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 | March 21, 2019 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on document review, videotape review, and interview, it was determined that the Hospital failed to ensure that 1:1 (one staff to one patient) monitoring was properly maintained; that every 15 minutes patient observations were conducted on all patients; and that an employee suspended for alleged abuse/misconduct of a patient was unable to work with other patients, pending the outcome of the investigation of abuse/misconduct. This potentially places all current and future patients 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 that 1:1 monitoring was maintained to enusre the safety of the patients. (A144-A). 2. The Hospital failed to ensure that every 15 minute patient observations were conducted to ensure the safety of the patients. (A144-B). 3. The Hospital failed to ensure that an employee on suspension for alleged sexual misconduct did not return to work during the suspension period. (A-145) An Immediate Jeopardy (IJ) began on 3/3/19, for the Hospital's failure to properly monitor and ensure a safe environment for patients at risk for serious harm to self and others. The IJ was identified and announced on 3/19/19 at 9:10 AM, during a meeting with the Vice President, Chief Nursing Officer, Chief Medical Officer, Interim Chief Executive Officer, Chief Executive Officer In-Training and the Director of Performance Improvement, Risk Management and Quality (PI/RMQ). The IJ was not removed by the survey exit date of 3/21/19. An IJ began on 3/2/19, for the Hospital's failure to protect patients from a suspended staff member, pending investigation of alleged abuse/misconduct, and put these patients at risk for serious harm/abuse. The IJ was identified and announced on 3/21/19 at 3:25 PM, during a meeting with the Chief Nursing Officer, Chief Medical Officer, Interim Chief Executive Officer, Chief Executive Officer In-Training, Director of PI/RMQ, and Nurse Consultant. The IJ was not removed by the survey exit date of 3/21/19. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on document review, videotape review, and interview, it was determined that for 1 of 2 patients (Pt. #7) records reviewed for 1:1 monitoring (continuous monitoring of 1 staff to 1 patient), the Hospital failed to ensure that 1:1 monitoring was properly maintained as ordered. This failure resulted in Pt. #7 being physically assaulted by a peer. Findings include: 1. On 3/14/19, the Hospital's policy titled, "Patient Observation Rounds and Precautions" (revised by the hospital on [DATE]), was reviewed. The policy included, " ...Levels of Special Observation - 1. 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. a) Staff is not assigned duties other than 1:1 b) Staff must remain at arm's length of patient at all times ...g) Patient should not sit in close proximity to other patients ...Criteria for one to one (1:1) The patient may need one to one if they have any one of the following: a) Is actively attempting to harm self or others. b) Has failed or is unsafe at lower levels of observation due to emotional or physical condition ...4. Modified One to one (1:1) ...b) Require one to one, but the 1:1 is modified based on specific patient need ...f. Sexual Acting Out (Victim/Aggressor) - Patients who have a history of sexual acting out or sexual assault, as either a victim or perpetrator, or is identified at risk for sexual aggression, sexualized behavior or accusations may be placed on precautions: i. Aggressor: a. Patient is placed on SAO [Sexual Acting Out] precautions per MD [Medical Doctor] order which may or may not include the following: b. MD order for no roommate c. One to one ..." 