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.
| ROSELAND COMMUNITY HOSPITAL | 45 W 111TH STREET CHICAGO, IL 60628 | Sept. 3, 2021 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on document review, video surveillance review, and interview, it was determined that the Hospital failed to ensure that patient's rights were protected. This potentially affect current and future patients admitted to the Hospital's psychiatric unit 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 provide care in the safe setting by failing to adequately monitor patients in the Behavioral Health Unit (BHU). See deficiency cited at A-144 A. 2. The Hospital failed to ensure that the physician's order for safety precautions was followed. See deficiency cited at A-144 B. The immediate jeopardy began on 6/24/2021, due to the Hospital's failure to provide care in the safe setting by failing to implement adequate measures to monitor patients in the BHU. This could potentially affect the safety of all psychiatric patients receiving care in the BHU. The IJ was identified and announced on 9/3/2021 at 4:15 PM, during a meeting with the Chief Executive Officer, Chief Nursing Officer, Director of Operations, and Interim Director of Quality. The IJ was cited at 42 CFR 482.13, Patient Rights, and was not removed by the survey exit date of 9/3/2021. |
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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, video surveillance review, and interview, it was determined that for 1 of 5 unusual occurrences reviewed, the Hospital failed to provide care in the safe setting by failing to adequately monitor patients in the Behavioral Health Unit (BHU). This could potentially affect the safety of all psychiatric patients receiving care in the BHU. Findings include: 1. On 9/1/2021, the Hospital's policy titled, "Patient Rights/Grievance Process" (revised 7/2020) was reviewed and included, " ... The patient has the right to receive care in a safe setting ... The (Name of the Hospital) staff should follow current standards of practice for environmental safety ... and security. The hospital must protect vulnerable patients ... Additionally, this standard is intended to provide protection for the patient's emotional health and safety as well as his/her physical safety ..." 2. On 9/01/2021 at approximately 2:10 PM, the Hospital's video surveillance footage from 6/24/2021, was reviewed with E #3 (Director of BHU) and E #8 (Assistant Director of Facilities). The video footage on 6/24/2021 showed: At 12:54:26 PM, the inside view of the BHU's day room was seen with an unidentified staff sitting outside the dayroom door. From the door, the staff could not visualize patients at the back of the room. Inside the day room, two males were sitting by the entrance of the day room, facing the television at the front of the room. At the back of the dayroom was a recessed area where an unidentified male individual was seen looking towards the front of the dayroom. The unidentified male was wearing a patient gown that appears raised above his waist and was leaning into another unknown person. The two unidentified individuals were engaging in sexual activity. The face of this male individual was visible on the video surveillance; however, the face of the other unknown person was not. 3. On 09/01/21 at approximately 12:20 PM, an interview was conducted with E #3 (Director of Behavioral Health Unit). E #3 stated that on 8/26/21, at the end of the day, E #3 was made aware of an inappropriate behavior between two patients in the day room of the BHU. E #3 was shown a video by E #7 (Risk Manager), who asked E #3 to identify the individuals in the video. E #3 stated that the incident occurred sometime around June 24 or 25, 2021 but was not sure of the time. E #3 said that E #3 was told by E #7 (Risk Manager) that they believed that one of the 2 individuals in the video was Pt. #2, and E #3 assumed that it was Pt. #2; however the identity of the individuals have not been determined. E #3 stated that she has not completed an investigation nor interviewed staff to identify the nature and root cause of the unusual occurrence because she (E #3) was notified at the end of the day, and she was off the next three days. E #3 also stated that she does not have supporting documentation on what has been done regarding the lack of monitoring for the incident that happened in the BHU dayroom. 4. On 09/01/21 at approximately 1:55 PM, an interview was conducted with E #8 (Assistant Director of Facilities). E #8 stated that he was conducting a video surveillance audit, due to an investigation that was being conducted of an incident from a patient who made an allegation that the staff put a comb on the patient's head that occurred on 7/23/2021. During this video audit, E #8 stated that there were three occasions where the video reverted to images of the dayroom from 6/24/21. E #8 said that he noticed that there was an unusual activity involving two people engaging in sexual activity during the footage from 6/24/21. E #8 stated that he brought this information to E #7 (Risk Manager) for further investigation between August 23, 2021 through August 26, 2021, but could not remember the exact date. 5. On 09/02/21 at approximately 9:25 AM, an interview was conducted with the Risk Manager (E #7). E #7 stated that there was a concern for the safety of the patients because of improper monitoring of patients. 