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.

THOREK MEMORIAL HOSPITAL 850 W IRVING PARK RD CHICAGO, IL 60613 Aug. 18, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation and interview it was determined that for 1 of 4 (Pt #1) patients reviewed for seclusion, the Hospital failed to promote the patient's rights and provide safe care for a patient who was secluded. This potentially affected all patients requiring seclusion.

As a result the Condition of Participation 42 CFR 482.13 Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure the patient's privacy was maintained while providing incontinence care, (A-143).

2. The Hospital failed to ensure that a physician's order was obtained for seclusion, (A-168).

3. The Hospital failed to ensure Pt #1 was removed from seclusion at the earliest possible time, (A-174).

4. The Hospital failed to ensure a one hour face-to-face evaluation was conducted, (A-184).
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, observation, and interview, it was determined for 1 (Pt #1) of 1 patient placed in the Quiet Room on the Behavioral Health Unit, the Hospital failed to ensure the patient's privacy was maintained while providing incontinence care.

Findings include:

1. Policy entitled "Patient Rights and Responsibilities" (revised 8/2016) indicated "III. Guidelines A. Patients have the right to: ...5. Personal privacy...21. Be treated with dignity, consideration and respect..."

2. On 8/16/2016 at approximately 10:30 AM the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male admitted on [DATE] with a diagnosis of aggressive behavior. Pt #1's past medical history included stroke with left side weakness. Pt #1 required a wheelchair and assistance with activities of daily living.

3. On 8/16/2016 at approximately 2:30 PM the video surveillance during the timeframe when Pt #1 was in the Quiet Room (QR) was reviewed. Pt #1 remained in the QR from 8/9/2016 at 5:00 PM to 8/10/2016 1:46 PM (a total of 20 hours and 46 minutes). The video included when Pt #1 received incontinence care, exposing his genital area. The staff did not stop the recording during the rendition of care.

The monitor for the surveillance video is located in the nurses' station behind a clear glass window. The surveillance video is continuously recording the QR, hallways and common areas of the unit. All BHU personnel and security officers have access to the monitor of the the surveillance video.

4. On 8/17/2016 at approximately 10:10 AM the Chief Nursing Officer (CNO) was interviewed. E#7 stated the surveillance cameras are always on and recording. The staff does not have the ability to turn off or alter the recording. E #7 stated that during the night shift the camera monitor located at the nurses' station, is turned toward the hallway. E #7 stated there is always a Mental Health Specialist (MHS) in the nurses' station monitoring the hallways and cameras during the night shift (7:00 PM-7:00 AM).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, observation and interview, it was determined that for 1(Pt #1) of 4 clinical records reviewed for restraints/seclusion, the Hospital failed to ensure that a physician's order was obtained for seclusion.

Findings include:

1. The policy entitled "Restraint" (Revised 4/2016) indicated " II. C. ...When a restraint/seclusion is initiated by a nurse, the attending physician must be notified immediately and an order is received. 1. Restraint and/or seclusion are ordered by the physician or LIP (NP)..."

2. On 8/16/2016 at approximately 10:30 AM the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male admitted on [DATE] due to aggressive behaviors. Pt #1 had a past medical history that included stroke with left side weakness and required the use of a wheelchair. The nurses' progress notes dated 8/9/2016 to 8/15/2016 were reviewed. There are 2 entries that indicate Pt #1 was located in the QR on 8/9/2016 at 6:55 PM and 8/10/2016 at 5:45 AM.

3. On 8/16/2016 at approximately 2:00 PM the video surveillance of Pt #1 in the QR was reviewed. On 8/9/2016 from approximately 5:00 PM - 5:38 PM, Pt #1 is in the QR sitting in his wheelchair, yelling, and hitting the door and walls with his arm sling. Pt #1 is seen on multiple occasions attempting to open the door by manipulating the door handle, unsuccessfully. Therefore Pt #1 was secluded during this time.