2. On 3/14/19, Pt. #7's medical record was reviewed. Pt. #7 was a [AGE] year old female, admitted on [DATE] for disruptive mood dysregulation disorder (a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts) and post traumatic distress syndrome (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -Pt. #7's Special Precautions order dated and signed 2/19/19 at 4:35 PM included, " ...block patient's room [no roommate]/SAO precautions ...Block patient's room due to SAO behavior. Patient [Pt. #7] pulling down pants in front of peers and also making sexual comments to staff. Pt. [Pt. #7] has a hx [history] of SAO." -Pt. #7's Special Precautions Order dated 2/23/19, included, "1:1 [one staff to one patient] ...Acute sexual aggression towards peers, both male and female staff." -Pt. #7's Special Precautions Order dated 2/23/19 at 5:00 PM, included, " ...Block patient's room - 1:1 modified 24/7 [24 hours per day and 7 days per week] for SAO ...Staff can sit by Pt's [Pt. #7] door while Pt. [Pt. #7] is asleep." 3. On 3/14/19, Pt. #8's medical record was reviewed. Pt. #8 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Pt. #8's physician's order, dated 3/7/19, included precautions for suicide/self-harm, assault/ aggressor and blocked room (no roommate) precautions. Pt. #8 was not on 1:1 monitoring but was on every 15 minute monitoring. 4. Pt. #7 (room 410-B) and Pt. #8's (room 404-B) patient observation records, dated 3/9/19 which covered the time period from 3/9/19 at 7:30 AM to 3/10/19 at 7:15 AM, included documentation that Pt. #7 and Pt. #8 were monitored by the same staff on 3/10/19 at 6:15 AM, 6:30 AM, 6:45 AM, 7:00 AM, and 7:15 AM. Pt. #7's 1:1 monitoring was not maintained. 5. On 3/18/19, Pt. #10's medical record was reviewed. Pt. #10 was a [AGE] year old female, admitted on [DATE], with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Pt. #10's physician's order, dated 2/28/19, included suicide and assault/ aggression - aggressor precautions. Pt. #10's physician's order also included blocked room (no roommate). 6. On 3/18/19, an adverse occurrence report dated 3/3/19, for Pt. #7 and Pt. #10 was reviewed. The report included, " ...Peer to peer altercation... Patient [Pt. #7] was with 1:1 during dayroom altercation. Patient [Pt. #10] was also in dayroom as well. I noticed [Pt. #10] beating [Pt. #7] in the head several times violently. Both Pt's. [Pt. #7 and Pt. #10] were physical and staff ran in and broke up the fight. Patient [Pt. #10] stated [Pt. #7] was throwing down gang aff. [affiliation] which is why she [Pt. #10] attacked [Pt. #7] ...[Pt. #10] on AP [assault precautions] with tx [treatment] plan danger to others." 7. On 3/20/19 at 3:01 PM, an interview with the Chief Nursing Officer (E #17) was conducted. E #17 stated that staff cannot conduct patient observation rounds while monitoring a patient on 1:1 observation. 8. On 3/18/19 at 12:23 PM, the 4th floor dayroom videotape footage of 3/3/19 from 9:16:00 PM - 9:17:30 PM was reviewed in the presence of the Chief Nursing Officer (E #17) and the Manager of Plant Operations (E #25) and included the following: -9:16:00 PM - 9:17:17 PM, Pt. #7 was sitting at a table interacting with a peer. Pt. #7's assigned Mental Health Worker (MHW/E #26) was sitting at a different table at the back of the dayroom, out of arm's length of Pt. #7. -9:17:17 PM, Pt. #10 physically assaulted Pt. #7 from behind, beating Pt. #7 in the head. -9:17:19 PM, E #26 (MHW) got up from the table at the back of the dayroom and moved toward Pt. #7 & #10. -9:17:20 PM, E #26 (MHW) separated Pt. #7 and Pt. #10. -9:17:30 PM, Pt. #7 was removed from the dayroom. 9. On 3/18/19 at approximately 11:54 AM, an interview with the Chief Nursing Officer (E #17) was conducted. E #17 stated that the patient should be at arm's length for 1:1 monitoring. B. Based on document review, videotape review, and interview, it was determined that for 11 of 11 patients (Pt. #7, Pt. #8, Pt. #9, Pt. #13, Pt. #14, Pt. #15, Pt. #16, Pt. #17, Pt. #18, Pt. #20, and Pt. #21), the Hospital failed to ensure that every 15 minute patient observations were conducted for patient safety. This failure has the likelihood to result in serious harm or injury to self or others. Findings include: 1. On 3/18/19, the Hospital's policy titled, "Patient Observation Rounds and Precautions" (revised by the hospital on [DATE]), was reviewed. The policy included, "1. Conducting rounds: A. Rounds shall be conducted at a minimum of every 15 minutes...C. During rounds 1) confirm patient's identity 2) observe respirations are normal 3) observe patient is not in distress 4) In addition to above, if patient is asleep or resting: a) approach patient quietly to arm's length proximity b) observe rise and fall of chest c) count at least three respirations d) note if patient has changed position..." 