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.

AURORA CHICAGO LAKESHORE HOSPITAL 4840 N MARINE DR CHICAGO, IL 60640 Dec. 20, 2019
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 interview, it was determined that for 1 of 1 (Pt #1) patient with suicidal precautions requiring every 15 minute safety monitoring observations, the Hospital failed to ensure the patient was provided care in a safe setting by conducting safety monitoring checks as required.

This placed all 41 patients with suicide precautions on census on 12/3/19, on the Adult Units (General Adult Unit and Intensive Treatment Unit), at risk.

Findings include:

1. The Hospital's policy entitled, "Patient Observation Rounds and Precautions," (revised 05/30/19 and 12/4/19) was reviewed on 12/18/19 at approximately 10:00 AM, and included, "...Procedures: Conducting Rounds: A. Rounds shall be conducted at a minimum of every 15 Minutes...C. During rounds: 1. confirm patient's identity...D. Be aware of the general safety of all the unit by assessing the following: 1) Location of patients...2. Observation Levels: A. Routine Observations - 2) All patients shall be placed on routine observations every 15 minutes...Routine observations are conducted a minimum of every 15 minutes, 24 hours a day. 3) Staff conducting rounds will make direct visual contact with each assigned patient a minimum of every 15 minutes and document observations concurrently, every 15 minutes...B. Special Observation - Any indication of suicidal intent...shall be immediately evaluated by a Registered Nurse (RN) staff member and action shall be taken..."

2. The clinical record of Pt #1 was reviewed on 12/17/19 at approximately 11:30 AM. Pt #1 was a [AGE] year old female who came into the Intake Department at 11:30 PM on 12/1/19. Pt #1 was then admitted on [DATE] at 12:30 AM, with an admitting diagnosis of major depressive disorder (MDD), recurrent episode severe. Pt #1's clinical record contained an admitting physician's order that required that Pt #1 be placed on suicide precautions with every 15 minute monitoring.

-Pt #1's clinical record contained an Intake Assessment from sending Hospital, dated 12/1/19 that included, " ...7. Mental Status ...Judgement: poor as evidenced by SI (suicidal ideation), Insight Poor as evidenced by SI ...Intake Evaluation of Risks: Current thoughts or actions to harm self; Suicide Plan - overdose, Suicide Ideation - took 26 pills, Did patient have recent suicide attempt ? (within last 6 months) 12-1-19 patient answered yes, History of SI / # number of attempts method(s) used within last 12 months - yes. Pt refused to provide details ...C-SSRS (Columbia Suicide Severity Rating Scale) Suicidal Ideation Intensity ...Frequency - How many times have you had these thoughts? Daily or almost daily. When you have the thoughts how long do they last? (4) 4-8 hours/most of the day ...Controllability (5) unable to control thoughts. Deterrents (5) Deterrents did not stop you. Reasons for ideation (4) Mostly to end or stop the pain. A total score or 22. Determination Level of Risk ...High Suicide Risk - Suicidal ideation with intent or intent with plan in past month ...Narrative Conclusion took over 20 pills in a suicide attempt. Pt reported other suicide attempts but refused to provide details ...Screening findings ...Suicide Risk Stratification - High ..."

-Pt #1's Nursing Admission assessment dated [DATE] at 1:58 AM, included, " ...Chief Complaint: 'I over dosed on my meds' ...RN (Registered Nurse) Narrative and Conclusions ...Pt (patient) was admitted because of suicide attempt. Pt overdosed on psych meds (psychiatric medications). Pt states she has tried several times ..."

-Pt #1's initial Psychiatric Evaluation, dated 12/3/19 at 10:50 AM, included, " ...Suicidal Ideations: Positive ..."

-Nursing documentation dated 12/3/19 at 7:17 PM included, "Pt found unresponsive with blue rubber band around neck. Found on bathroom floor ..."

-Nursing documentation dated 12/3/19 at 10:00 PM included, "Pt was found unresponsive on the bathroom floor. Code blue was called, vs (vital signs) taken, O2 (oxygen) applied, MD (MD #1 and #2)were notified, and order to transfer to ER (emergency room ) received ..."

