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 Nov. 21, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation and interview, it was determined that the Hospital failed to protect the patient rights for 1 of 1 (Pt. #1) patient who attempted suicide, by failing to obtain and implement an order for safety precautions when a patient informed the staff of suicidal ideation, thus putting any current or future patients who voice a desire to self-harm at a serious risk for self-harm; and for 1 of 1 psychiatric patient (Pt. #3) waiting for an intake assessment right, to ensure the patient was protected from alleged sexual abuse by another patient (Pt. #2) with high risk for sexually acting out behaviors

As a result, it was determined that the Condition of Participation for Patient Rights, CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to obtain and implement an order for safety precautions when a patient (Pt. #1) informed the staff of suicidal ideation. See deficiency at A-144 A.

2. The Hospital failed to ensure a patient was protected from alleged sexual abuse by another patient (Pt. #2) with high risk for sexually acting out behaviors. See deficiency at A-144B.

The immediate jeopardy began on 10/4/19, due to the Hospital's failure to monitor a patient with known SAO (sexually acting out) behaviors, allowing a patient to be kissed; and for the Hospital's failure to obtain and implement an order for safety precautions, when a patient informed the staff of suicidal ideation, allowing a patient to attempt suicide.

The IJ was identified on 11/20/19 and was announced on 11/20/19 at 1:30 PM, during a meeting, with the Chief Executive Officer, the Chief Nursing Officer, the Risk/Performance Improvement Officer, the Chief Financial Officer and the Chief Medical Officer. The IJ was not removed by the survey exit date of 11/21/19.
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 and interview, it was determined that for 1 of 1 (Pt. #1) patient who attempted suicide, the Hospital failed to provide care in a safe setting, and to obtain and implement an order for safety precautions when a patient informed the staff of suicidal ideation. This potentially places all current and future patients who voice suicidal ideation (desire to kill self) at risk for self harm.

Findings include:

1. The Hospital's policy titled, "Patient Observation Rounds and Precautions (revised 5/30/19) was reviewed on 11/19/19 and required, "Special Observation - Any indication of suicidal intent ... Shall be immediately evaluated by a Registered Nurse and action shall be taken immediately to ensure the safety of the individual ... A physician's order must be obtained as soon as possible ... One to one (1:1) [continuous observation by staff member] - This level of observation is the most intense level and utilized when a patient is in imminent threat to self ..."

2. The clinical record of Pt. #1 was reviewed on 11/19/19. Pt. #1 was admitted on [DATE] to the GAU (General Adult Unit) with a diagnosis of ETOH (alcohol) Detox (rid the body of poisons). The Intake Assessment, dated 11/5/19 at 5:30 PM, included a suicide risk assessment score of a zero (low risk). Pt. #1's admitting orders included, "Detox precautions" (monitoring every 15 minutes).

-The Charge Nurse (E#9) on the GAU, who was on duty 11/6/19 (day of attempted suicide of Pt. #1), was interviewed on 11/19/19 at 1:00 PM. E#9 stated that E#9 had gone into Pt. #1's room because the patient did not want to come to breakfast and was agitated. E#9 stated, "I gave [Pt. #1] an Ativan [sedative], because her blood pressure was high, with her other morning medications [per the medication administration record - given at 9:30 AM]. [Pt. #1] did not want to get up and stated, 'wanted to hurt self'. I left [Pt. #1's] room to go about my business caring for my assigned patients.

- A nurse's note dated 11/6/19 at 12:25 PM included, "Patient found in room by MD and medical student at 12:09 PM with a sheet wrapped around neck. Pt. was unresponsive initially ... code blue [emergency announced when a patient requires emergency treatment for heart or breathing problems] was called, staff responded. Pt. was able to talk to staff ... Dr. gave orders to transfer patient [to another hospital] for evaluation ... Patient transferred off unit at 12:25 PM."

- The Code Blue Record, dated 11/6/19, included that the code was called at 12:10 PM. The patient was alert and responsive when code team arrived. The time that the RN and MD arrived were left blank on the "Code Blue Record." Pt. #1 was transferred to another hospital at 12:20 PM.

- A physician's progress note, dated 11/6/19, included, "Strangulation without injury. Cleared at ER [emergency room ]. Will monitor clinically."

