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.

NORTHWEST COMMUNITY HOSPITAL 1 800 W CENTRAL ROAD ARLINGTON HEIGHTS, IL 60005 April 15, 2021
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 3 (Pt. #12) clinical records reviewed for non-violent restraints, the Hospital failed to ensure the restraints order was renewed as required by Hospital policy.

Findings include:

1. The Hospital's policy titled, "Restraints and/or Seclusion Use and Indications in the Acute Care Setting" dated 09/14/2020, was reviewed and included, "...11..If restraint or seclusion needs to continue beyond the expiration of the time ...obtain a new order from the licensed independent practitioner ...6. ...Nonviolent/Non self-destructive restraint orders are renewed daily... by a physician..."

2. On 04/14/2021 at approximately 1:00 PM, the clinical record of Pt. #12 was reviewed. Pt. #12 was admitted on [DATE] with a diagnosis of Cerebral Vascular Accident (CVA/Stroke). Pt. #12's clinical record included a physician's order dated 01/16/2021 at 5:10 PM, for soft wrist restraints to both left and right wrists. Pt. #12 was placed in restraints from 01/16/2021 at 5:10 PM through 01/18/2021 at 12:06 AM. The physician's order for restraints expired on [DATE] at 5:10 PM.

3. Pt. #12's clinical record lacked the documentation indicating the renewal of the patient restraints on 01/17/2021 at 5:10 PM. The total time lapsed while Pt. #12 remained on restraints without a physician's order was approximately seven (7) hours.

4. On 04/14/2021 at approximately 2:00 PM, the Clinical Practice Specialist (E #14) was interviewed. E #14 stated that, the physician's order for restraints should be renewed daily every 24 hours. The primary nurse failed to renew the restraints orders for Pt. #12. E #14 continued that there was no documentation indicating the order was renewed.