2. On 3/18/19, the Hospital's Adolescent Girls Unit census for 3/12/19 and 3/13/19 was reviewed. The census included 11 patients on 3/12/19 and 12 patients on 3/13/19. During 3 days (3/13/19, 3/14/19 and 3/18/19), the medical records for 11 patients (Pt. #7, Pt. #8, Pt. #9, Pt. #13, Pt. #14, Pt. #15, Pt. #16, Pt. #17, Pt. #18, Pt. #20 and Pt. #21) were reviewed and included the following: -Pt. #7, Pt. #8, Pt. #9, Pt. #13, Pt. #14, Pt. #15, Pt. #16, Pt. #17, Pt. #18, Pt. #20 and Pt. #21 were on every 15 minutes patient observation rounds. The Patient Observation Records, dated 3/12/19 and 3/13/19, for these 11 patients included documentation that every 15 minute patient observations were conducted by staff on 3/13/19 from 7:00 AM to 7:45 AM. -Pt. #7 was a [AGE] year old female, admitted on [DATE] with a diagnosis of disruptive mood dysregulation disorder (is a childhood condition of extreme irritability, anger, and frequent, intense temper outburst) Pt. #7's Special Precautions Order dated 2/23/19 at 5;00 PM, included, Block patient's room - 1:1 (one staff member monitoring one patient) modified 24/7 (24 hours per day and 7 days per week) for SAO (sexually acting out)... Staff can sit by Pt's [Pt. #7] door while Pt. [Pt. #7] is asleep. -Pt. #8 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Pt. #8's physician's order, dated 3/7/19, included precautions for suicide/self-harm, assault/aggressor and blocked room precautions. -Pt. #9 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder. Pt #9's physician's orders, dated 3/9/19, included precautions for suicide/self-harm, sexual aggression - victim precautions. -Pt. #13 was a [AGE] year old female, admitted on [DATE], with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Pt. #13's physician's order, dated 3/12/19, included suicide precautions. -Pt. #14 was a [AGE] year old female, admitted on [DATE] with a diagnosis of disruptive mood dysregulation disorder. Pt. #14's physician's order, dated 3/10/19, included precautions for suicide/self-harm, and assault/aggression - aggressor precautions. -Pt. #15 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder with psychotic features. Pt. #15's physician's order, dated 3/11/19, included suicide/self-harm precautions. -Pt. #16 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of major depressive disorder. Pt. #16's physician's order, dated 3/8/19, included suicide precautions. -Pt. #17 was a [AGE] year old female, admitted on [DATE], with a diagnosis of disruptive mood dysregulation disorder. Pt. #17's physician's order, dated 1/7/19, included precautions for suicide/self-harm and assault/aggression. -Pt. #18 was an [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder. Pt. #18's physician's order, dated 3/11/19, included precautions for suicide/self-harm. -Pt. #20 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder. Pt. #20's physician's order, dated 3/1/19, included, suicide precautions. -Pt. #21 was a [AGE] year old female, admitted on [DATE], with a diagnosis of major depressive disorder. Pt. #21's physician's order, dated 2/28/19, included, suicide/self-harm, assault/aggression, and elopement. 3. On 3/18/19 at approximately 12:35 PM, videotape footage of the Adolescent Girls Unit 4th floor North hall on 3/13/19 from 7:00:16 AM - 7:56:30 AM was reviewed in the presence of the Chief Nursing Officer (E #17) and the Manager of Plant Operations (E #25) and included the following: -7:00:16 AM - 7:56:30 AM, (for 56 minutes) there were no patient observation rounds conducted on the Adolescent Girls Unit; -7:00:16 AM - 7:43:12 AM, (for 43 minutes) Mental Health Worker (E #20) was sitting in the hallway outside of Pt. #7's room door; -7:39:48 AM - 7:43:12 AM, (for over 4 minutes), E #20 was sitting in the hallway with her back facing Pt. #7's room door while talking with another Mental Health Worker (E #4). -7:56:30 AM, E #20 and the Charge Nurse (E #21) conducted patient observation rounds. 