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.

INGALLS MEMORIAL HOSPITAL 1 INGALLS DRIVE HARVEY, IL 60426 April 9, 2021
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**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 #11) clinical records reviewed for restraints, the Hospital failed to ensure that trained staff monitored a restrained patient, as required.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion" (dated 1/18/2021), was reviewed on 4/8/2021, and required, "Non-violent restraints: Nursing assessment and documentation must occur at least every 2 hours or sooner according to the patient's condition in the patient's medical record under the medical surgical restraint flowsheet..."

2. The clinical record for Pt #11 was reviewed on 4/8/2021. Pt #11 was admitted on [DATE], with a diagnosis of AMS (altered mental status). Pt #11's physician's order dated 04/06/2021 at 10:00 PM, included, "Assess restraint medical surgical soft extremity: Upper right (3 limbs only). Soft extremity: Upper left [non-violent restraints]. Every 2 hours for 1 day."

- Pt #11's restraint assessments from 4/6/2021-4/8/2021, were reviewed. The restraint documentation on 4/7/2021 included restraint assessments on 4/7/2021 at 6:00 AM and then subsequent documentation on 4/7/2021 at 8:00 PM (14 hours time lapse). The clinical record lacked the required every 2 hour restraint assessments.

3. On 4/8/2021 at 3:30 PM, an interview was conducted with the East 4 Assistant Unit Director (E #2). E #2 stated that when a patient is in non-violent restraints, restraint documentation is required every 2 hours. E #2 stated that if there was a time when the restraint was taken off or discontinued, the nurse should document that it was.