HospitalInspections.org | Report Detail

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	June 27, 2019
VIOLATION: PATIENT RIGHTS		Tag No: A0115
Based on document review, observation, and interview, it was determined that the Hospital failed to ensure care in a safe setting, by ensuring that 13 of 13 patient rooms were free from ligature risks and patients were appropriately monitored for safety. This potentially places all current and future suicidal patients at risk for serious harm. 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 patients' rooms on the Behavioral Health Unit were free from ligature risks to prevent serious harm to the suicidal patients. (A 144-A) 2. The Hospital failed to ensure that patients on 1:1 precautions were safely monitored. (A 144-B) An Immediate Jeopardy (IJ) was identified due to the Hospital's failure to ensure that the Behavioral Health Unit was free from ligature risks, and failure to ensure that the appropriate level of patient safety monitoring was in place as required, thus placing all psychiatric patients, who are suicidal, at potential risk for serious harm. The IJ was identified and announced on 6/26/19 at 9:15 AM, during a meeting with the Director of Nursing and the Director of Hospital Operations. The IJ was not removed by the survey exit date of 6/27/19.
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, observation, and interview it was determined that for 1 of 1 Behavioral Health Unit (Adolescent Behavioral Health Unit - ABHU), the Hospital failed to maintain care in a safe setting, by ensuring that for 13 of 13 patient rooms were free from ligature risks. This could potentially affect the 6 suicidal patients on census as of 6/25/19 and all future patients on the unit who become suicidal. Findings include: 1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08, 2017, was reviewed on 6/25/19 and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include... door frames...handles, hinges and closures. Attachment A - Advanced Copy... Environmental Safety Risks...Ligature risk include but not limited to, hand rails, door knobs, door hinges... exposed plumbing..." 2. The Hospital's policy titled, "Patients' Rights and Responsibilities" (revised 03/2018) was reviewed on 6/26/19 and included, "...The patient has the right to receive care in a safe setting..." 3. An observational tour of the ABHU was conducted on 6/25/19, between 1:00 PM and 1:45 PM. The unit had 13 patient rooms ( #2032, #2033, #2034, #2035, #2036, 2037(occupied with patients) and rooms #2011, #2013, #2015, #2024, #2026, #2028, #2030 (unoccupied and locked)). Rooms #2011, 2013, 2030, 2032,2033, 2034, 2035, 2036 , and 2037 were semi private rooms (contained 2 beds in each). There were 8 patients on census, of which 6 were on suicide precautions and 2 patients being monitored as 1:1(continuous visual monitoring by 1 staff/sitter to 1 patient) precautions. Each patient room had it's own bathroom and the following ligature risks were identified: - Each room's entry door had a protruding door knob facing the interior of the room. All patient room entry doors were unlocked while the patients were inside the room. - There was a moveable plastic chair in all of the rooms, which could potentially be used by patients to reach higher ligature points for hanging. - All patient rooms had a solid wooden bathroom door that extended to the full length of the frame and with metal pull handles on each side that were approximately 3-4 feet from the floor. The door was not designed to break away when weight was applied. Bathroom doors could not be locked. Patients were able to access their bathrooms at any time while inside their rooms. - Each patient bathroom had an overhanging sink (not flushed to the wall) and had a curved water faucet with separate handles to control hot and cold water that create a ligature risk. 4. On 6/25/19 at approximately 12:40 PM, an interview was conducted with the Senior Director of Support Services (E #1). (E #1) stated, "We have not done a ligature risk assessment on the psychiatric unit (ABHU)." 5. On 6/25/19 at approximately 12:45 PM, during an interview Chief Nursing Officer (E #2) stated, "For suicidal patients, we utilize the 15 minute safety checks." B. Based on document review and interview, it was determined that for 2 of 6 (Pt #1 and #2) open clinical records and 4 of 4 (Pt #5, #6, #7 and #8) closed clinical records reviewed of patients on monitoring with 1:1 precautions (continuous visual monitoring by 1 staff/sitter to 1 patient), the Hospital failed to ensure that patients were safely monitored as required. This has the potential to affect all current and future patients placed on 1:1 monitoring. Findings include: 1. The clinical record of Pt #1 was reviewed on 6/25/19 at approximately 11:15 AM. Pt #1 was a [AGE] year old male, admitted on [DATE], with a diagnosis of mood disorder. The clinical record contained a physician's order dated 6/13/19 that required Pt #1 be placed on elopement precautions, assault precautions, self-injury precautions, suicide precautions, fall precautions, and 1:1 precautions. 2. The clinical record of Pt #2 was reviewed on 6/25/19 at approximately 11:30 AM. Pt #2 was a [AGE] year old female, admitted on [DATE] with a diagnosis of mood disorder. The clinical record contained a physician's order dated 4/21/19 that required Pt #2 be placed on elopement precautions, suicide precautions, self-injury precautions, and 1:1 precautions. 