4. On 3/13/19 at approximately 3:45 PM, an interview was conducted with a Mental Health Worker (E #4). E #4 stated that patient observation rounds are conducted every 15 minutes. 5. On 3/18/19 at approximately 12:40 PM, an interview with E #17 was conducted. E #17 stated that the patient observation rounds were not conducted every 15 minutes, but they should have been conducted. C. Based on document review and interview, it was determined that for 1 of 5 clinical records reviewed (Pt. #1), the Hospital failed to ensure that patients or their legal representatives gave consent prior to receiving psychotropic medication. Findings include: 1. On 3/18/19 at 3:30 PM, the Hospital's policy titled, "Administration of Medication" (reviewed by the Hospital in 11/2018), was reviewed. The policy required, "III. Administration Procedure... Adults must sign medication consent form for all psychotropic medications before administering." 2. On 3/13/19 at 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of schizophrenia (a mental illness characterized by thoughts or experiences that seem out of touch with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A psychosocial assessment dated [DATE] at 10:41 AM, included, "Patient has legal guardian ..." A "Letters of Office - Plenary [absolute] Guardian of Person of a Disabled Person" document dated 11/20/12, included that Pt. #1's Mother was his Guardian. 3. A "Consent for Medication Form - Scheduled Medications" dated 11/1/18 at 11:30 AM, did not include Topiramate (brand name: Topamax) (treats seizures, prevent migraine headaches, and acts as a mood stabilizer). 4, Pt. #1's physician's orders dated 10/29/18 at 7:41 PM, included Topiramate, 25 mg (milligrams) HS (hour of sleep). The Topiramate order lacked the route of administration. 5. Pt. #1's Medication Administration Records dated 10/30/18 and 10/31/18, included administration of Topiramate (Topamax), 25 mg (milligrams), PO (by mouth), HS (hour of sleep), administered on 10/30/18 and 10/31/18 at 9:00 PM. 6. On 3/18/19 at 9:30 AM, an interview was conducted with the Chief Nursing Officer (E #17). E #17 stated that Pt. #1's physician's orders for Topiramate should have included the route of administration and Pt. #1's psychotropic consent form should have included Topiramate. D. Based on document review and interview, it was determined that for 1 of 1 clinical record reviewed (Pt. #1), for an injured patient placed in restraints, the Hospital failed to ensure that an adverse event report was generated. Findings include: 1. On 3/18/19 at 3:30 PM, the Hospital's policy titled, "Clinical Adverse Events" (reviewed by the Hospital in 11/2018), was reviewed. The policy required, "... A clinical adverse event is any accident, incident, event or circumstance that causes unintended or unexpected injury..." The policy did not provide instructions as to who completes the adverse event report. 2. On 3/13/19 at 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of schizophrenia (a mental illness characterized by thoughts or experiences that seem out of touch with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Pt. #1's "Seclusion and Restraint" note dated 10/29/18 at 8:30 PM, written by a Mental Health Worker (MHW, E #3), included, "Patient was running to the front door to elope [at approximately 7:00 PM], saying he didn't want to be here. Started to pull out the wires/ cords from the lobby door. Patient became a danger to himself. The Patient started to fight with staff when staff removed the wires/ cords from his hand. Code White [a call for help with an aggressive patient] was initiated... Patient became aggressive." 