- A physician's order dated 11/6/19 at 5:00 PM [after Pt. #1's return to the hospital], included, "1:1 continuous monitoring Transfer to ITU4 [intensive treatment unit- higher acuity unit]."
The re-assessment suicide risk score dated 11/6/19 at 5:00 PM included a score of 21 (high suicide risk), which included yes answers to the questions since last contact, "wish to be dead; current suicidal thoughts; suicidal thoughts w[with]/methods; suicidal intent without specific plan; intent with plan; Have you ever done anything, started to do anything, or prepared to do anything to end your life?...Explain: Pt was found in her room trying to strangle herself with a sheet...Risk Stratification High Suicide Risk Suicidal Ideation WITH intent or intent WITH plan since last contact...Suicide Risk Stratification-High." Pt. #1 remains an inpatient at the hospital, as of 11/21/19, and 1:1 precaution remains in place.

- A physician's progress note, dated 11/7/19 at 6:30 AM, included, "Patient tried to commit suicide yesterday. She strangled herself with the bed sheet. Patient passed out and woke up by nursing staff. Sent to ER of [another hospital]."

3. On 11/18/19, an investigative report (dated 11/6/19) was reviewed. The investigation concluded that, "The charge Nurse (E#9) should not have sent the patient back to her room without supervision after she made the report of self-harm." There was no evidence that the Hospital monitored for staff compliance indicated in the investigative summary report.

4. The Charge Nurse (E#9) on the GAU, who was on duty 11/6/19 (day of attempted suicide of Pt. #1), was interviewed on 11/19/19 at 1:00 PM. E#9 stated that there were 2 nurses on duty on 11/6/19. E#9 had 10 patients and an agency nurse had 13 patients. The agency nurse was assigned to Pt. #1. E#9 stated that E#9 had gone into Pt. #1's room because the patient did not want to come to breakfast and was agitated. E#9 stated, "I gave [Pt. #1] an Atvian [sedative], because her blood pressure was high, with her other morning medications [per the medication administration record - given at 9:30 AM]. [Pt. #1] did not want to get up and stated, 'wanted to hurt self'. I told [Pt. #1] to rest, to reduce stimuli. I left [Pt. #1's] room to go about my business caring for my assigned patients. I thought [Pt. #1] was already on suicide precautions. I was going to call the doctor with an update, but when I was calling, the doctor had found [Pt. #1] in her room with a sheet around the neck". E#9 stated, "It could have been several hours from the time I talked to [Pt. #1] and trying to call the doctor, but all of our patients are monitored every 15 minutes." E#9 stated that patient precautions are identified by a sticker on the chart, on the monitoring flow sheet and during daily report. E#9 does not remember why she thought that Pt. #1 was already on suicide precautions. E#9 stated that she had been inserviced about suicide precautions policies earlier, in the spring of this year [2019]. E#9 did not recall receiving any recent training or receiving a memo about suicide assessments, though E#9's signature was on the sign in sheet. E#9 stated, "I should not have left [Pt. #1] unsupervised once she voiced wanting to self-harm."

5. Pt. #1's Attending Psychiatrist (MD#1) was interviewed on 11/19/19 at 12:45 PM. MD#1 stated that he was not Pt. #1's psychiatrist at the time of the suicide attempt; but, was present on the unit at the time of the incident. MD#1 stated, "I heard a commotion down the hall a little after 12:00 PM, and when I got to the room, I saw a patient in distress. I asked for a code blue and 911 to be called." MD#1 stated that the patient was transferred in stable condition. MD#1 stated, "As the CMO (Chief Medical Officer), I had a debriefing with the psychiatrist, who was making rounds, and [with] staff after this event. It was decided to send out a memo to the staff, to address the suicide assessment requirements, as an opportunity to educate the staff."

6. The CEO (Chief Executive Officer - E#11) was interviewed on 11/19/19 at approximately 1:45 PM. E#11 stated that E#9 had not been presented with the Corrective Action because corporate approval was required. E#11 stated the Corrective Action was signed by the Charge RN today (after the above interview with E#9). E#11 stated, "After the suicide attempt, all staff were sent a memo on 11/6/19 about suicide assessment and re-assessment."

