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.

WESTLAKE HOSPITAL 1225 LAKE ST MELROSE PARK, IL 60160 Feb. 17, 2015
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and staff interview, it was determined, for 1 of 10 psychiatric patients (Pt. #1), the hospital failed to ensure a patient received a restriction of rights notice when forced to take psychotropic medications involuntarily.

Findings include:

1. On 2/17/15 at 3:20 PM, hospital policy #1308.75, titled, "Patient's Refusal of Medication and Condition for Emergency Use of Medication", revised May 2013, was reviewed. The policy required, "If the patient is refusing medication and the patient's behavior is a serious and imminent threat to self and/or others, prior to emergency administration of medication, the RN is responsible... Completes a restriction of rights form... appropriate notification [including the patient]".

2. On 2/11/15 at 10:45 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of bipolar disorder, manic phase with psychosis, and cannabis abuse. A progress note dated 2/8/15 at 8:15 PM included, Pt. #1 threw water on a female staff member and threatened to physically hurt her. Pt. #1 "refused to follow directions, loud, yelling, screaming, danger to self and others..."

3. Pt. #1's medication administration record (MAR) included documentation Pt. #1 had received 3 emergency psychotropic medications - Haloperidol on 2/8/15, at 8:31 PM, for agitation; Lorazepam on 2/8/15, at 8:31 PM, for agitation and threatening staff; and Zyprexa on 2/8/15 at 8:31 PM, for threatening staff. There was no documentation Pt. #1 took these medications voluntarily and a "Notice Regarding Rights of Recipients" was not found for any of the 3 emergency psychotropic medications administered.

4. On 2/17/17 at approximately 2:30 PM, and interview was conducted with the Chief Nursing Officer (E #2). E #2 reviewed Pt. #1's MAR, nursing notes, and consents in the clinical record and computer and was not able to find the notice of restriction of rights for the 3 psychotropic medications administered on 2/8/15. E #2 stated that nurses chart by exception, so the patient may have voluntarily taken the medications.

B. Based on document review and staff interview, it was determined, for 1 of 10 psychiatric patients (Pt. #1), the hospital failed to ensure a patient was informed about psychotropic medications and signed a psychotropic medication consent, prior to psychotropic medication administration.

Findings include:

1. On 2/17/15 at 3:55 PM, hospital policy #1300.60, titled, "Patient Rights and Responsibilities", revised July 2007, was reviewed. The policy required, "9.2 The exercise of Patient's Rights provides for... the right to make informed decisions regarding his or her care... the right to consent or refuse treatment after being informed of the benefits and risks of, and alternative to treatment..."

2. On 2/11/15 at 10:45 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of bipolar disorder, manic phase with psychosis, and cannabis abuse. Pt. #1's physician's orders included Ativan/Lorazepam (dated 2/7/13), Haldol/Haloperidol (dated 2/7/15), Seroquel (2/7/15), and Zyprexa (dated 1/29/15).

3. Pt. #1's psychotropic medication consent, dated 1/27/15 did not include Ativan, Haldol, Seroquel, or Zyprexa.

4. On 2/17/17 at approximately 2:30 PM, and interview was conducted with a Quality Analyst (E #10). E #10 reviewed Pt. #1's MAR, nursing notes, and consents in Pt. #1's clinical record and computer and stated she was not able to find a psychotropic medication consent form for Ativan, Haldol, Seroquel, or Zyprexa.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and staff interview, it was determined, for 1 of 1 restrained psychiatric patient (Pt. #1), the hospital failed to ensure physical hold/restraint was applied safely, to avoid patient injury.

Findings include:

1. On 2/17/15 at 3:55 PM, hospital policy #1300.60, titled, "Patient Rights and Responsibilities", revised July 2007, was reviewed. The policy required, "9.2 The exercise of Patient's Rights provides for... the right to receive care in a safe setting... the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff (restraint or seclusion... may only be imposed to ensure the immediate physical safety of the patient..."

2. On 2/11/15 at 10:45 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of bipolar disorder, manic phase with psychosis, and cannabis abuse. Nursing notes written on 2/2/15 at 4:00 PM, by a mental health counselor (E #1) indicated Pt. #1 was impulsive and agitated, and refused to return to his room during quiet time. Pt. #1 became hostile and defiant stating "I am going to make this phone call no matter what and no MF is going to stop me." E #1 attempted to redirect Pt. #1 to his room, but Pt. #1 pushed E #1 causing E #1 to fall. Staff came to assist and security was called. The note did not describe the the physical hold/restraint techniques used. An earlier physician's order dated 1/29/15 at 8:45 PM, included, "No outside phone calls due to harassment." Pt. #1 had been harassing his residential facility with frequent threatening phone calls.

3. On 2/11/15 at 9:15 AM, an interview was conducted with Pt. #1 on the 4 West psychiatric unit, male side. Pt. #1 stated he was afraid of E #1 after he pulled him to the floor an put his knee on his head. Pt. #1 stated he pleaded to breath, but became unconscious, urinated, and defecated on himself, due to E #1's physical hold. Pt. #1 stated he informed the unit manager (E #9) that E #1 had hurt him and he was afraid of E #1, but E #1 remained on the unit.

4. On 2/17/15 at 1:30 PM, a undated written statement from a mental health counselor (E #8) acquired by the unit manager (E #9) during her investigation, was reviewed. The statement included, E #8 heard Pt. #1 yelling and a "loud thump" and came to assist E #1 who was laying on the floor physically holding Pt. #1. E #8 wrote, "During the process I noticed that [E #1] was very upset and aggressive as evidenced by his voice tone and the amount of pressure he applied according to the statement from the patient ("stop it you are hurting me." "I can't breath"). I then asked [E #1] to swap-out with me so that he could calm himself down, but he refused to let go of the patient. Shortly thereafter the patient was transported to the quiet room and placed in mechanical restraints. "

5. A nursing note the next day, on 2/3/15 at 1:25 PM, written by the psychiatric nurse manager (E #9) included Pt. #1 informed E #9 he was injured yesterday during the restraint episode. E #9 contacted the hospitalist, according to the note.

6. A hospitalist note dated 2/3/15, included Pt. #1's face had "minimal redness, purple rosaria... Patient had been placed in restraints 2/2/15 and is complaining of abrasion from yesterday's incident. However, patient stated area of complaint has improved."

7. On 2/11/15 at 3:00 PM, a phone interview was conducted with a medical health counselor (E #1). E #1 stated he placed his hand on Pt. #1's jaw and forced Pt. #1's face toward the ground to stop Pt. #1 from spiting and biting, but did not cover Pt. #1's mouth or nose. E #1 stated when Pt. #1 was in the quiet room, he asked "how long was I out." E #1 stated Pt. #1 was attempting to manipulate the staff when stating he was unconscious because he was yelling the whole time and walked to the quiet room, with staff assistance. E #1 stated he did not think Pt. #1 was injured, but in the future, would not attempt to hold someone again, without assistance.