3. On 3/13/19 at 4:35 PM, an interview was conducted with a Mental Health Worker (E #3). E #3 stated that Pt. #1 tried to elope at approximately 7:00 PM. Pt. #1 tried to push open the locked front door. Pt. #1 got his ankle through the locked door and the ankle was "caught" between the 2 exit doors. E #3 called for assistance (Code White) and it took 5 to 7 minutes to release Pt. #1's leg from the door. E #3 stated that Pt. #1 had bruises on his ankle. Pt. #1 was placed in restraints and transported upstairs to the Intensive Treatment Unit (ITU-3) 4. Pt. #1's "Seclusion and Restraint" notes dated 10/29/18 at 8:30 PM, continued, " ...Patient verbalized complaint of body ache upon assessment. Bruises/ redness observed to bilateral upper arms, knees, outer elbow, right leg above the ankle area. Superficial cuts noted to Patient's right palm [hand] area. Writer instructed primary nurse to inform [Medical] Doctor [MD #3]." 5. Pt. #1's "History and Physical Examination," dated 10/30/18 at 8:45 AM, written by a Medical Doctor (MD #3), included, "abnormal findings: ecchymosis (a discoloration of the skin resulting from bleeding underneath) left frontal area ... bilateral elbows inflamed, right arm inflamed, cuts all fingers, left antecubital (something positioned anteriorly {in front} to the elbow) ecchymosis, left auxiliary (armpit) ecchymosis, bilateral knees inflamed ... refer to psych." 6. On 3/13/19 at 11:00 AM, an interview was conducted with Pt. #1's Psychiatrist (MD #2). MD #2 stated that Pt. #1 tried to elope and was restrained. MD #2 stated that Pt. #1 was "paranoid, suspicious, and psychotic ... entitled." Pt. #1 "didn't feel the necessity for treatment," and Pt. #1 "felt [his] violent outbursts were justified." MD #2 did not recall any injury to Pt. #1 and stated that PRN (when needed) medication can cause bruising to the upper arm. 7. On 3/13/19 at 10:15 AM, the Adverse Occurrence Log from 10/29/18 through 3/13/19 was reviewed. There was no adverse occurrence report for Pt. #1. 8. On 3/13/19 at approximately 1:00 PM, the Director of Risk Management (E #2) stated there was no adverse occurrence report made for Pt. #1. 9. On 3/20/19 at 1:15 PM, another interview with E #2 was conducted. E #2 stated that the Nurse Manager told her today (3/20/19) that an incident report was completed but it was not sent to the office. |
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| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 1 staff suspended (E#15) for alleged abuse/misconduct toward a patient (Pt #6) on the Adolescent Boys Behavioral Health Unit, the Hospital failed to ensure that patients were protected, pending investigation of the alleged abuse/misconduct. This failure placed the 8 patients on census on the Adolescent Boys Unit on 3/2/19 potentially at risk for serious harm/abuse. Findings include: 1. The Hospital's policy titled, "Investigatory Leave" (effective 10/29/2018), was reviewed on 3/19/19 at 10:30 AM and required, "...Allegations of abuse neglect, or other serious allegations of employee misconduct or incompetence may result in the need for an employee to be placed on an investigatory leave during the pendency of an investigation..." 2. The clinical record of Pt. #6 was reviewed on 3/18/19 at 11:00 AM. Pt. #6 was a [AGE] year old transgender female, admitted on [DATE] to the Adolescent Boys Behavioral Health Unit, with a diagnosis of major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life, recurrent severe without psychotic features. Pt. #6 was discharged on [DATE]. 3. The Grievance Log from 10/24/18 to 3/12/19 was reviewed on 3/14/19, and indicated that a grievance was filed on 2/26/19 in relation to Pt. #6 and a Mental Health Worker (E#15) and included, "Patients [Pt. #6's] mom complained to the advocate that a male staff member [E#15] was stroking and caressing her daughter's [Pt. #6's] hair/shoulders while she [mom] and her husband were visiting their daughter [Pt. #6] ..." 4. An occurrence report, dated 2/26/19, was reviewed on 3/19/19 at 9:30 AM and included, "...[Pt. #6's] parents reported... that staff [E#15] 'caressed' patient's [Pt. #6] hair in front of parents during visitation on 2/25/19 ... Corrective Actions: ... Staff removed from the schedule pending investigation..." 