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 July 27, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review, observation and interview, it was determined for 3 of 3 Psychiatric Units (2 General Adult Unit, 3 Intensive Treatment and 4 Intensive Treatment), the Hospital failed to ensure patients' rooms were free from ligature risks. This could potentially affect all 49 patients on suicide precautions on census as of 7/27/18.

Findings include:

1. On 7/24/2018 at approximately 10:20 AM, an observational tour was conducted on the Second (2nd) floor General Adult Unit (GAU). There were 27 patients on the Unit during the tour. The Unit consisted of 20 patient rooms, of which there were 17 bathrooms. Rooms 202 and 203; 222 and 223; 224 and 225 each shared a bathroom. The room entrance doors and bathroom doors were all unlocked. The doorframes were square and the doors reached to the top. Of the 27 patients, 8 were on suicide precautions.

2. On 7/24/18 at approximately 1:30 PM the 4th floor ITU (Intensive Treatment Unit), was toured. There were 25 patients on a 31 patient unit. The Unit consisted of 16 rooms with 13 bathrooms in the rooms. Rooms 404 and 405, 423 and 422, and 424 and 425 had shared bathrooms. The room entrance doors and bathroom doors were all unlocked. The doorframes were square and the doors reached to the top of the frame. Of the 25 patients on the unit, 21 were on suicide precautions.

3. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08,2017, reviewed on 7/25/18 at approximately 2:00 PM included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames..."

4. On 7/25/18 at approximately 10:30 AM the ITU 3 Unit was toured. There were 25 patients on a 34 patient unit. The Unit consisted of 16 patient rooms. Rooms; 322 and 323; 324 and 325 share bathrooms. The room entrance doors and bathroom doors were all unlocked. The doorframes were square and the doors reached to the top. Of the 25 patients on the unit, 20 were on suicide precautions.

5. On 7/25/18 at approximately 11:02 AM the Chief Nursing Officer (E #3) and the Director of Performance Improvement, Risk Management, and Quality Improvement (E #4) were interviewed. E #4 stated, "What we are doing is, we have ordered the soft door. We are aware of the ligature point risk. We have a mitigation plan in place. We are aware that they (doors) pose a risk." E #4 stated, "The doors have been back ordered a couple of times."

6. The Hospital identified this issue on 10/2017 by doing a risk analysis of the units. The Hospital's mitigation plan included, "A. Short Term Plan: Timeline: This process will begin 10/27/17. Rein-servicing staff regarding suicide assessments, 15 minute monitoring, observation of patients during bathroom use, implement updated environmental rounds tool, and the Unit Registered Nurse (RN) to conduct environmental rounds twice per shift. B. Intermediate Plan: Timeline: This process will begin by 11/20/2017: Complete revision of the suicide risk assessment. C. Long Term Plan: Timeline: This project will be completed by 10/1/2018. All patient bedroom door hinges and door handles in patient rooms and patient care areas will be replaced. All door handles will be replaced. All bathroom doors will be replaced. All faucets will be replaced. All toilets will be replaced. Sink fillers will be added. Closures will be added. Mirrors will be replaced. Grab bars will be replaced..." A purchase order dated 5/14/2018 included, 82 special collapsible doors. An Email between the door company to the Hospital dated July 3, 2018, included, "I want to update you on your door status....If all goes as planned with our supplier, your order should be ready to ship the week of July 23rd."

7. On 7/27/18, the Hospital presented a current Hospital census for the adult units. The census included: 25 patients with seven on suicide precautions on the GAU; 22 patients with 20 on suicide precautions on the 3 ITU; and 24 patients with 22 on suicide precautions on the 4 ITU.

8. On 7/27/18 at approximately 9:30 AM, the Chief Executive Officer (E #5) stated during an interview, "We have doors coming in on Monday (July 30, 2018). They have been rescheduled three times before and they were promised this time. We have changed door hinges and latches. We just need our doors."

B. Based on document review and interview, it was determined that for 3 of 3 Units (GAU, 3 ITU, and 4 ITU), the Hospital failed to ensure Safety Rounds were completed as required. This has the potential to affect the safety of all 90 patients (average daily census of 90) admitted to the Hospital.

