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 | July 9, 2021 |
| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| Based on document review and interview, it was determined that the Hospital's Governing Body who is legally responsible for the Medical Staff be accountable and carry out the functions described for the quality of care and post-discharge continuity of care for patients, in accordance with the Hospital's Professional Staff Bylaws & Rules and Regulations. As a result, the Condition of Participation, 42 CFR 482.12 Governing Body, was not in compliance. Findings include: 1. The Governing Body failed to ensure that the medical staff be accountable for the quality of care and post-discharge continuity of care provided to patients discharged by Psychiatrists (MD#1 and MD #3) as required by the Bylaws & Rules and Regulations. See A-0049. An immediate jeopardy (IJ) began on 6/21/2021, for the Hospital's failure to ensure that the Medical Staff be accountable to the Governing Body for the quality of care, and post-discharge continuity of care was provided to patients discharged by Psychiatrists (MD #1 and MD #3). The IJ was identified and announced on 07/09/2021 at 3:40 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Interim Chief Nursing Officer, Director of Behavioral Health, and Director of Operations, and was not removed by the survey exit date of 7/09/2021. |
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| VIOLATION: MEDICAL STAFF - ACCOUNTABILITY | Tag No: A0049 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 58 patients discharged from the Behavioral Health Unit between 6/21/2021-7/8/2021, the Governing Body failed to ensure that the medical staff be accountable to the governing body for the quality of care and post-discharge continuity of care provided to patients discharged by Psychiatrists (MD#1 and MD #3) as required by the Bylaws & Rules and Regulations. Findings include: 1. On 07/08/2021, the Hospital's "Professional Staff Bylaws & Rules and Regulations" (revised 2/6/2020) were reviewed and required, " ...(b) The Duties of the Executive Committee shall be to ... (8) Review and act on reports of services, departments, and committees the professional staff ...The Hospital Medical Director, President/CEO of the Hospital, ...identify activities to improve clinical effectiveness, patient safety, ...actively participate in efforts for improvement ...serve as a forum for policies, protocols regarding patient care..." 2. The personnel file of the Social Worker (E #9) was reviewed and indicated that E #9 was terminated on 6/21/2021. The BHU does not have a Social Worker. 3. On 07/08/2021, the Hospital's Discharge Log, dated 06/01/2021 to 07/08/2021, was reviewed and indicated that there had been 58 patients discharged to the community/homes since 06/21/2021. Three patients (Pt. #2, #3 and #4) clinical records were reviewed for discharge planning and continuity of care post-discharge. The clinical records lacked documentation of discharge planning and Social Worker's psycho-social assessments and notes. 4. On 7/8/2021, Pt. #2's clinical record was reviewed and indicated that Pt. #2 was admitted on [DATE] (active patient) with the diagnosis of Schizoaffective Disorder, Bipolar Type (mood disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each). -MD #1's Psychiatric Evaluation note dated 7/2/21, included, " ...reports an endorsement of active suicidal ideations ... unstable family or limited support system, incapable of independent living ..." -Psychiatric Progress note dated 7/6/21, and included, " ...Social Work (SW) to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a SW had met with Pt. #2 for implementation of a discharge plan, or that a psychosocial assessment had been completed. The clinical record lacked discharge planning notes. 5. On 7/8/2021, Pt #3's clinical record was reviewed and indicated that Pt. #3 was admitted on [DATE] with the diagnosis of Bipolar Disorder and discharged on [DATE]. -MD #1's Psychiatric Evaluation note dated 7/2/2021, included, " ...liabilities ... limited support system, incapable of independent living ...Disposition ... Nursing Home ..." -MD #3's Psychiatric Progress note dated 7/5/21, included, " ...Social work to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a SW had met with Pt. #3 for implementation of of a discharge plan, or that psychosocial assessment was completed. The clinical record lacked discharge planning notes. 6. On 7/8/2021, Pt #4's clinical record was reviewed and indicated that Pt #4 was admitted on [DATE] with the diagnosis of Schizoaffective Disorder, Bipolar Type and discharged on [DATE]. -MD #3's Psychiatric Progress note dated 7/5/21, and included, " ...Social Work to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a SW had met with Pt. #4 for implementation of of a discharge plan, or that psychosocial assessment was completed. The clinical record lacked discharge planning notes. 