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.

NORTHSHORE UNIVERSITY HEALTHSYSTEM - EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON, IL 60201 July 16, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview, it was determined that the Hospital failed to ensure care in a safe setting by not providing formal suicide screening education and training to the Social Service staff.


Findings include:


1. The Medical Social Work's Job Description and Performance Appraisal, required, "...This position is also responsible for completing psychosocial assessments, providing counseling/emotional support, assessing and managing cases of suspected abuse, and advocating for patient rights...2. Responsibility: Knowledge and application of [Hospital] policies and procedures that apply to job and area of responsibility."

2. On 7/15/2020 at 9:35 AM, an interview was conducted with the Licensed Clinical Social Worker (E#5). E #5 stated that the Social Services staff have not received formal training on suicide screening and assessment of inpatients.

3. On 7/15/2020 at approximately 2:30 PM, the Associate Vice President of Quality (E #1). E #1 presented a required training module designed for the nursing staff. The module included suicide training that instructs the nurses to complete a Columbia-Suicide Severity Scale (suicide screening tool) on admission to the unit, every shift, and with any behavior change. E#1 stated that this is a required training for the nurses but has not been required for the Social Workers. E #1 stated that the Social Workers will be trained on the suicide risk screening and assessment tool beginning next week.