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 | Aug. 15, 2019 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on document review, videotape review, and interview, it was determined that the Hospital failed to provide care in a safe setting. This potentially placed 3 patients (Pt. #1, Pt. #7, and Pt. #12) at risk for sexual assault and/or self 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 that a patient was protected from abuse. See A-145. 2. The Hospital failed to promote care in a safe setting due to failing to provide 1:1 (one staff assigned to continuously monitor one patient) staffing as required. See A-144. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on document review and interview, it was determined that for 2 of 4 patient (Pts. #7 and #12) records reviewed for patients assigned with a sitter, the Hospital failed to promote care in a safe setting due to failing to provide 1:1 (one staff assigned to continuously monitor one patient) staffing as required. Findings include: 1. The Hospital's policy titled, "Inpatient Staffing/Acuity Plan" (revised 7/2019), was reviewed on 8/14/19 and required, " ... Each unit and shift have a predetermined maximum patient-to-staff ratio to be used as a guideline when determining appropriate staffing levels. (See staffing matrix) ... B. Staffing Matrix Adult Units: ... 3. On the 11 [PM] - 7 [AM] shift ... the MHW [Mental Health Worker] will be assigned one (1) patient specifically (who [with] no other assignments) if the patient requires a 1:1 observation ..." 2. The Hospital's Staffing Grid for 2019 (revised 2/2019) was reviewed on 8/12/19 and required staffing to include 1 Registered Nurse (RN) and 2 Mental Health Workers (MHWs) for a census of 15-20 patients on the ITU (Intensive Treatment Unit), during the night shift (11:00 PM to 7:00 AM). 3. The Hospital's policy titled, "Patient Observation Rounds and Precautions" (revised 5/30/19), was reviewed on 8/13/19 and required, "One to one (1:1) - This level of observation is the most intense level and is utilized only when a patient is an imminent danger to self or others or if the patient's behavior places the patient in imminent threat of harm. Definition: One staff is assigned the single responsibility of maintaining one patient under constant supervision, within arm's length at all times ... Modified One to One (1:1): ... Require one to one, but the 1:1 is modified based on specific patient need. For example ... staff will sit within reach of the patient, but not arm's length ..." 4. The Intensive Treatment Unit (ITU) Staff Assignment sheets from 7/29/19-7/31/19 and 8/2/19-8/4/19, were reviewed on 8/12/19 and 8/13/19. - The Night Shift (11:00 PM to 7:00 AM) "Daily Patient Assignment Sheet" on 8/3/19 indicated that 20 patients were on census, of which 2 patients were on 1:1. The unit was staffed with 1 RN and 3 MHWs and did not meet the staffing grid requirements for 4 MHWs (2 plus 2 more for 1:1s) for 20 patients. The Night Shift "Staff Assignment Flow Sheet" indicated that only 1 MHW was assigned to do 1:1 monitoring for 2 patients (Pts. #7 and #12) on 8/3/19. - The Night Shift (11:00 PM to 7:00 AM) "Daily Patient Assignment Sheet" on 8/4/19 was requested on 8/12/19 at 8:45 AM, and again on 8/13/19 at 8:39 AM and 1:15 PM. The Chief Nursing Officer (E#2) could not find the "Daily Patient Assignment Sheet" for the night shift on 8/4/19. The patient census on 8/4/19 was 21, of which 2 patients were on 1:1 monitoring. The Night Shift "Staff Assignment Flow Sheet" (provided by E#2 on 8/12/19), indicated that only 1 MHW was assigned to do 1:1 monitoring for 2 patients (Pts. #7 and #12) on 8/4/19. 5. The clinical records of the 2 patients on 1:1 were reviewed on 8/12/19 and 8/13/19. - Pt. #7 was admitted with a diagnosis of schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Physicians orders, dated 7/27/19 at 11:00 AM and 7/28/19 at 4:55 PM, indicated that Pt. #7 was placed on 1:1 precautions for self-harm and SAO (sexually acting out) behaviors. The Patient Observation Records, dated 8/3/19 and 8/4/19, indicated that Pt. #7 was monitored by the same staff (E #11) assigned to monitor another patient (Pt. #12) in the same room from 8/3/19 at 9:30 PM to 8/4/19 at 7:15 AM (9 hours and 45 minutes) and on 8/4/19 from 11:30 PM to 6:45 AM (7 hours and 15 minutes). - Pt. #12 was admitted with a diagnosis of major depressive disorder. Physicians orders, dated 8/3/19 at 6:45 PM and 8/4/19 at 10:15 PM, indicated that Pt. #12 was placed on 1:1 precautions for self-harm behaviors. The Patient Observation Records, dated 8/3/19 and 8/4/19, indicated that Pt. #12 was monitored by the same staff (E #11) assigned to monitor another patient (Pt. #7) in the same room from 8/3/19 at 9:30 PM to 8/4/19 at 7:15 AM (9 hours and 45 minutes) and on 8/4/19 from 11:30 PM to 6:45 AM (7 hours and 15 minutes). 