4. On 8/16/2016 at approximately 1:45 PM Pt #1's psychiatrist (MD #1) was interviewed. MD #1 stated he would have ordered the seclusion due to Pt #1's aggressive behavior, if he would have been made aware.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, observation and interview, it was determined that for 1 of 4 clinical records (Pt #1) reviewed for seclusion, the Hospital failed to ensure Pt #1 was removed from seclusion at the earliest possible time.

Findings include:

1. The policy entitled "Restraints" (Revised 4/2016) indicated II.C. 4. ...the requirement that restraint use be ended at the earliest possible time applies to all uses of all restraints... D. 2. The following will be assessed by the RN and documented every hour after the initiation of the restraint/seclusion:...Restraint/seclusion release readiness..."

2. On 8/16/2016 at approximately 10:30 AM the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male admitted on [DATE] due to aggressive behaviors. Pt #1 was verbally aggressive and frequently using racial slurs toward staff and other patients on the unit.

3. On 8/16/2016 at approximately 2:00 PM the video surveillance of Pt #1 in the QR was reviewed. On 8/9/2016 from approximately 5:00 PM - 5:38 PM, Pt #1 is in the QR. Pt #1 is in his wheelchair, yelling at times, hitting the door and walls with his arm sling. Pt #1 is seen on multiple occasions attempting to open the door by manipulating the door handle, unsuccessfully. Therefore, Pt #1 was secluded. At 5:54 PM Pt #1 threw himself on the floor. The staff opened the door and removed his wheelchair from the room. Per the video during staff rounds Pt #1 is calm and resting in the bed, speaking calmly with the staff.

According to the video, even though, Pt #1 remained calm, without noted aggressive behavior from 8/9/2016 at 6:08 PM through 8/10/2016 at 1:46 PM, the patient remained in seclusion.

4. On 8/17/2016 at approximately 10:10 AM the Registered Nurse (E #7) was interviewed. E #7 stated she did not complete an assessment of Pt #1's readiness to be removed from seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**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 #1) clinical records reviewed for seclusion, the Hospital failed to ensure a one hour face-to-face evaluation was conducted.

Findings include:

1. The policy entitled "Restraints" (revised 4/2016) indicated " II. G. When a ...seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient...the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a physician or licensed independent practitioner or trained nurse...If a patient's violent or self-destructive behavior resolves and ...the seclusion intervention is discontinued before the practitioner arrives to perform the 1-hour-face-to face evaluation, the practitioner is still required to see the patient face-to-face and conduct evaluation within 1 hour after the initiation of this intervention."

2. On 8/16/2016 at 9:30 AM Pt #1's clinical record was reviewed. Pt #1 was a [AGE] year old male admitted on [DATE] due to aggressive behaviors. The clinical record of Pt #1 indicated he was verbally aggressive and frequently using racial slurs toward staff and other patients on the unit. The nurses' notes in the record included 2 entries, on 8/9/2016 at 6:55 PM and 8/10/2016 at 5:43 AM, Pt #1 was in the QR. The clinical record did not include documentation of the 1 hour face-to-face evaluation by the physician or licensed independent practitioner (LIP).

3. On 8/16/2016 at approximately 2:00 PM the video surveillance of Pt #1 in the QR was reviewed. On 8/9/2016 from approximately 5:00 PM - 5:38 PM, Pt #1 is in the QR sitting in his wheelchair, yelling, and hitting the door and walls with his arm sling. Pt #1 is seen on multiple occasions attempting to open the door by manipulating the door handle unsuccessfully. At 5:54 PM Pt #1 threw himself on the floor. The staff opened the door and entered to assist Pt #1.

Pt #1 remained secluded from 8/9/2016 at 5:00 PM to 8/10/2016 at 1:46 PM when staff removed Pt #1 from the QR.

4. On 8/17/2016 at approximately 10:10 AM the Registered Nurse (E #7) was interviewed. E #7 was Pt #1's assigned nurse during the time he was secluded in the QR. E #7 stated "the door was locked for approximately 15 minutes." E #7 stated she did not identify Pt #1 as being in seclusion during her shift. E #7 stated she did not notify the physician for the face-to-face evaluation to be conducted.