Findings include:

1. The Hospital's policy entitled, "Safety Rounds," (revised 07/18) included, "I Policy: In order to insure the safety and security of all program units, unit staff on a routine basis conducts safety rounds...II. Procedure: A. During each shift, a staff member will survey the unit using the Safety Checklist for their unit..."

2. On 7/25/18 at approximately 11:30 AM the Hospital's Safety Checklists for the Month of June 2018, for the GAU, 3 ITU, and 4 ITU were reviewed. Except for 6/3/2018 and 6/11/2018 on the 3 ITU and 6/2/2018, 6/3/2018, 6/6/2018, 6/7/2018, 6/16/2018, and 6/19/2018 on the 4 ITU, the checklists for all three units missed an average of at least one patient safety check per day, for the month of June 2018.

3. During an interview on 7/25/18 at approximately 2:15 PM, the Chief Nursing Officer (E #3) stated, "The safety rounds should be done every shift."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation, and interview, it was determined that the Hospital failed to ensure patients were safe from ligature risks. This potentially places all current and future patients who are suicidal, at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure the patient's complaint was documented and investigated, as required (A118).

2. The Hospital failed to ensure all patients were informed, prior to the administration of psychotropic medications (A131).

3. The Hospital failed to ensure patients' rooms were free of ligature risks (A144-A).

4. The Hospital failed to ensure Safety Rounds were completed as required (A144-B).


An Immediate Jeopardy (IJ) began on 10/27/17 for the Hospital's failure to remove the identified ligature risks, thus potentially placing all psychiatric patients who are suicidal, at potential risk for serious harm.

The IJ was identified and announced on 7/27/18 at 9:30 AM, during a meeting with the Chief Executive Officer, Chief Nursing Officer, and the Director of Performance Improvement/Risk Management/Quality Improvement. The IJ was not removed by the survey exit date, 7/27/18.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**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) clinical record reviewed of a patient with a documented complaint, the Hospital failed to ensure the complaint was investigated, as required.

Findings include:

1. On 7/24/2018, the Hospital's policy titled, "Abuse, Neglect and Exploitation Reporting, Investigation and Response," (Revised 12/2017) was reviewed and included, "...B. Reporting, a. Upon witnessing or become aware of ...allegation that may reasonably be considered abuse ...employees are required to report this incident to one of the following administrative staff...C. Response to allegations or witnessed events: a. Upon becoming aware of an allegation and depending on the nature of the allegation...iv. In the event If the event involves a criminal act (e.g., sexual assault...) additional measures for any cases involving sexual assault..."

2. On 7/24/2018, the Hospital's policy titled, "Patient Complaint and Grievance Process," (Reviewed 12/2017) included, "G. All verbal or written complaints regarding abuse, neglect, patient harm...compliance with CMS requirements, are to be considered a grievance that requires immediate attention..."

3. The clinical record for Pt #1 was reviewed on 7/24/2018, at approximately 9:00 AM. Pt #1 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of major depressive disorder, recurrent with severe psychotic symptoms. The clinical record contained a document titled, "PSYCHOSOCIAL ASSESSMENT," dated 6/21/2018 1:00 PM and signed by a Medical Social Worker (E #1). This document included, "Pt (Pt #1) is a 34 year old...Pt (Pt #1) disclosed she was transferred from ER (emergency room - previous Hospital) due to sexual assault, woke up with bruises and vaginal pain, unsure what happened to her..."

4. On 7/24/2018 at approximately 12:06 PM, an interview was conducted with a Psychiatrist (MD #2). MD #2 stated, "...She (Pt #1) was paranoid, extremely sexually preoccupied, frequently agitated, and she (Pt #1) was not cooperative...She stated one of our female social workers raped her..."

5. On 7/24/2018 at approximately 12:13 PM, an interview was conducted with a Clinical Psychologist (E #2). E #2 stated, "She was anxious, tended to be accusatory. She accused one of our staff social workers of rape. I do not recall of what was reported or to whom. I am not sure if there was an incident report done..."