7. The CNO (Chief Nursing Officer - E#12) was interviewed on 11/20/19 at 10:30 AM. E#12 stated that the only unit staff that had signed verification of receiving the memo was the GAU unit staff (1 of 7 units). Staff are randomly asked about policy requirements. There is no way to verify that all nursing staff read the memo and understood the expectations of the policy reminder. There was no evidence that staff implemented any of the education that was provided.





B. Based on document review and interview, it was determined that for 1 of 1 psychiatric patient (Pt. #3) waiting for an intake assessment, the Hospital failed to provide care in a safe setting, to ensure the patient was protected from alleged sexual abuse by another patient (Pt. #2) with a high risk for sexually acting out behaviors.

Findings include:

1. On 11/20/19, the Hospital's policy titled, "Patient Rights and Responsibilities," (revised 4/2019), was reviewed. The policy required, "C. The Patient's Bill or Rights shall include... 3. Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse..."

2. On 11/20/19, the Hospital's policy titled, "Patient Observation Rounds and Precautions," (revised 5/30/19), was reviewed. The policy required, "B. Special Observation - Any indication of potential sexually acting out ... Shall be immediately evaluated by a Registered Nurse and action shall be taken immediately to ensure the safety of the individual ... A physician's order must be obtained as soon as possible ... One to one (1:1) [continuous observation by staff member] - This level of observation is the most intense level and utilized when a patient is in imminent threat to self ... E. Precaution Levels... e. Sexual Acting Out [SAO] (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. Patient is placed on SAO precautions per MD [Medical Doctor] order..."

3. On 11/19/19, Pt. #2's clinical record was reviewed. Pt. #2 arrived at the hospital on [DATE] at 5:50 PM, with a diagnosis of schizophrenia (bipolar type) (schizophrenia - a mental disorder involving the breakdown in the relation between thought, emotion, and behavior, leading into fantasy and delusion, and a sense of mental fragmentation; bipolar - excited and depressive mood swings). Pt. #2's initial Intake Assessment on 10/4/19 at 5:50 PM, included that Pt. #2 was using "PCP (Phencyclidine - mind altering drug), marijuana, and ETOH (ethyl alcohol). Pt. #2 was hearing voices telling Pt. #2, "to kill people who hurt kids."

- Pt. #2's complete Intake Assessment on 10/4/19 at 6:50 PM, included a "sexual acting out risk screen" score of 15 from increase in sexual thoughts (5 points), manic state (5 points), and sexually explicit speech (5 points). The Intake Assessment included that a score of 15 was "high risk" and provided a directive to follow, "RN to consult MD for SAO precaution ..." There was no documentation, in the clinical record, that a Physician was notified that Pt. #2 was a high risk for sexually acting out, and no SAO precautions were ordered / initiated.

4. On 11/19/19, Pt. #3's clinical record was reviewed. Pt. #3 arrived at the hospital on [DATE] at 8:11 PM, with the diagnoses of major depressive disorder (a mental health disorder characterized by persistent depressed mood or loss of interest in activities) and suicidal ideation (desire to kill self).

5. On 11/19/19, a video recording that recorded coverage of the corridor in the Intake Area on 10/4/19 from 7:55 PM to 8:30 PM, was reviewed. The video included visualization of the intake area entrance door, 3 of 3 holding rooms doors, and the Intake office door. The video did not include visualization of the inside of the holding rooms. The video was reviewed with the Director of Risk and Performance Improvement (E #13).

- The video footage included Pt. #3 arriving in the Intake Area on 10/4/19 at 8:11:05 PM and being escorted into a holding room by a Mental Health Worker (E #14). E #14 was the only staff member observed on the video conducting monitoring duties in the Intake Area. Pt. #2 had arrived in the Intake Area earlier and was assigned to another holding room, near Pt. #3's holding room.

- E #14 left the Intake area unattended on several occasions for short periods of time, the longest being from 8:20:15 PM, until 8:25:25 PM, for over 5 minutes . During this time, Pt. #2 entered and exited Pt. #3's holding room 3 times including:

-- Pt. #2 entered Pt. #3's holding room at 8:20:40 PM, and exited at 8:20:50 PM, 10 seconds later.

-- Pt. #2 again entered Pt. #3's holding room at 8:20:55 PM, and exited at 8:21:00 PM, 5 seconds later.