6. An interview was conducted with the Chief Nursing Officer (E#2) on 8/13/19, at approximately 1:25 PM. E#2 stated that when a patient is on 1:1, there needs to be 1 staff monitoring only that patient. E#2 stated that if 2 patients are in the same room and both are on 1:1, there needs to be 2 staff present, one for each patient. E#2 stated that if an order for 1:1 indicates that staff does not need to be at arm's length, the assigned staff member can remain at the doorway. After reviewing the patients' (Pts. #7 and #12) records and the ITU (Intensive Treatment Unit) staffing assignment sheets for 8/3/19 and 8/4/19, E#2 stated that one staff should not have been assigned to monitor two 1:1 patients. At approximately 3:00 PM, E#2 confirmed that E#2 could not find any evidence that 2 staff were monitoring Pts. #7 and #12 during the night shifts on 8/3/19 and 8/4/19. 7. A telephone interview was conducted with a MHW (E#11) on 8/14/19, at approximately 10:46 AM. E#11 stated that a MHW should not monitor two 1:1 patients at the same time. E#11 stated that the Charge Nurse is responsible for making the assignments for the shift. E#11 stated that a couple weekends ago E#11 was assigned to monitor a 1:1 patient. E#11 stated that the Charge Nurse gave E#11 another 1:1 patient's observation book for monitoring. E#11 stated that E#11 told the Charge Nurse, "This is not right." E#11 stated that the Charge Nurse said someone else was coming to monitor the other 1:1 patient; however, E#11 could not recall if someone ever came. E#11 could not explain why E#11 had signed off on both 1:1 patients' observation records. |
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| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical records sampled for alleged abuse, the Hospital failed to ensure care in a safe setting to provide protection from sexual abuse. Findings include: 1. On 8/13/19 at 2:00 PM, the Hospital's policy titled, "Patient Rights and Responsibilities," (revised 4/19) was reviewed. The policy required, "II. Policy... C. The Patient's Bill of Rights shall include, but not be limited to the patient's right to... 3. Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation." 2. On 8/14/19, the Hospital's policy titled, "Patient Observation Rounds and Precautions, (effective 7/15/14), was reviewed. The policy required, "E. Precaution levels... e. Sexually Acting Out (Aggressor) - Patients who have a history of sexual acting out or sexual assault, as either a victim or a perpetrator, or is identified at risk for sexual aggression, sexualized behavior or accusations may be placed on precautions. Patient is placed on SAO precautions per MD [Medical Doctor] order which may or may not include the following: 1. "12-foot rule" from peers, b. MD order for no roommate, c. One to one... f. Vulnerability: Patient with a history of sexual assault and/or physical assault shall be placed on precautions. (Please refer to Vulnerability Risk Assessment)." 3. On 8/12/19, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted with the diagnoses of schizoaffective disorder (a combination of symptoms of schizophrenia {losing touch with reality with symptoms including hallucinations, disorganized thinking, unreal beliefs, and involuntary movements} and mood disorder, such as depression or bipolar disorder {AKA manic/ depressive disorder - causes unusual shifts in mood, activity levels, and the ability to carry out day-to-day tasks}), suicidal and homicidal ideation and developmental disabilities. 4. Pt. #1's "Intake Assessment," dated 7/29/19 at 9:45 PM, included a sexual assault "Vulnerability Risk Screen" with a risk score of 15 (5 points for being developmentally delayed, 5 points for a history of victimization, and 5 points for a history of sexual abuse). The Assessment included the rating acuity: 0 - 5 Low Risk: No special vulnerability precautions. 6 - 14 Moderate Risk: RN to consult MD for vulnerability precautions ... 15 + (plus) High Risk: Patient should be roomed close to the nurses' station in a private room or with a roommate who is not on DTO [Danger to Others]/SAO precautions. RN to consult with MD for observation levels as appropriate." 5. The vulnerability precautions did not address how vulnerable patients would be protected outside their room i.e. in the corridor and other areas on the unit. 6. Pt. #1's "Initial Psychiatric Evaluation and Treatment Plan," dated 7/29/19, included, "The patient was discharged earlier this month from our unit. He was then sent to a Group Home. Yesterday when they were having an outside activity [shopping at Walmart], he started acting out and started screaming out loud, getting attention saying that he was going to kill himself and so security staff called 911. - The patient started reporting that he was going to kill himself, that he was hearing voices, that he wanted to kill himself ... his mother was able to clarify that he has been showing these acting-out behaviors for a long period of time in order to obtain attention ... and episodes of mood escalation have become more frequent ... He states that he still wants to harm himself by cutting himself with his [finger] nails ... - He has multiple previous psychiatric hospitalization s and diagnosis of intellectual disability and also schizoaffective disorder ... Attention span is impaired. The patient has difficulty with calculations. Recent and remote memories are intact. He is able to recall recent and biographical events. Abstract reasoning is impaired ... Intelligence is below average by vocabulary and history. Insight and judgement are poor. The patient is unable to anticipate outcomes, unable to understand [the] severity of his illness ..." Pt. #1's clinical record did not provide an assessment of Pt. #1's mental age. Pt. #1 was assigned to the Adult Intensive Treatment Unit (ITU). 