5. The personnel file of E#15 was reviewed on 3/14/19 and 3/18/19. - A Progressive Discipline Documentation Form, dated 9/11/18, included, "[E#15] saw Director of Business Development walk into New Hire Orientation. He [E#15] saw her legs and then said out loud Hey, Hey because she had nice legs. He [E#15] made an inappropriate comment ..." - A Progressive Discipline Documentation Form, dated 3/8/19, included, "A complaint was received from a child's parents that employee violated therapeutic boundaries ... Employee had one written warning in the past 12 months ... A review of the camera by the Risk Manager and CNO [Chief Nursing Officer] confirmed the violation of therapeutic boundaries ... Due to the nature of the infraction, employee is terminated ..." 6. The staffing assignments for 3/2/19 and E#15's time card from 2/26/19 to 3/10/19, were reviewed on 3/18/19 at 10:00 AM, and indicated that E#15 was assigned to work on the Adolescent Boys Behavioral Health Unit on 3/2/19 and had worked from 6:56 AM to 3:52 PM, even though the investigation was still pending. 7. The Adolescent Boys Unit "Daily Patient Assignment Sheet" and "Assignment Flow Sheet" for 3/2/19, from 7:00 AM to 3:30 PM, was reviewed on 3/21/19 at 1:00 PM and indicated that 8 patients were on census. E#15 was assigned to work with two patients (Pt. #22 and Pt. #29). E#15 was assigned to 1:1 monitoring (one staff member assigned to monitor one patient within arms length at all times) for Pt. #29 from 7:15 AM to 10:00 AM and from 2:15 PM to 3:15 PM. From 11:15 AM to 2:00 PM, E#15 was assigned to "Rounds by Staff" and "Dayroom." E#15 was also assigned to perform the 1st Safety Check of the shift. 8. On 3/21/19, the medical records of the 8 patients (Pt. #22 - #29) on census on 3/2/19 between 7:00 AM and 3:30 PM were reviewed, and included the following: - Pt. #22 was a [AGE] year old male, admitted on [DATE], with diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), suicidal ideations, and attention deficit hyperactivity disorder (ADHD / a chronic condition/disorder that makes it difficult for a person to pay attention and control impulsive behaviors). Pt. #22's Psychiatric Evaluation, dated 3/1/19 at 1:15 PM, indicated that Pt. #22 had a history of physical abuse. A physician's order, dated 2/28/19, included precautions for suicide/self-harm, assault/aggression and elopement. - Pt. #23 was a [AGE] year old male, admitted on [DATE], with diagnoses of major depressive disorder, suicidal ideations, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A physician's order, dated 2/25/19, included precautions for suicide/self-harm. - Pt. #24 was a [AGE] year old male, admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder (a childhood condition of extreme irritability, anger, and frequent, intense temper outburst), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and ADHD. Pt. #24's Psychiatric Evaluation (undated) indicated that Pt. #24 had a history of physical and sexual abuse. Physician orders, dated 2/15/19 and 2/27/19, included blocked room (no roommate) precautions for assault/aggression, age and SAO (sexually acting out). - Pt. #25 was an [AGE] year old male, admitted on [DATE], with diagnoses of major depressive disorder, suicidal ideations, and confirmed child psychological abuse. Pt. #25's Psychiatric Evaluation, dated 3/1/19, indicated that Pt. #25 had a history of childhood abuse. A physician's order, dated 3/1/19, included precautions for suicide/self-harm. - Pt. #26 was a [AGE] year old male, admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder and autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact). Physician orders, dated 2/13/19 and 2/28/19, included modified 1:1 (modified with exception when patient is in the room, staff may stay in hallway) and blocked room precautions for self-injury and aggression. - Pt. #27 was a [AGE] year old male, admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder, suicidal ideations and ADHD. Pt. #27's Psychiatric Evaluation, dated 3/1/19, indicated that Pt. #27 had a history of physical abuse. A physician's order dated, 2/28/19, included precautions for suicide/self-harm, assault/aggression, and elopement. - Pt. #28 was a [AGE] year old male, admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder, unspecified psychosis (a mental disorder characterized by a disconnection from reality) not due to substance or know physiological condition, and homicidal ideations. A physician's order, dated 2/27/19, included precautions for assault/aggression. - Pt. #29 was a [AGE] year old male, admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Physician orders, dated 2/26/19 and 2/28/19, included precautions for assault/aggression, blocked room for SAO, and modified 1:1 from 7:00 AM to 11:00 PM while patient is in room (sitter at arms length when in common areas). 