-- Pt. #2 entered Pt. #3's holding room a third time at 8:24:00 PM, and Pt. #3 (not Pt. #2) exited the holding room at 8:24:50 PM, 50 seconds later. Pt. #3 walked to the Intake Office door approximately 5 feet across the hall and knocked on the Intake Office door.

- At 8:25:00 PM, Pt. #2 exited Pt. #3's holding room and returned to Pt. #2's holding room.

- At 8:25:15 PM, E #14 returned to the Intake Area, and escorted Pt. #3 outside of the Intake Area at 8:25:25 PM.

- E #14 had not been in the Intake Area, for more than 5 minutes from 8:20:15 PM to 8:25:25 PM which created an opportunity for Pt. #2 to allegedly abuse Pt #3. E#14 was observed walking over to the Intake Office at 8:20:15 PM. There were no other staff in the Intake Area to monitor Pt's. #2 & #3 during that time.

6. Pt. #3's progress note, dated 10/4/19 at 9:00 PM, included, "Patient reported that there was an incident in intake that involved another patient. Patient stated that 'I was kissed on the neck by another patient while waiting in my room to be transferred to the Unit.'"

7. On 11/20/19, an investigative report (initiated on 10/4/19 and completed on 10/7/19) was reviewed. The investigation concluded that E #14 should not have left the 2 patients unsupervised in the Intake Area. There was no evidence that the Hospital monitored for staff compliance indicated in the investigative summary report.

8. On 11/20/19 at 11:25 AM, a phone interview was conducted with the Nursing Supervisor (E #16), who was on duty on 10/4/19, when the alleged sexual abuse occurred. E #16 stated that Pt. #3's mother phoned the Intake Office to inform E #16 of the incident. E #16, the Night Nursing Supervisor, and an Intake Clinician met with Pt. #3 in the Triage Room. Pt. #3 was crying and told them that another patient (Pt. #2) came into her room and rubbed her head and kissed her.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 1 alleged sexual abuse incident (Pt. #3 on 10/4/19) in the Intake Area, the Hospital failed to fully implement preventative actions and mechanisms that include feedback and learning.

Findings include:

1. On 11/20/19, the Hospital's "Performance Improvement Plan," (revised 4/2019), was reviewed. The plan required, "V. Methodology: A. The Plan, Do, Check, Act (PDCA) methodology is utilized to plan, design, measure, assess and improve functions and processes related to patient care and safety throughout the organization. 1. Plan... d. Performance measures for processes that are known to jeopardize the safety of patients... will be monitored... which may include... 8. SAO [sexually acting out] incidents... 4. Act: a. Take actions to correct identified problem areas... b. Evaluate the effectiveness of the actions taken and document the improvement in care. c. Communicate the results of the monitoring..."

2. On 11/20/19, the Hospital's policy titled, "Incident Reports (revised 5/2019) was reviewed and required, "Incident: Defined as an unusual event involving a patient ... The event is considered unusual if it was unintended, undesirable or unexpected. ... The CMO (Chief Medical Officer) will conduct a clinical review... After review, the Performance Improvement Committee will make recommendations for changes/follow up ... The Committee will then ensure that all recommendations are implemented."

3. On 11/19/19, Pt. #3's clinical record was reviewed. Pt. #3 arrived at the hospital on [DATE] at 8:11 PM, with the diagnoses of major depressive disorder (a mental health disorder characterized by persistent depressed mood or loss of interest in activities) and suicidal ideation (desire to kill self).

4. Pt. #3's progress note dated 10/4/19 at 9:00 PM, included, "Patient reported that there was an incident in intake that involved another patient (Pt. #2). Patient stated that 'I was kissed on the neck by another patient while waiting in my room to be transferred to the Unit.'"

5. On 11/19/19, Pt. #2's clinical record was reviewed. Pt. #2 arrived at the hospital on [DATE] at 5:50 PM, with a diagnosis of schizophrenia (mental disorder involving the breakdown in relation between thought, emotion, and behavior, leading into fantasy and delusion, an a sense of mental fragmentation). Pt. #2's Intake Assessment on 11/4/19 at 6:50 PM, included a "sexual acting out risk screen" score of 15 from increase in sexual thoughts (5 points), manic state (5 points) and sexually explicit speech (5 points). There was no documentation, in the clinical record, that a Physician was notified that Pt. #2 was a high risk for sexually, and no SAO (sexually acting out) precautions were ordered/initiated.

