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 14, 2021
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 for 1 of 1 (Pt. #1) clinical record reviewed for allegation of physical abuse, the Hospital failed to report the allegation of abuse in accordance with the IDPH (Illinois Department of Public Health) regulations, to ensure patient was free from all forms of abuse or harassment.

Findings include:

1. Per TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIESPART 250 HOSPITAL LICENSING REQUIREMENTS ... Section 250.260 Patients' Rights ... c) Patient Protection from Abuse ... 3) Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this subsection (c)... 5) Upon receiving a report under subsection (c)(3), the hospital shall submit the report to the Department within 24 hours after obtaining such report..."

2. On 4/13/2021, the Hospital's document titled, "Managing Allegations of Abuse" (undated) was reviewed and included, " ... Reports of Abuse can be received from a Variety of Sources ... 1. Abuse report is received - Immediately referred to Risk Management ... 5. Allegation Credible ... Reporting Duty: IDPH (Illinois Department of Public Health) ..." The document indicated that only "Credible" allegation of abuse is reported to IDPH.

3. On 4/13/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital's ED (emergency department) on 1/13/2021 with a diagnosis of bipolar disorder, current episode manic severe with psychotic features. Pt. #1 was discharged from the hospital on [DATE].

4. On 4/13/2021, the Hospital's Letter to E #8 (Deputy Litigation Counsel/Director of Risk Department) dated 2/15/2021 was reviewed and included, " ... On 1/27/2021 ... received a 1/24/2021 email from (Pt. #1) ... (Pt. #1) alleges that he was mistreated in the ED and that he was 'physically harmed, drugged against (his) will and was forced to sign papers ..." The letter included an analysis of the investigation made regarding the allegation of abuse. However, the allegation of abuse was not reported to IDPH.

5. On 4/13/2021 at approximately 12:15 PM, an interview was conduced with E #8 (Director of Risk Management). E #8 stated that Pt. #1's allegation of abuse was not reported to IDPH. E #8 said that only credible allegation of abuse are reported to IDPH.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed regarding use of violent restraints, the Hospital failed to discontinue the restraints at the earliest possible time.

Findings include:

1. On 4/13/2021, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital's ED (emergency department) on 1/13/2021 with a diagnosis of bipolar disorder, current episode manic severe with psychotic features (mental disorder). The Physician's order dated 01/13/2021, included four-point restraints for 4 hours. The clinical record indicated that Pt. #1 was placed on four-point restraint (a violent/self-destructive behavioral restraint) due to aggressive behavior on 01/13/2021 from 9:53 AM through 12:30 PM. However, the monitoring sheet indicated that Pt. #1 was quiet and sleeping from 11:00 AM to 12:30 PM (one hour and 30 minutes).

2. On 4/13/2021, the Hospital's policy tiled, "Restraint and/or Seclusion Use and Indications in the Acute Care Setting" (revised 9/2020) was reviewed and included, "... Policy... 9. Restraint use is minimized and removed at the earliest possible time when the patient's behavior assessment determines the need for restraint... is no longer needed... C. Violent/Self-Destructive Behavioral Restraint... 9. Patients are released from violent/self-destructive behavioral restraint when the criteria to discontinue restraints are achieved. Examples of this criteria are: a. patient is no longer violent... b. patient is calm..."

3. On 4/13/2021 at approximately 12:30 PM, findings were discussed with E #10 (Nurse Educator, ED). E #10 stated that the restraint for Pt. #1 should have been discontinued sooner than 12:30 PM because Pt. #1 was quiet and not exhibiting violent behavior.