9. An interview was conducted with the Chief Executive Officer (E#1) on 3/18/19 at approximately 12:37 PM. E#1 stated that there was some miscommunication between scheduling and nursing staff that resulted in E#15 working a shift while suspended. E#1 stated that nursing staff noted that E#15 was "unable to work"; however, nursing staff were not aware that E#15 was suspended and was not supposed to return to work. E#1 stated that changes to the "Investigatory Leave" policy have been made to address the miscommunication. 10. An interview was conducted with the Staffing Coordinator (E#22) on 3/19/19 at 9:35 AM, with the Chief Nursing Officer (E#17) present. E#22 stated that when she is notified by Administration that an employee is suspended pending investigation, she (E #22) will just cross the employee's name out on the schedule. E#22 stated that she will not write down that the employee was suspended for the employee's privacy. E#22 stated that she is the only Staff Coordinator for both buildings (Adult and Children). E#22 stated that she was not aware of any changes made to policies or procedures regarding employees on suspension pending investigation. 11. An interview was conducted with the Chief Nursing Officer (E#17) on 3/19/19 at 9:50 AM. E#17 stated that the Staffing Coordinator (E#22) had not yet been educated on the changes to the "Investigatory Leave" policy. 12. An interview was conducted with the Director of Risk Management (E#2) and the Chief Executive Officer In-Training (E#1) on 3/21/19 at 1:04 PM. E#2 stated that the original (1st) investigation was completed on 3/2/19 after E#2 found E#15 working on the Adolescent Boys Unit. E#2 stated after interviewing E#15 on 3/2/19 at approximately 3:30 PM, it was concluded that E#2 did violate therapeutic boundaries. Both E#2 and E#1 stated that E#15 was on suspension from 2/26/19 until he was terminated on 3/8/19, and should not have worked during this time period. E#2 stated that E#15 did have a previous infraction upon new hire orientation, when he made an inappropriate comment to an Administrator and that this was "part of the decision to terminate" E#15. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0160 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 2 (Pt. #3) clinical records reviewed of behavioral (violent) patients requiring restraint, the Hospital failed to complete the "Notice Regarding Restriction of Rights" document, to ensure appropriate use of restraints as required. Findings include: 1. The Hospital's Policy titled, "Aggression Management Code Yellow / Code White" (revised 11/2016), was reviewed on 3/13/19 at 12:50 PM and required, " ... 'Code White' - will be utilized in the event that a patient is at imminent risk of causing harm to themselves or others... PRN [as needed] medication, if ordered, is administered to the patient. If the patient refuses medication and poses a risk to self or others, medication is administered, the behavior is documented, and a restriction of rights is completed according to policy. If medication has not been ordered, the Physician is notified to assess if a Stat [immediate] or PRN emergency medication is indicated..." 