7. On 07/08/2021 at approximately 10:30 AM, an interview was conducted with the Director of Behavioral Health Unit (E #2). E #2 stated that they have not been conducting discharge rounds on BHU since there has been no Social Worker. 8. On 07/08/2021, at approximately 1:15 PM, the newly hired (07/02/2021) Psychiatrist (MD #3) was interviewed. MD #3 stated that he started seeing patients on 07/02/2021. MD #3 stated that he was not aware there was no Social Worker on the BHU. MD #3 stated that Pt. #2, Pt. #3 and Pt. #4 were discharged on [DATE], based on clinical assessment. MD #3 stated that it is absolutely not safe to discharge patients to the community without proper placement and assistance by the Social Worker. 9. On 07/08/2021, at approximately 2:30 PM, the Chief Medical Officer (MD #2) was interviewed. MD #2 stated that he was not aware that there had been no Social Worker on the BHU. MD #2 stated that it is essential to have a Social Worker on the BHU for psycho-social assessments and continuity of care prior to discharging the patients from the Hospital. 10. On 07/08/2021, at approximately 2:40 PM, the President/Chief Executive Officer (E #1) was interviewed. E #1 stated that he was not aware that there had been no Social Worker on the BHU. E #1 continued that the previous Psychiatrist (MD #1) who is no longer with the Hospital, should have ensured that there is proper quality of care, and patients are discharged safely. 11. On 7/9/2021, at approximately 10:00 AM, an interview with the Chairman of Department of Medicine (MD #4) was conducted. MD #4 stated that he was not aware that the BHU did not have a Social Worker. MD #4 stated that BHU had not submitted any reports of their meetings to the Governing Body/MEC (Medical Executive Committee). MD #4 stated, "I am not aware of what is going on on that unit." |
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| VIOLATION: PATIENT RIGHTS: INFORMED CONSENT | Tag No: A0131 | |
| Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) psychiatric patient's clinical record reviewed for Patient Rights, the Hospital failed to ensure patients were informed about and signed consent, prior to the administration of psychotropic medication. Findings include: 1. On 07/09/2021 at 11:45 AM, the Hospital's policy titled, "Informed Consent Medication/Psychoactive" (effective 06/13/2021) was reviewed and required, "A. The physician will discuss use of medications, reasons for treatment, target symptoms ...B. The physician will document in a progress note the above was completed ...The patient...will sign the Informed Consent after reading about possible side effects ..." 2. On 07/08/2021 at approximately 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's Behavioral Health Unit (BHU) on 07/01/2021 at 4:02 AM with diagnosis of Schizophrenia. Pt. #1's clinical record included: -MD #1's Physician's orders, dated 06/30/2021 at 11:20 PM, included Ativan (Anti-Anxiety Medication), Benadryl (Sedative), Seroquel (Anti-Psychotic Medication), Haldol (Anti-Psychotic Medication) and Trazadone (Anti-Depressant Medication). Pt. #1's MAR (Medication Administration Record) indicated that Pt. #1 received Haldol on 07/03/2021 at 11:58 PM and Benadryl and Ativan were administered for agitation on 07/03/2021, at 11:59 PM. 3. The "Consent to Medication" was reviewed and lacked documentation by the Physician that education was provided about medications. The signed consent form by Pt. #1 did not list any medications. 4. On 07/08/2021 at approximately 12:00 PM, the above finding were discussed with E #2 (Director of Behavioral Health Unit). E #2 stated, " ...I really cannot tell you why the nurse had (Pt. #1) sign a blank consent form. I don't make excuses, but I will ask the nurse involved ..." |
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| VIOLATION: DISCHARGE PLANNING | Tag No: A0799 | |
| Based on document review and interview, it was determined that the Hospital failed to ensure an appropriate discharge planning process. As a result, it was determined that the Condition of Participation for 42 CFR 482.43, Discharge Planning was not in compliance. Findings include: 1. The Hospital failed to arrange for the assessment of patient's needs prior to discharge. See A-0800. 2. The Hospital failed to arrange for the development and initial implementation of a discharge plan for patients. See A-0801. 3. The Hospital failed to ensure that a discharge planning evaluation was conducted to assess the needs of patients being discharged . See A-0808. The immediate jeopardy began on 6/21/2021, due to the Hospital's failure to ensure an appropriate discharge planning process was implemented, and as a result a total of 58 Behavioral Health Unit patients were discharged without appropriate discharge evaluations and planning. The IJ was identified and announced on 07/09/2021 at 42 CFR 482.43, Discharge Planning. The IJ was announced on 07/09/2021 at 3:30 PM during a meeting with the Chief Executive Officer, Chief Medical Officer, Interim Chief Nursing Officer, Director of Behavioral Health, and Director of Operations, and was not removed by the survey exit date of 7/09/2021. |