6. On 9/2/2021 at approximately 3:45 PM, an interview was conducted with E #11 (Interim Director of Quality). E #11 said that having sexual activity on a psychiatric unit between two individuals is an adverse event. E #11 said that the Hospital's quality department has not received a report from the Director of the Behavioral Health Unit in order for the quality department to analyze and institute appropriate measures to ensure patient safety. As of 9/2/2021, the Hospital has not identified the two individuals involved in the unusual occurrence. 7. On 9/2/2021, an interview was conducted with E #9 (Chief Nursing Officer). E #9 stated that this type of situation is very serious and puts patients at very high risk for violation of rights and safety. E #9 also stated that there is a high risk for sexual abuse. E #9 stated, "This occurrence should have been reported and an investigation should have been conducted immediately. As of now we have not identified the persons in the video." B. Based on document review and interview, it was determined that, the Hospital failed to ensure that the physician's order for safety precautions was followed, to ensure patients receive care in a safe setting. Findings include: 1. On 09/01/21 at approximately 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Behavioral Health Unit (BHU) on 6/24/21at 5:30 PM and discharged on [DATE] at 1:00 PM. Pt. #2's clinical record included the following: - Psychiatric Evaluation dated 06/25/21 at 9:17 AM, included, "Inpatient Status: Involuntary ... History ... with active suicidal ideations but this time without any particular plan. (Pt. #2) very verbally aggressive towards staff ... psychotic, delusional, and restless ... Past Psych History 1) Bipolar Disorder 2) Schizoaffective Disorder 3) Schizophrenia ...9) Aggressive behavior ... Judgement: Poor. Inability to maintain safety of self or others ...Level of Observation: 1:1 CO(one to one close observation). Ensure patient's safety. -Physician Order Detail dated 06/25/21 at 9:32 AM, included, "Sitter 1:1 (one to one-patient must be within arm's reach at all times), start 06/25/21, Order Complete/Discontinued 06/28/21." - "BHU Observation Record" flow sheets dated 06/25/21 at 9:30 AM through 06/28/21 at 1:00 PM, were reviewed and indicated that Pt. #2 was being monitored every 15 minutes. The flow sheets did not indicate that Pt. #2 had staff assigned to conduct 1:1 observation as ordered by the physician. 2. On 09/01/21 the BHU daily staffing assignment sheets for 06/25/21 through 06/28/21 were reviewed, the assignment sheets did not list a sitter assigned to Pt. #2. 3. On 9/1/2021, the clinical record of Pt. #4 was reviewed. Pt. #4 was admitted on [DATE] with a diagnosis of schizoaffective disorder. Pt. #4's clincal record included a physician's order for a suicide precaution (SP) every 15 minutes, dated 8/27/2021. The every-15 minute observation flowsheet did not indicate that Pt. #4 was monitored for suicide precaution on 8/30/2021 and 8/31/2021. 4. On 9/2/2021, the Hospital's policy titled "Safety Precautions" (reviewed by Hospital 4/19) was reviewed and included, " ... To provide a safe environment for the patient and prevent self-destructive behavior ... 7. Patients who may verbalize or behave in a manner that is indicative of an imminent threat to self or others ... will be placed on 1 to 1 observation .... Safety precautions will be discontinued only after evaluation by multidisciplinary team and an order from psychiatrist ..." 5. On 9/2/2021, the Hospital's policy titled, "Precaution" (revised 7/2021) was reviewed and included, "Policy: Precautions are implemented to ensure that (Name of the Hospital's) patients are protected and monitored for behaviors... Procedure: 1. Patients admitted to (Name of the Hospital) will be placed on any of the following precautions... a. SP = Self-Injury/Suicide Precaution... 2... The physician will be called to obtain and validate the precaution order... 4... a. Patients on any of the special precautions (SP...) will be monitored every 15 minutes and the patient status will be documented by the staff on the observation flow sheet..." 6. On 9/1/2021 at approximately 10:30 AM, findings were discussed with E #3 (Director, Behavioral Health Unit). E #3 stated that the observation flow sheet should have indicated that Pt. #4 was on suicide precaution to ensure that patient was being monitored, as required. 7. On 09/01/21 at approximately 1:30 PM, E #9 (Chief Nursing Officer) was asked to review Pt. #2's observation flow sheets from 6/25/21 through 6/28/21, and the BHU Patient-Staffing assignment sheets. E #9 confirmed that Pt. #2's clinical record or the staff-patient assignment sheets did not indicate that Pt. #2 was assigned a staff to conduct 1:1 observation. E #9 could not explain the reason for the findings. |
