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 July 30, 2020
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for restraints, the Hospital failed to ensure a physician's order was obtained, as required.

Findings include:

1. On 7/28/2020 at approximately 10:30 AM, the Hospital's policy titled "Restraints, Seclusion and the 1 Hour Face to Face" dated 03/2019 was reviewed and included, "...Restraints shall be ordered by a physician...authorized by the medical staff... the order shall specify the method of restraint and/or seclusion to be used ..."

2. On 7/28/2020 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED) on 6/24/2020 for psychiatric evaluation. The clinical record indicated that Pt. #1 was aggressive, abusive, and was threatening to hospital staff. The clinical record did not include a physician's order for restraints.

3. On 7/28/2020 at approximately 2:00 PM, an email dated 6/24/2020 was reviewed and included, " ... Subject: Code Armstrong (security assistance) ... A Code Armstrong was called ... (Pt. #1) was ... restrained with the assistance of PSOs (public safety officers) ..."

4. On 07/29/2020 at approximately 1:52 PM, an interview was conducted with the Public Safety Officer (E #13). E #13 stated that restraints were applied to Pt. #1.

5. On 07/28/2020 at approximately 3:30 PM, an interview was conducted with the ED Physician (MD #1). MD #1 stated that a physician's order is required when a patient is restrained.

6. On 07/29/2020 at approximately 4:00 PM, findings were discussed with the Chief Nursing Officer (E #7). E #7 could not provide a physician's order for Pt. #1's restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for restraints, the Hospital failed to ensure patient was monitored while in restraints.

Findings include:

1. On 7/28/2020 at approximately 10:30 AM, the Hospital's policy titled "Restraints, Seclusion and the 1 Hour Face to Face" dated 03/2019 was reviewed and included, "...Behavioral Restraint and Seclusion (Violent... behavior)... Monitoring and Care: ...A. Qualified registered nurse shall assess the patient at the initiation of restraints or seclusion ...B. Qualified staff members ...RN ...monitors patient in restraint or seclusion every 15 minutes..."

2. On 7/28/2020 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED) on 6/24/2020 for a psychiatric evaluation. The clinical record indicated that Pt. #1 was aggressive, abusive, and was threatening hospital staff. The clinical record did not include the monitoring of Pt. #1 while in restraints.

3. On 7/28/2020 at approximately 2:00 PM, an email dated 6/24/2020 was reviewed and included, " ... Subject: Code Armstrong (security assistance) ... A Code Armstrong was called ... (Pt. #1) was ... restrained with the assistance of PSOs (public safety officers) ..."

4. On 07/29/2020 at approximately 1:52 PM, an interview was conducted with the Public Safety Officer (E #13). E #13 stated that restraints were applied to Pt. #1.

5. On 07/29/2020 at approximately 4:00 PM, findings were discussed with the Chief Nursing Officer (E #7). E #7 stated that patients should be monitored while in restraints, and documented by staff. E #7 could not provide documentation of staff monitoring while Pt. #1 was in restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required.

Findings include:

1. On 7/28/2020 at approximately 10:30 AM, the Hospital's policy titled "Restraints, Seclusion and the 1 Hour Face to Face" dated 03/2019 was reviewed and included, "...One hour face to face assessment: The physician ... or trained registered nurse ... shall perform a face to face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint..."

2. On 7/28/2020 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED) on 6/24/2020 for psychiatric evaluation. The clinical record indicated that Pt. #1 was aggressive, abusive, and was threatening hospital staff. The clinical record did not indicate that Pt. #1 was placed in restraint or that the one-hour face to face evaluation within 1 hour of the initiation of the restraint occurred.

3. On 7/28/2020 at approximately 2:00 PM, an email dated 6/24/2020 was reviewed and included, " ... Subject: Code Armstrong (security assistance) ... A Code Armstrong was called (unknown time) ... (Pt. #1) was ... restrained with the assistance of PSOs (public safety officers) ..."

4. On 07/29/2020 at approximately 1:52 PM, an interview was conducted with the Public Safety Officer (E #13). E #13 stated that restraints were applied to Pt. #1.

5. On 07/29/2020 at approximately 4:00 PM, findings were discussed with the Chief Nursing Officer (E #7). E #7 could not provide documentation of a one-hour face to face evaluation for Pt. #1.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for patient assessment, the Hospital failed to conduct a reassessment to ensure care was supervised and evaluated by a registered nurse.

Findings include:

1. The Hospital's policy titled, "Pain Assessment, Reassessment and Management" dated 10/2017 was reviewed and included, "Pain is assessed for all patients ...it is (the) responsibility of all clinical staff to screen all patients for the presence of pain ...clinical assessment of pain, duration, including the intensity and quality ...the patient will undergo reassessment of pain at least once per shift ...the ongoing reassessment should be done minimally every two (2) hours ..."

2. The Hospital's policy titled, "Assessment/Reassessment - Multidisciplinary" (revised 2/19) was reviewed and included, "... all patients will be assessed and reassessed for their physical... status... RN (registered nurse)... ED (Emergency Department)... Reassessment: Q (every) 2 hours..."

3. On 7/28/2020 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED) on 6/24/2020 at 12:25 PM with chief complaint of eye pain. The clinical record included:

- The nursing triage screening note dated 6/24/2020 at 12:29 PM, included, " ...(Pt. #1)... feels something crawling under (Pt. #1's) skin, all over... body... eyes ...Vital Signs ...Pain Assessment/Pain Present Now? No ...Triage Acuity Level ESI 3 (Emergency Severity Index- a five level triage algorithm 1 being most urgent to 5 least urgent)."

- A history and physical note dated 6/24/2020 at 6:51 PM, included " ...Stated Complaint: Pain in eye ...Pt (Pt. #1) c/o [complaints of] very vague Sx (symptoms) of crawling sensation over his entire body; says he feels like some bugs are crawling under skin ..."

- The clinical record did not include a nursing pain assessment/reassessment from 6:51 PM on 6/24/2020 until Pt. #1's discharge on 6/25/2020 at 1:33 AM.

4. On 07/29/2020 at approximately 4:00 PM, the Chief Nursing Officer (E #7) was interviewed. E #7 stated, "(Pt. #1) came to ED complaining of eye pain, and no pain reassessment done in the ED by the registered nurse (E #8) is not acceptable." E #7 could not provide documentation of a nursing pain assessment/reassessment for Pt. #1 from 6:51 PM on 6/24/2020 until Pt. #1's discharge.