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| VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS | Tag No: A0800 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 4 of 4 (Pt. #1, #2, #3 and #4) clinical records reviewed for discharge planning on Behavioral Health Unit (BHU), the Hospital failed to ensure the completion of a psychosocial assessment prior to the patient's discharge. Findings include: 1. On 07/8/2021, Pt #1's clinical record was reviewed and indicated: -Pt #1 was admitted to the BHU (Behavioral Health Unit) on 07/1/2021 with the diagnosis of Schizophrenia (a long term mental disorder). -Pt. #1's clinical record lacked completion of psychosocial assessment by a Social Worker to determine discharge needs for Pt. #1 prior to discharge. -Pt. #1 was discharged from the BHU on 07/06/21. 2. On 7/8/2021, Pt. #2's clinical record was reviewed and indicated: -Pt. #2 was admitted on [DATE] (active patient) with the diagnosis of Schizoaffective Disorder, Bipolar Type (mood disorder). -MD #1's Psychiatric Evaluation note dated 7/2/21, included, " ...reports an endorsement of active suicidal ideations ... unstable family or limited support system, incapable of independent living ..." -MD #3 Psychiatric Progress note, dated 7/6/21, and included, " ...Social Work (SW) to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a SW has met with Pt. #2, or that a psychosocial assessment or implementation of a discharge plans has been completed. 3. On 07/08/2021, Pt #3's clinical record was reviewed, and indicated: Pt. #3 was admitted on [DATE] with the diagnosis of Bipolar Disorder and discharged from the BHU on 07/06/21. -Psychiatric Evaluation note dated 7/2/2021, included, " ...liabilities ... limited support system, incapable of independent living ...Disposition ... Nursing Home ..." -Psychiatric Progress note dated 7/5/21, included, " ...Social work to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a psychosocial assessment was completed upon admission or prior to discharge. 4. On 7/8/2021, Pt #4's clinical record was reviewed and indicated: - Pt #4 was admitted on [DATE] with the diagnosis of Schizoaffective Disorder, Bipolar Type and discharged home from the BHU on 7/6/2021. -Psychiatric Progress note dated 7/5/21, and included, " ...Social Work to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a psychosocial assessment was completed upon admission and prior to discharge. 5. On 07/09/2021 at 1:24 PM, the Hospital's policy titled, "Referral Sources to Social Work Services (Revised 05/21)" was reviewed and included, "Indirect Referral Sources: Social work personnel designate certain high-risk patients as being in need of services and case-finding referrals ...All patients inpatient or observation status are evaluated by the social worker. The case manager works with the social worker to gather a complete picture of the patient's situation ...Sources of Referrals to Social Work Services ...Psychiatric patients/Depressed patients ... 6. On 07/09/2021 at 1:41 PM, the Hospital's policy titled, "Discharge Planning and Referral (Effective 05/2019) was reviewed and included, " ...The social worker/and or case manager assure that discharge plans are initiated, updated and reassessed throughout the patients hospitalization ...2. If patient is "High Risk", the social worker/charge nurse is responsible for A. Reviewing the patients medical record, focusing on the patient's personal goals for discharge, providing consultation and initiated the referral process for area resources ...E. Arranging services to meet the patient's needs, after and assessment for the following needs has been completed: Physical, emotional, homemaking, transportation, social and others...F. Documenting updates to the discharge plan in the progress notes of the patients medical record, and or on the Discharge Planning and Continuum of Care Assessment ..." 7. On 07/08/2021, at approximately 2:30 PM, the Chief Medical Officer (MD #2) was interviewed. MD #2 stated that he was not aware that there had been no Social Worker on the BHU. MD #2 stated that it is essential to have Social Worker on the Behavioral Health Unit for psycho-social assessment and continuity of care prior to discharging the patients from the Hospital. |