6. On 11/20/19, an investigative summary report, dated 10/7/19, was reviewed. The investigation revealed that a Mental Health Worker (E #14) left Pt. #3 alone in the Intake Area unmonitored with another patient for more than 5 minutes. The corrective actions that were indicated in the summary report included terminating E #14 and the sending of a memo to Intake Staff reminding the staff to monitor the area, never leave a patient unattended, and if an incident does take place - notify the Intake Supervisor Immediately. There was no evidence that the Hospital monitored for staff compliance indicated in the investigative summary report.

7. On 11/20/19 at 8:45 AM, an interview was conducted with the Director of Risk Management and Performance Improvement (E #13). E #13 stated that no monitoring of staff performance "that she knows of" has been implemented since the 10/4/19 incident.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for 1 of 8 patients (Pt #6) reviewed for treatment plans, the Hospital failed to keep a current, interdisciplinary nursing care plan.

Findings include:

1. On 11/18/19, the Hospital's policy titled "Multidisciplinary Treatment Plan" (revised 8/18) was reviewed and required "...Multidisciplinary Staffing Updates...A three day staffing review and weekly staffing will be conducted and staff will document patients' perception of their progress/movement towards meeting their goal for treatment will be documented in the patient's progress notes section of the medical record..."

2. On 11/18/19, Pt #6's clinical record was reviewed. Pt #6 was admitted on [DATE] with the diagnosis of major depressive disorder, recurrent severe without psychotic features. Pt #1's treatment plan, dated 11/8/19, listed Pt #6's problem as "danger to self.'' Pt #6's clinical record did not include any updated treatment plans.

3. On 11/18/19 at approximately 11:00 AM, an interview was conducted with the Interim Director of Clinical Services (E #1). E #1 stated that treatment plans should be updated weekly.





B. Based on document review and interview, it was determined that for 2 of 5 (Pt #4 and Pt #5) clinical records reviewed for treatment plans, it was determined that the Hospital failed to ensure that the multidisciplinary treatment plans were reviewed by the multidisciplinary team, as required per policy.

Findings include:

1. The Hospital's policy titled, "Multidisciplinary Treatment Plan" (reviewed by the hospital 08/2018) was reviewed on 11/18/19 and required, "... The Treatment/Discharge plan is reviewed by the multidisciplinary team including community case managers, family/guardians... Evidence of involvement in the Treatment/Discharge Plan will be documented by signing the Treatment/Discharge plan or by indicating involvement via phone participation... Multidisciplinary Staffing Updates:... weekly staffing will be conducted and staff will document patients' perception of their progress/movement towars weeting their goal for treatment... All parties will be informed of changes made to the treatment/discharge plan as evidenced by signatures or phone participation..."

2. The clinical record for Pt #5 was reviewed on 11/18/19. Pt #5 was admitted on [DATE] with a diagnosis of disruptive mood dysregulation disorder (mental disorder in children and adolescents characterized by a persistently irritable or angry mood). Pt #5's Master Treatment Plan Reviews (multidisciplinary treatment plan weekly reviews/updates), dated 11/8/19 and 11/15/19 lacked Physician's and Registered Nurse's (RN) signatures, to indicate that they were involved in the review of the Master Treatment Plan.

3. The clinical record for Pt #4 was reviewed on 11/18/19. Pt #4 was admitted on [DATE] with a diagnosis of major depressive disorder (mental disorder that causes a persistent feeling of sadness). Pt #4's Master Treatment Plan, dated 11/10/19, lacked the Physician's signature, to indicate that the Physician was involved in the development of the Master Treatment Plan.

4. On 11/18/19 at approximately 11:55 AM, an interview was conducted with the Nurse Manager of the Children's Pavilion (E #2). E #2 stated that if the RN is not present for the weekly staffing (meeting to review the treatment plan), then the RN should sign the treatment plan when they have reviewed it. E #2 stated that sometimes the physician attends the meeting over the telephone. E #2 stated that if the physician attends the meeting over the phone, then this should be documented on the treatment plan, and the physician should sign the form the next time he/she is at the Hospital.