6. On 7/24/2018 at approximately 1:10 PM an interview was conducted with a Medical Social Worker (E #1). E #1 stated, "...She (Pt #1) was very inconsistent, and made statements that she (Pt #1) was possibly assaulted before she came here to this unit. She (E #1) could not really tell if it was an ex or another boyfriend. The story kept changing and I couldn't get a straight answer. I asked her if she wanted to file a report but she (Pt #1) wanted to talk to her ex-husband whom I believe is a cop. He did not want to file a report, stating it was out of his jurisdiction or conflict of interest. She (Pt #1) had different stories, first said it was someone on the fourth floor, but she (Pt #1) couldn't point out a person to me. She (Pt #1) was pointing out bruises on her body. But, I told her we had to document bruises with another staff present. She (Pt #1) claimed she had a black eye, but I could not see a black eye. I was her social worker, not her case manager. She (Pt. #1) was not cooperative with me."

7. On 7/25/2018 at approximately 11:10 AM, an interview was conducted with the Chief Nursing Officer (E #3). E #3 stated, "There should have been a work up, and a rape kit done once the patient (Pt #1) alleged sexual assault. The police should have been called and an occurrence report started. The person that found out should have started the process."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 6 of 6 (Pt's #1, #2, #3, #4, #6, and #7) clinical records reviewed for psychotropic medications, the Hospital failed to obtain informed consents for all 6 patients, prior to the administration of the medications.

Findings include:

1. The Hospital's policy entitled, "Psychotropic Medication Informed Consent," (reviewed 7/18) included, "...Procedure: A. Adult Units...5. The Psychiatrist must sign the Medication Consent Form found found in the MAR (medication administration record) for all patients that have routine orders for psychotropic medications..."


2. The clinical record for Pt #1 was reviewed on 7/24/2018, at approximately 9:00 AM. Pt #1 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of major depressive disorder, recurrent with severe psychotic symptoms. The clinical record included a document titled, "MEDICATION RECONCILIATION PHYSICIAN ORDERS," dated 6/19/2018, and included, "New Medication Orders - "Ativan (Anxiolytic-used to reduce anxiety) 2 milligrams PO (by mouth)/IM (intramuscularly) every 6 hours as needed." Pt #1's clinical record contained an undated document titled, "Consent For Medication Form-Scheduled Medications," which lacked the patient's and doctor's signatures.





3. The clinical record of Pt #2 was reviewed on 7/25/18 at approximately 11:10 AM. Pt #2 was a [AGE] year old male admitted on [DATE] with a diagnosis of major depressive disorder. Pt #2's clinical record contained a "Consent for Medication Form-Scheduled Medications" for Seroquel (atypical anti-psychotic). The Form was not been signed by the physician.

4. The clinical record of Pt #3 was reviewed on 7/25/18 at approximately 11:12 AM. Pt #3 was a [AGE] year old male admitted on [DATE] with a diagnosis of opiod dependence withdrawal. Pt #3's clinical record contained a "Consent for Medication Form-Scheduled Medications" for Seroquel and Haldol (typical anti-psychotic). The Form was not been signed by the physician.

5. The clinical record of Pt #4 was reviewed on 7/25/18 at approximately 11:14 AM. Pt #4 was a [AGE] year old male admitted on [DATE] with a diagnosis of major depressive disorder. Pt #4's clinical record contained a "Consent for Medication Form-Scheduled Medications" for Haldol and Ativan. The Form was not signed by the physician.

6. The clinical record of Pt #6 was reviewed on 7/25/18 at approximately 11:15 AM. Pt #6 was a [AGE] year old female admitted on [DATE] with a diagnosis of schizoaffective disorder, bipolar type. Pt #6's clinical record contained a "Consent for Medication Form-Scheduled Medications" for Haldol. The Form was not signed by the physician.

7. The clinical record of Pt #7 was reviewed on 7/25/18 at approximately 11:16 AM. Pt #7 was a [AGE] year old male admitted on [DATE] with a diagnosis of bipolar disorder. Pt #7's clinical record contained a physician's order dated 7/20/18 that included Haldol 5 mg IM/PO (intramuscular/by mouth) every 6 hours as needed and Ativan 2 mg (milligrams) PO/IM every 6 hours as needed. Pt #7's clinical record contained a "Consent for Medication Form-Scheduled Medications," that did not include either Haldol or Ativan.

8. The Hospital's list of approved psychotropic medications was reviewed on 7/25/18 at approximately 11:30 AM. The list included: Seroquel; Haldol; and Ativan.

9. During an interview on 7/25/18 at approximately 11:20 AM, the Chief Nursing Officer (E #3) stated, "The medication consent should have been signed by the physician."