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| VIOLATION: QAPI | Tag No: A0263 | |
| Based on document review, video surveillance review, and interview, it was determined that the Hospital failed to ensure unusual occurrence/adverse events were reported and investigated, in accordance with the Quality Assurance and Performance Improvement Plan. This potentially affects all patients admitted to the Hospital's psychiatric unit. As a result, the Condition of Participation, 42 CFR 482.21, Quality Assurance, was not in compliance. Findings include: 1. The Hospital's Quality Committee failed to analyze, track, and implement preventive actions to address an unusual/adverse event. See deficiency cited at A-286. The immediate jeopardy began on 8/26/2021, due to the Hospital's failure to ensure that the Quality Committee analyze, track, and ensure clear expectations for safety were established, potentially affecting the care of all psychiatric patients in the Behavioral Health Unit (BHU). The IJ was announced on 9/3/2021 at 4:15 PM, during a meeting with the Chief Executive Officer, Chief Nursing Officer, Director of Operations, and Interim Director of Quality, and was not removed by the survey exit date of 9/3/2021. |
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| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, video surveillance review, and interview, it was determined that for 1 of 5 unusual occurrences/adverse events reviewed, the Hospital's Quality Committee failed to analyze, track, and implement preventive actions to address an unusual/adverse event, potentially affecting the safety of all patients in the psychiatric unit. Findings include: 1. On 9/2/2021, the Hospital's Quality and Assessment Performance Improvement Plan (dated 6/2020) was reviewed and included, " ... Purpose: The plan creates a vehicle and process to measure the degree to which it meets its mission and to scientifically affect its patient outcomes, through objective and systematic monitoring and evaluation of the quality and appropriateness of patient care. The organization endeavors to implement continuous quality assessment and performance improvement measures and processes in the identification and resolution of patient care issues and problems ... VII. Program Scope. The scope will include but not be limited to measurement, analysis, and tracking of the following data ... I. Measure, assess and report to appropriate Medical Staff Department and/or Committees the following required patient care indicators ... Risk Management activities to include adverse patient events ..." 2. On 9/2/2021, the Hospital's policy titled, "Procedure for Reporting Adverse and Sentinel Events" (revised 4/2021) was reviewed and included, " ... To provide a ... mechanism of identification ... and follow-up of all incidents that pose an actual or potential safety risk to patients, families, visitors and staff ... The following events should be reported using the QMOR (Quality Management Occurrence Report/Unusual Occurrence Report Form) ... 3. Situations that may lead to potential harm ... Procedure ... The intent of the QMOR is to improve patient safety by analyzing root causes of events and implementing operational changes to promote patient safety. All patient occurrences will be reported to Risk Management ... Steps to Complete QMOR ... Document the ... patient details, unit the event took place ... Document all related information pertaining to the event i.e. Was the event related to safety ... Narrative Description of the Occurrence ... State all actions that may prevent reoccurrences ... All department managers must complete an investigation on all submitted Quality Management Occurrence Report. All Managers must complete the Quality Management Investigation Form and submit with the (QMOR). Both forms must be submitted to the Quality Risk Manager within 72 hours of the incident ... Staff involved in discovering or witnessing a reportable event must complete a QMOR ..." 3. On 9/2/2021, the Hospital's Quality Management Occurrence Department Investigation Form (dated 4/2021) was reviewed and included, " ... The ... (QMOR) is a required tool used for reporting occurrences ... Reportable occurrences are defined as any situation which could or did results in physical or psychological harm ... All questions must be answered ... 1. Date and Time notification of incident ... 3. Did the Manager, Director or Assigned Designee complete a department investigation of this incident ... 4. What are the findings of the investigation ... 5. What factors contributed to the incident ... 6. Have all parties involved been interviewed ... What is the plan of correction to prevent reoccurrence of this incident ..." 