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| VIOLATION: DISCHARGE PLANNING - MD REQUEST FOR PLAN | Tag No: A0801 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 3 of 3 clinical records (Pt. #2, Pt #3, and Pt #4) reviewed for discharged planning, the Hospital failed to arrange for the development and initial implementation of a discharge plan for the patient. Findings include: 1. On 7/8/2021, the Hospital's policy titled, "Discharge Planning and Referrals" (effective 5/2019) was reviewed and required, "...Prior to discharge from the hospital, each patient receives appropriate discharge planning...discharge planning begins at the time of admission...evaluation should be completed by the social worker or designee within 24-48 hours of admission..." 2. On 7/8/2021, Pt. #2's clinical record was reviewed and indicated: -Pt. #2 was admitted on [DATE] (active patient) with the diagnosis of Schizoaffective Disorder, Bipolar Type (mental illness). -MD #1's Psychiatric Evaluation note dated 7/2/21, included, " ...reports an endorsement of active suicidal ideations ... unstable family or limited support system, incapable of independent living ..." -MD #3's Psychiatric Progress note dated 7/6/21, and included, " ...Social Work (SW) to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a SW has met with Pt. #2, or that a psychosocial assessment or implementation of a discharge plans has been completed. 3. On 7/8/2021, Pt #3's clinical record was reviewed and indicated: -Pt #3 was admitted on [DATE] with the diagnosis of Bipolar Disorder (mental illness) and discharged on [DATE]. -MD 3's Psychiatric Progress note dated 7/5/21, and included, " ...Social Work to continue with aftercare and discharge planning ..." The clinical record lacked documentation that a psychosocial assessment, and an initial discharge evaluation was completed prior to discharge. 4. On 7/8/2021, Pt #4's clinical record was reviewed and indicated: -Pt #4 was admitted on [DATE] with the diagnosis of Schizoaffective Disorder, Bipolar Type. -Pt #4 was discharged from the BHU on 7/6/2021. Pt #4's clinical record lacked documentation of an initial discharge evaluation upon admission and discharge planning notes prior discharge. 5. On 7/8/2021, at 12:15 PM, an interview was conducted with the Intake Coordinator (E#5). E #5 stated that she did not do any discharge planning for Pt #2, Pt #3 and Pt #4. E #5 stated that discharge planning should be documented in the patient's clinical record. 6. On 7/8/2021, approximately 1:15 PM, the newly hired (7/2/2021) Psychiatrist (MD #3) was interviewed. MD #3 stated that he was not aware that there was no Social Worker on the BHU. MD #3 stated that it is absolutely not safe to discharge patients to the community without proper placement and assistance by the Social Worker. 7. On 7/8/2021, at approximately 2:30 PM, the Chief Medical Officer (MD #2) was interviewed. MD #2 stated that he was not aware that there had been no Social Worker on the BHU. MD #2 stated that is essential to have a Social Worker on the BHU for psycho-social assessments and continuity of care prior to discharging the patients from the Hospital. |
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| VIOLATION: POST-HOSPITAL SERVICES | Tag No: A0808 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 3 of 3 clinical records (Pt #1, Pt #3 and Pt #4) reviewed for discharge planning, the Hospital failed to ensure that discharge planning evaluation was completed and included the patient's medical record. Findings include: 1. On 7/8/2021, the Hospital's policy titled, "Discharge Planning and Referrals" (effective 5/2019) was reviewed and required, "...Prior to discharge from the hospital, each patient receives appropriate discharge planning...discharge planning begins at the time of admission...evaluation should be completed by the social worker or designee within 24-48 hours of admission..." 2. On 7/8/2021, Pt #1's clinical record was reviewed and indicated: -Pt #1 was admitted to the BHU (Behavioral Health Unit) on 7/1/2021 with the diagnosis of Schizophrenia (mental illness) - Pt #1's clinical record lacked discharge planning evaluation to establish appropriate discharge need. - Pt #1 was discharged to home from the BHU on 7/6/2021. 3. On 7/8/2021, Pt #3's clinical record was reviewed and indicated: -Pt #3's clinical record lacked documentation of discharge planning to establish appropriate discharge needs. -Pt #3 was admitted on [DATE] with the diagnosis of Bipolar Disorder (mood disorder) and discharged from the BHU on 7/6/2021. 4. On 7/8/2021, Pt #4's clinical record was reviewed and indicated: -Pt #4's clinical record lacked documentation of discharge planning to establish appropriate discharge needs. -Pt #4 was admitted on [DATE] with the diagnosis of Schizoaffective Disorder, Bipolar Type and discharged from the BHU on 7/6/2021. 5. On 07/08/2021 at approximately 10:30 AM, an interview was conducted with the Director of Behavioral Health Unit (E #2). E #2 stated that they have not been conducting discharge rounds on BHU since there has been no Social Worker. E #2 continued that the Intake Coordinator assists with discharge planning. 6. On 7/8/2021 at 12:15 PM, an interview was conducted with the Intake Coordinator (E#5). E #5 stated that she did not do any discharge planning for Pt #1, Pt #3 and Pt #4. E #5 stated that discharge planning should be documented in the patient's clinical record. |
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