3. A video review of 12/3/19 from 5:22 PM through 6:26 PM was conducted on 12/18/19. The following is a timeline of events:
At 5:30 PM - The Mental Health Worker (MHW) (E#2) began patient rounds.
At 5:35 PM - E#2 reached Pt. #1's room, stood in the doorway for approximately 2 seconds and walked away.
At 5:45 PM - MHW (E#2) again began patient rounds.
At 5:49 PM - E#2 reached Pt. #1's room and walked away from door after approximately 5 seconds.
At 6:00 PM - A different MHW (E#4) began patient rounds.
At 6:05 PM - E#4 reached Pt. #1's room and enters room. Additional staff is seen running to/from room. Staff arrive with blood pressure machine and oxygen.
At 6:21 PM - Fire Department (4) personnel arrived.
At 6:26 PM - Fire Department left room with Pt. #1 on a rolling chair.

4. An interview was conducted on 12/18/19 at approximately 1:15 PM with the CNO (Chief Nursing Officer - E #6) and Director of Quality (E #7). E #6 stated, I was made aware of the incident the day the patient was being sent to the Hospital and then started the investigation the next day. The findings included that the patient was found unresponsive on the bathroom floor with a rubber band around her neck. The MHW (E #2) did not do his safety rounds correctly, he did not visually see the patient. We had disciplined him in June or July of this year for rounding issues, so we terminated him.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that in 1 of 1 (Pt #1) clinical record reviewed of a patient with suicidal precautions requiring every 15 minute safety monitoring checks, the Hospital failed to ensure that the patient's safety checks information was documented accurately.

Findings include:

1. The clinical record of Pt #1 was reviewed on 12/17/19 at approximately 11:30 AM. Pt #1 was a [AGE] year old female who came into the Intake Department at 11:30 PM on 12/1/19. Pt #1 was then admitted on [DATE] at 12:30 AM, with an admitting diagnosis of major depressive disorder (MDD), recurrent episode severe. Pt #1's clinical record contained an admitting physician's order that required Pt #1 be placed on suicide precautions with every 15 minute monitoring.

-Pt #1's clinical record contained the required 15-minute safety checks for the dates of 12/1/19 (admitted at 11:30 PM, intake), 12/2/19, and 12/3/19. However, the safety checks documented that, on 12/3/19 at 5:30 PM, Pt #1 was in the shower, and at 5:45 PM Pt #1 was documented as sitting in the day room.

2. A video review of 12/3/19 from 5:22 PM through 6:26 PM was conducted on 12/18/19. The following is a timeline of events from 5:22 PM to 6:05 PM:

At 5:26 PM - Pt. #1 returned to her room.
At 5:35 PM - E#2 (MHW assigned to do safety checks) reached Pt. #1's room, stood in the doorway for approximately 2 seconds and walked away.
At 5:45 PM - Mental Health Worker (MHW - E#2) again began patient rounds.
At 5:49 PM - E#2 reached Pt. #1's room and walked away from the door after approximately 5 seconds.
At 6:00 PM - A different MHW (E#4) began patient rounds.
At 6:05 PM - E #4 reached Pt #1's room and Pt #1 was found unresponsive on the floor with blue rubber band around her neck.
The video lacked evidence that E #2 visualized Pt #1's actual location during this time period. The E #2's 15-minute safety checks were documented as Pt #1 in the shower at 5:30 PM, and as sitting in the day room at 5:45PM. - Inaccurate documentation.

3. The Hospital's policy entitled, "Patient Observation Rounds and Precautions," (revised 05/30/19) was reviewed on 12/18/19 at approximately 10:00 AM, and included, "...Procedures...Staff conducting rounds will make direct visual contact with each assigned patient a minimum of every 15 minutes and document observations concurrently, every 15 minutes..."

4. An interview was conducted on 12/18/19 at approximately 1:15 PM with the Chief Nursing Officer (CNO - E #6) and Director of Quality (E #7). E #6 stated, "I was made aware of the incident the day the patient was being sent to the Hospital and then started the investigation the next day. The findings included that the patient was found unresponsive on the bathroom floor with a rubber band around her neck. The MHW did not do his safety rounds correctly and did not document correctly."