3. The Hospital's policy entitled, "Sitter Precautions (Close Observation) Patient (Last Hospital review April 2019)," was reviewed on 6/25/2019 and included, "Procedures ...5. The patient should be in view of the sitter at all times at no times should the sitter leave any patient unattended ..." 4. The Hospital's policy entitled, "Close Observation," (Hospital review date 4/2019) included, " ...Procedure ...F ...1.1:1 Observation: a. The identified patient is to be under constant observation by an assigned staff member ...b. Staff must remain in close proximity to the patient, as determined by the written order, and the patient must be in view of staff at all times. C. Staff are to maintain a close proximate, as specified by the written order, to the patient at all times ...Under these conditions, the patient's safety and protection outweighs his/her right to privacy." 5. The ABHU unit census for 6/19/19 through 6/25/19 was reviewed on 6/26/19 at approximately 1:00 PM. The census indicated that for this time period, Pt #1 was housed in room 2036 and Pt #2 was housed in 2032 (separated by room 2034). 6. The ABHU Observation Records dated 6/19/19 through 6/24/19, for Pt #1 and Pt #2 were reviewed: From 6/19/19 to 6/24/19, both patients were being monitored by 1 employee at the same time. -Documentation on 6/19/19 at 6:15 PM and 6:30 PM, indicated that Pt #1 was monitored by a Mental Health Associate ( MHA -E #20), as being in the hall and using the phone, while Pt #2 was also monitored by a (E #20), in the small group room. -Documentation on 6/21/19 at 8:00 AM, indicated that Pt #1 and Pt #2 were monitored by a MHA (E #21), and both patients were in their beds asleep. -Documentation on 6/24/19 at 7:30 AM, indicated that Pt #1 and Pt #2 were monitored by a MHA (E #21), and both patients were in their rooms asleep. At 9:30 AM, Pt #1 was in the shower and Pt #2 was in the hall talking. At 3:15 PM, Pt #1 and Pt #2 were in their rooms. 7. An interview was conducted with the ABHU Unit Manager (E #3), on 6/25/19 at approximately 11:25 AM. E #3 stated, "While doing the 1:1 observation, the staff cannot take their eyes off of the patient. They must remain in line of site. This is not always being followed and should be." 8. The closed clinical record of Pt #5 was reviewed on 6/26/19 at approximately 1:15 PM. Pt #5 was a [AGE] year old male, admitted on [DATE] with a diagnosis of mood disorder. The clinical record contained a physician's order dated 5/3/19 that required Pt #5 be monitored with assault precautions, elopement precautions, suicide precautions, self injury precautions, and 1:1 line of sight. 9. The closed clinical record of Pt #6 was reviewed on 6/26/19 at approximately 1:20 PM. Pt #6 was a [AGE] year old female, admitted on [DATE] with a diagnosis of major depressive disorder. The clinical record contained a physician's order dated 4/29/19 that required Pt #6 be monitored with elopement precautions, suicide precautions, self injury precautions, and 1:1 line of sight. 10. The closed clinical record of Pt #7 was reviewed on 6/26/19 at approximately 1:25 PM. Pt #7 was a [AGE] year old female, admitted on [DATE] with a diagnosis of major depressive disorder. The clinical record contained a physician's order dated 5/3/19 that required Pt #7 be monitored with elpoement precautions, suicide precautions, self injury precautions, and 1:1 close observation. 11. The closed clinical record of Pt #8 was reviewed on 6/26/19 at approximately 1:30 PM. Pt #8 was a [AGE] year old female, admitted on [DATE] with a diagnosis of mood disorder. The clinical record contained a physician's order dated 4/30/19 that required Pt #8 be monitored with suicide precautions, assault precautions, self injury precautions, and 1:1 observation. 12. The ABHU Observation Records dated 5/3/19, indicated that from 4:00 PM to 4:30 PM, Pt #5, #6, #7, and #8 were monitored by one Mental Health Technician (E #17). 13. On 6/26/19 at approximately 2:45 PM, an interview was conducted with a MHA (E #17) that worked from 7:00 AM to 7:00 PM on 5/3/19. During the interview E #17 stated, "That is quiet time (4:00 PM) and it's hard to monitor the one to one patients. At that time staff go on break, so I will have the Nurse come out and watch the patients. We have to make sure the patients are safe. I will go from room to room and check on the patients." 14. On 06/26/2019 at 2:30PM, an interview was conducted with a Mental Health Associate (MHA - E #16) that worked from 7:00 AM to 7:00 PM on 5/3/19. E #16 stated, "That is quiet time (4:00 PM). Sometimes, the Intake personnel come out and the Nurse will come out and watch the patients so I can do the 15 minute checks." 15. An interview was conducted with the ABHU Nurse Manager (E #3) on 6/27/19 at approximately 8:00 AM. E #3 stated, "Quiet time on our Unit is from 2:00 PM to 4:00 PM. It is not appropriate for the MHA to be making rounds on all of the patients during that time. If there is a Nurse or an Intake person sitting with the patient who is on 1:1 precautions then I expect that person to document on the Flow Sheet. They are all ABHU staff and qualified to do so."