2. The clinical record of Pt. #3 was reviewed on 3/13/19 at 10:00 AM. Pt. #3 was a [AGE] year old male, admitted on [DATE], with diagnoses of opiate/opioid (drug derived from opium, medically used for pain relief) use disorder (a problematic pattern of opioid use that causes significant impairment or distress), sedative/hypnotic use disorder (a condition characterized by the harmful consequences of repeated use of sedative-like drugs, a pattern of compulsive use of sedative-like drugs, and sometimes physiological dependence on sedative-like drugs with tolerance and/or withdrawal) with benzodiazepines (class of drugs primarily used for treating anxiety), and bipolar disorder depressed (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). - A physician's order, dated 11/30/18 at 12:25 AM, included, 50 mg [milligrams] Benadryl [a medication to treat allergy symptoms that can be used to induce sleep] IM [intramuscularly] x 1 [once] Now [STAT] and 50 mg Thorazine [a medication used to treat certain mental/mood disorders such as bipolar disorder that may cause drowsiness] IM x 1 Now for agitation. - The Medication Administration Record indicated that 50 mg Benadryl and 50 mg Thorazine were given on 11/30/18 at 12:40 AM. - The Initial Psychiatric Assessment or Admission Evaluation, dated 11/30/18 at 10:45 AM, included, "The patient [Pt. #3] ... did experience a blackout becoming physically and verbally aggressive. The patient does not remember the events. He only remember[s] that he was restrained by hospital staff and given IM [intramuscular] p.r.n. [as needed] [medications], which had to be done because per staff documentation the patient continued to be aggressive despite attempts to redirect ... His memory for the events over the past 12 hours is somewhat impaired given his inability to recall the incident last night that resulted in his being physically and chemically restrained ..." - A Restriction of Rights form, dated 11/30/18 at 12:10 AM, included, "Pt [patient] was physically aggressive towards staff. He rushed into the hallway stating he wants to kill himself. Pt was placed on a physical hold for safety." The box labeled, "administered emergency medication," was not marked and the form lacked documentation that emergency medications (Benadryl and Thorazine) were administered. 3. The Seclusion and Restraint Staff Debriefing Report for Pt. #3's incident on 11/30/18, indicated that the code began at approximately 12:10 AM and included, "...Code was called to de-escalate the patient and prevent him from hurting himself. [Medical Doctor] called for Benadryl and Thorazine order." 4. An interview was conducted with the Director of Nursing (E#17) on 3/19/19 at 9:07 AM and again at 9:40 AM. At 9:07 AM, E#17 stated that she verified there was only one Restriction of Rights form for Pt. #3. At 9:40 AM, E#17 stated that if emergency medications are given against a patient's will, the details should be documented on the Restriction of Rights form. E#17 reviewed Pt. #3's Restriction of Rights form and verified that there was no documentation that emergency medications were given. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0171 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 1 clinical record reviewed (Pt. #1), for a patient placed in restraints, the Hospital failed to ensure that the physician's orders included the time restriction for restraints. Findings include: 1. On 3/18/19 at 3:40 PM, the Hospital's policy titled, "Use of Restraint and Seclusion," (reviewed by the Hospital in 11/2018), was reviewed. The policy required, "I. Procedure... C. 'Restraint/ Seclusion Order Sheet' shall contain the following... d. length of time for the restraints..." 2. On 3/13/19 at 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of schizophrenia (a mental illness characterized by thoughts or experiences that seem out of touch with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Pt. #1's "Seclusion and Restraint" note dated 10/29/18 at 8:30 PM, included, "Patient was running to the front door to elope [at approximately 7:00 PM], saying he didn't want to be here. Started to pull out the wires/ cords from the lobby door. Patient became a danger to himself. The Patient started to fight with staff... Code White [a call for help with an aggressive patient] was initiated..." 3. Pt. #1's physician's order dated 10/29/18 at 7:41 PM, included, "Place Patient in restraints for danger to self/ others, extreme agitation ..." The length of time for the restraint was not included. 4. On 3/18/19 at 9:30 AM, an interview was conducted with the Director of Nursing (E #17). E #17 stated that Pt. #1's restraint order should include the length of time restraints can be applied. |
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