7. Per the Chief Nursing Officer (E #2) in an interview on 8/15/19 at 3:00 PM, E #2 stated that when Pt. #1 arrived on the Unit, the patient's room was changed by the Charge Nurse (E #10), because another patient needed a blocked room (no roommate), and that room was a single bed room. Pt. #1's new room was a two bed room and was 2 doors from the nursing station. 8. Pt. #1's Physician's orders dated 7/29/19 at 9:00 PM, included precautions for "suicide/self harm (SIP)" and "assault/ aggression." The Physician's order failed to ensure Pt. #1 was placed on SAO precautions, to include the "12-foot rule" from peers, an MD order for no roommate, or one to one monitoring, which may have prevented the incident. 9. Pt. #1's Progress Note dated 7/31/19, included, "On 7/31/19 at 8:45 AM, Patient [Pt. #1] approached the nursing station and reported that he was raped on the night of 7/30/19 after dinner. Patient reported that his peer [Pt. #2] went to his room and raped him. Patient complained of pain in his anal area." 10. A Progress Note dated 8/1/19 at 6:25 AM, included, "Allegations set forth by Patient [Pt. #1] seem to have been validated ... by confession of offender [Pt. #2] and reported video confirmation. Offender entering patient's room was seen [on a video recording] and [Pt. #1 was] evaluated at ... [the Medical Hospital's emergency room ]..." 11. On 8/12/19 at 10:30 AM, Pt. #2's clinical record was reviewed. Pt. #2 was admitted with the diagnoses of major depressive disorder, suicidal, and homicidal ideation. The record further included that Pt. 2 was positive for Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (liver infection). - Pt. #2's "Intake Assessment," dated 7/30/19 at 12:17 PM, included a "Sexual Acting Out Risk Screen" with a sexual risk score of 0 and a "Vulnerability Risk Screen" score of 10 (5 points for history of victimization and 5 points for history of sexual abuse). Pt. #2's Physician's orders failed to ensure Pt. #2 was placed on SAO precautions, to include the "12-foot rule" from peers, an MD order for no roommate, or one to one monitoring, which may have prevented the incident. 12. On 8/12/19 at 1:43 PM, the video surveillance of the incident that occurred between Pt. #1 and Pt. #2 on 7/30/19, was reviewed. Pt. #1 and Pt. #2 entered Pt. #1's room at 5:36:12 PM and exited the room at 5:38:43, two and one half minutes later. 13. On 8/12/19 at approximately 12:45 PM, the the incident report regarding Pt. #1 dated 7/31/19 was reviewed and included, "Sexual incident - patient/patient... Description of Occurrence (Facts Only): Patient [Pt. #1] states, 'I was sexually assaulted last night when I was sleeping by a man [Pt. #2] who just got here yesterday." 14. The Hospital's Investigation Summary of the incident regarding Pt. #1 and Pt. #2 was reviewed on 8/12/19 and included, "Summary: On 7/31/19 [Pt #1] reported to the nurse that he was sexually assaulted the night before by [Pt #2] in his room while he was sleeping... Conclusion: After camera review, staff interviews and speaking with both patients it was determined that a sexual interaction possibly occurred in less than 2 minutes based on the patients report. Area detectives came up to [the Hospital] to speak with the nursing supervisor and notify the hospital that [Pt #1] had recanted his allegation during his interview with them..." Although the investigative summary indicated Pt. #1 was assaulted during the night, it conflicted with the progress note which indicated the incident occurred after dinner. 15. On 8/13/19 at 11:15 AM, an interview was conducted with the Chief Medical Officer (CMO) / Pt. #1 & Pt. #2's Psychiatrist (MD #1). MD #1 acknowledged only being CMO for 2 weeks when Pt. #1's sexual assault occurred. MD #1 denied being aware of vulnerability precautions prior to this event, was instructed by the Chief Nursing Officer, and in turn had a meeting with all medical staff to inform them about vulnerability precautions. MD # 1 stated that MD #1 was in the Hospital speaking with the Chief Nursing Officer (E #2) at the time Pt. #1 informed the Nurse he had been raped. MD #1 interrupted the meeting to interview and assess Pt. #1. Pt. #1 told MD #1 that the rape took place the previous day (7/30/19) at approximately 5:00 PM. MD #1 stated that the police were called and Pt. #1 told the police that the sexual episode was consensual. Pt. #1 and Pt. #2 knew each other from previous admissions and had been "flirting," which was confirmed by Pt. #2. 16. Pt. #1's Emergency Department (ED) documentation dated 7/31/19, at the Medical Hospital Emergency Department included a Chicago Police Department Report Notice #JC 1, that documented police notification of Pt. #1's "Criminal Sexual Assault / Non-aggravated" event occurring on 7/30/19 at 5:00 PM. The report did not have any information regarding the incident. 17. On 8/13/19 at 1:15 PM, an interview was conducted with the Chief Nursing Officer (CNO) (E #2). E #2 stated that Pt. #1's room should have been blocked (no roommate) and should have been near the nursing station to reduce Pt. #1's vulnerability. E #2 denied knowing why Pt. #1 was moved. |
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