4. On 9/1/2021, the Hospital's Unusual Occurrence/Incident Report Log from March 1, 2021, through September 1, 2021, was reviewed. The log did not indicate that a QMOR was completed regarding an unusual occurrence between two unidentified individuals on the Hospital's Behavioral Health Unit (BHU) dayroom on 6/24/2021, which was captured on a video surveillance footage. It was identified by the hospital on [DATE], while conducting a video surveillance review for a different investigation of an incident that occurred on 7/23/2021. 5. On 9/3/2021, the Hospital's job description for the Chief Quality Officer (undated) was reviewed and included, "This individual has oversight and responsibility over all quality, risk management and patient safety related activities within the organization. Directs the efforts of all performance improvement initiatives... Works with clinicians and administrators to improve overall patient safety and systems-level outcomes. Responsible for the facilities quality, patient safety and risk management..." 6. On 9/01/2021 at approximately 2:10 PM, the Hospital's video surveillance footage from 6/24/2021 was reviewed with E #3 (Director of BHU) and E #8 (Assistant Director of Facilities). The video footage on 6/24/2021 showed: At 12:54:26 PM, the inside view of the BHU's day room was seen with an unidentified staff sitting outside the dayroom door. From the door, the staff could not visualize patients at the back of the day room. Inside the day room, two males were sitting by the entrance of the day room, facing the television at the front of the day room. At the back of the dayroom was a recessed area where an unidentified male individual was seen looking towards the front of the dayroom. The unidentified male was wearing a patient gown that appears raised above his waist and he was leaning into another unknown person. The two unidentified individuals were engaging in sexual activity. The face of this male individual was visible on the video surveillance; however, the face of the other unknown person was not. 7. On 09/01/21 at approximately 12:20 PM, an interview was conducted with E #3 (Director of BHU). E #3 stated that on 8/26/21, at the end of the day, E #3 was made aware of an inappropriate behavior between two patients in the day room of the BHU. E #3 was shown a video by E #7 (Risk Manager), who asked E #3 to identify the individuals in the video. E #3 stated that the incident occurred sometime around June 24 or 25, 2021 but was not sure of the time. E #3 said that E #3 was told by E #7 (Risk Manager) that they believed that the person in the video was Pt. #2, and E #3 assumed that it was Pt. #2; however the identity of the individuals have not been determined. E #3 stated she did not file a QMOR when she became aware of the incident and was off the following day (8/27/21) and returned on 8/31/21. E #3 stated that she has not completed an investigation nor interviewed staff to identify the nature and root cause of the unusual occurrence because it was notified at the end of the day, and she was off the next three days. 8. On 09/01/21 at approximately 1:55 PM, an interview was conducted with E #8 (Assistant Director of Facilities). E #8 stated that he was conducting a video surveillance audit, due to an investigation that was being conducted of an incident from a patient who made an allegation that the staff put a comb on the patient's head that occurred on 7/23/2021. During the video audit, E #8 stated that there were three occasions where the video recording reverted to images dated 6/24/21. E #8 said that he noticed that there was an unusual activity involving two people engaging in sexual activity during the footage from 6/24/21. E #8 stated that he brought this information to E #7 (Risk Manager) for further investigation between August 23, 2021 through August 26, 2021, but could not remember the exact date. 9. On 09/02/21 at approximately 9:25 AM, an interview was conducted with the Risk Manager (E #7). E #7 stated that the BHU Manager (E #3) should have filed a QMOR report for this unusual occurrence and initiated an investigation according to the Hospital's policy. E #7 stated that there was a concern for the safety of the patients because of improper monitoring of patients. E #7 stated, "Occurrences like this should be investigated as soon as possible. There is potential for harm if an investigation is not done right away to maintain safety measures or correct any concerns. I have not received a QMOR report as of now, I do not know the status of the investigation." 10. On 9/2/2021 at approximately 3:45 PM, an interview was conducted with E #11 (Interim Director of Quality/Chief Quality Officer). E #11 said that having sexual activity on a psychiatric unit between two individuals is an adverse event and an incident report should have been written. E #11 said that the Hospital's quality department has not received a report from the Director of the Behavioral Health Unit in order for the quality department to analyze and institute appropriate measures to ensure patient safety. |
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