:45 PM included, "Patient was tearful during the shift due to a select male peer making her feel uncomfortable. Patient was transferred from 407-B to 412-B for safety."

A nurse's note dated 10/23/17 at 8:00 PM included, "At 7:00 PM, patient [Pt. #1] reported being raped by a male peer [Pt. #2] on Sunday evening second shift. Patient [Pt. #1] says she was scared to report the issue ..."

3. The Hospital policy titled, "Sexually Acting Out Behavior (revised 11/16) was reviewed on 11/7/17. The policy required, "Patient's are assessed for current and past history of risk for sexual intimidating and/or abusive behavior as well as vulnerability. Any patient assessed as potentially harmful to other patients (via sexual abuse or intimidation) shall be placed on precautions as part of his/her treatment plan."

4. The Psychiatrist (MD#1) of Pt. #1 and #2 was interviewed on 11/6/17 at 10:20 AM. MD#1 stated that he was informed of Pt. #1's allegation a day after the alleged rape. MD#1 stated that he treated the allegation of rape "at face value" and sent Pt. #1 to the hospital for a rape kit and police report.

5. The Director of Performance Improvement/Risk (E#1) was interviewed on 11/6/17 at 1:00 PM. E#1 stated, "We determined that (Pt. #2) should have been placed on SAO precautions, but was not."




B. Based on document review and interview, it was determined that for 1 of 4 (Pt. #3) psychiatric patients clinical records reviewed on the 4th floor Intensive Treatment Unit (4 ITU), the Hospital failed to document the type of precautions to indicate that the patient was appropriately monitored.

Findings include:

1. On 11/7/17 at approximately 11:40 AM, the Hospital's policy titled "Patient Routine Rounds" (revised 11/16) was reviewed and required, "...Upon admission, the intake nurse will notify the admitting physician... and receive orders from the physician... On admission, all patients are placed on q15 min (every 15 minutes) observation status..."

2. On 11/7/17 at approximately 10:20 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a [AGE] year old female admitted on [DATE] with a diagnosis of bipolar disorder. The clinical record included a physician's admission order for escape precaution (EP), assault precaution (AP), and self injury precaution (SIP) dated 11/5/17. However, the documentation of the type of precautions observed were not documented on the 15 minute Patient Observation Record dated 11/5/17, to indicate that the patient was appropriately monitored.

3. The Hospital's policy titled, "Precautions and Observation Levels Section 2: Provision of Care, Treatment, and Services (revised 11/2017) was reviewed and required, "...F. Precautions.....b. Assault/Aggression (Victim Aggressor) - Patients who have a high history of aggression or assault.....i. Will remain in close proximity to staff ii. Will not be assigned to a roommate who is an assault victim c. Self-injury -Patients who have inflicted or have threatened or attempted to inflict injury to self or is assessed to be at risk for self-injury may be placed on precautions. i. Will remain at arm's length when off the unit ii. Will be allowed on patio but remain at arm's length of staff iii. Will be asked to remain away from exits.....e. Elopement - Patients who attempt, is threatening to elope or whose behavior indicates intent to elope.....may be placed on precautions. i. Will be restricted to unit ii. Will be allowed on patio at arm's length of staff iii. Will be asked to remain away from exits...."

4. On 11/7/17 at approximately 10:25 AM, findings were discussed with E #3. E #3 stated that, "it was an error... the assault, elopement, and suicide precautions should have been marked."