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||Nov. 10, 2021|
|VIOLATION: COMPLIANCE WITH 489.24||Tag No: A2400|
|Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.
1. The Hospital failed to ensure that a patient's underlying psychiatric condition was stabilized prior to the patient leaving the Hospital, in order to prevent injury to self or others. See deficiency at A-2407.
|VIOLATION: POSTING OF SIGNS||Tag No: A2402|
|Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Departments, the Hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA), and whether the Hospital participates in the Medicaid program.
1. The Hospital's policy titled, "Emergency Medical Treatment (EMTALA)" (revised 5/2021), was reviewed on 11/8/2021 and required, "...Hospital shall post a sign in a conspicuous location in the Emergency Department and Labor and Delivery areas where patients are screened which specifies the rights of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and specifies that the hospital participates in the Medicaid program."
2. A tour of the Emergency Department and Patient Entrance Areas were conducted on 11/8/2021, between approximately 10:00 AM and 10:56 AM with the Emergency Department (ED) Nurse Manager (E#1). There was no EMTALA signage posted throughout the Emergency Department.
3. An interview was conducted on 11/8/2021, at approximately 10:38 AM, with the ED Nurse Manager (E#1) and the Interim Director of Quality (E#3). E#1 was not sure where the EMTALA sign would be posted and stated, "There should be one." E#2 stated that the Hospital has been undergoing some construction since COVID-19 (approximately March 2020) and during construction some signs were removed/replaced. E#2 pointed out the wall next to the registration desk where the sign used to be posted. In it's place was a sign, indicating that all patients and staff must be screened and included a list of COVID-19 symptoms of COVID-19. At approximatley 1:45 PM, E#2 confirmed with the Facilities Department regarding the missing signage, and stated, "It was an oversight."
|VIOLATION: EMERGENCY ROOM LOG||Tag No: A2405|
|Based on document review and interview, it was determined that for 38 individuals who presented to the Emergency Department (ED) from 4/5/2021-11/5/2021, the Hospital failed to ensure that the ED centralized log was maintained to include the chief complaint and disposition of each individual who presented to the ED.
1. The Hospital's policy titled, "Emergency Medical Treatment (EMTALA)" (revised 5/2021), was reviewed on 11/8/2021 and required, "...Records and Records Retention: A centralized log of all patients presenting to the ED shall be maintained and include the name of the patient, chief complaint, outcome and any refusal of care and whether patient was transferred, admitted and treated, stabilized and transferred or discharged ..."
2. The Hospital's ED centralized logs from 4/5/2021, 6/5/2021, 7/5/2021, 8/5/2021, 9/5/2021, 10/4-10/5/2021, and 11/5/2021 were reviewed on 11/8/2021 and lacked documentation of the following:
- 4/5/2021: 1 of 45 patients lacked documentation of the chief complaint; 2 of 45 patients lacked documentation of the disposition.
- 6/5/2021: 6 of 59 patients lacked documentation of the chief complaint; 2 of 59 patients lacked documentation of the disposition.
- 7/5/2021: 6 of 69 patients lacked documentation of the chief complaint; 2 of 69 patients lacked documentation of the disposition.
- 8/5/2021: 5 of 57 patients lacked documentation of the chief complaint; 3 of 57 patients lacked documentation of the disposition.
- 9/5/2021: 1 of 47 patients lacked documentation of the chief complaint and disposition.
- 10/4/2021: 7 of 81 patients lacked documentation of the chief complaint; 2 of 81 patients lacked documentation of the disposition.
- 10/5/2021: 1 of 73 patients lacked documentation of the chief complaint; 2 of 73 patients lacked documentation of the disposition.
- 11/5/2021: 4 of 58 patients lacked documentation of the chief complaint; 4 of 58 patients lacked documentation of the disposition.
3. An interview was conducted with ED Nurse Manager (E#1) on 11/9/2021, at approximately 1:15 PM. E#1 stated that the ED centralized log is generated automatically from the electronic medical record system. E#1 stated that the log is suppose to include information on the patient's chief complaint and disposition; however, sometimes there are glitches and all of the information may not popluate in the ED log. E#1 stated that she tries to review them daily to see if any information is missing such as the dipsosition. E#1 stated that there is a way to manually input the missing information into the log; however, stated that she was told not to as it could mess with the patient's medical record. E#1 stated that the system is a bit antiquated and is in the process of being updated.
|VIOLATION: STABILIZING TREATMENT||Tag No: A2407|
|Based on document review and interview, it was determined that for 1 of 1 record reviewed for a patient who absconded from the emergency department, the Hospital failed to ensure that a patient's underlying psychiatric condition was stabilized prior to the patient leaving the Hospital, in order to prevent injury to self or others.
1. The Hospital's policy titled, "Emergency Medical Treatment (EMTALA)" (revised 5/2021), was reviewed on 11/8/2021 and required, "...With respect to psychiatric conditions, the patient is considered 'stable' for purposes of transfer when the patient is protected and prevented from injuring self or others (by adequate chemical or physical restraint). Stability for discharge means the patient is no longer a threat to self or others, as clinically determined... If the patient has an emergency medical condition, the patient is to be treated in the ED or as an inpatient until the condition is stabilized or the patient is to be transferred appropriately..."
2. The clinical record of Pt. #15 was reviewed on 11/9/2021. Pt. #15 presented to the Emergency Department (ED) by ambulance (EMS) on 7/5/2021, at approximately 9:30 PM, for a psychiatric evaluation due to aggressive behavior.
- The Medical Screening Examination, dated 7/5/2021 at 10:21 PM, included, "According to the EMS, as the patient is refusing to talk to anyone and is threatening to injure any staff members who come near him, as well as the city police department, the patient has been noncompliant with his medications, his father called 911 because of patient was claiming suicidal and homicidal ideation although he was nonspecific on what his plan was... Diagnosis: Acute schizophrenia, acute psychosis, suicidal ideation, violent behaviors... Hospital Course: Patient seen in the main emergency department immediately upon EMS arrival in the ambulance by hallway. Multiple diagnoses were considered based upon the patient's chief complaint. Patient was brought immediately to room #11 [designated area for psychiatric patients] while the police and EMS were here, we did obtain medications, 2 administered to the patient [to] sedate to him [as] he is well known to be extremely violent and [has] already expressed violent behaviors here in the ED as well as his belligerent and his desire to hit someone, so for his safety [and] the staffs... we did give him Haldol Benadryl and Ativan [sedatives] and the patient was able to be examined and is medically cleared clinically for psychiatric evaluation at [10:00 PM]. Patient will be admitted to the ED observation area as we currently do not have a psychiatrist available and will be evaluated by psychiatry in the morning."
- Nurses Notes included, "7/5/2021 at 10:33 PM: Patient presented to the ED via EMS c/o [complaints of] HI [homicidal ideation] and SI [suicidal] ideation... 7/6/2021 at 12:11 AM: ...Patient's petition and certification completed [for involuntary admission]... 7/6/2021 at 4:00 AM: Patient in bed sleeping. No status change. Will continue to monitor... 7/6/2021 6:02 AM: Patient came out of his room screaming he wanted to use the phone and threatening ER personnel. Personnel tried to bring patient back to his room. Patient was threatening, MD notified. Patient walked out of the ED and ignored redirection."
- A Petition for Involuntary/Judicial Admission was completed for Pt. #15 on 7/6/2021 at 12:00 AM. The petition was initiated by reason of "Emergency Inpatient admission by certificate" and indicated that due to mental illness, Pt. #15 was in need of immediate hospitalization for prevention of harm. The petition included, "Patient reports suicidal and homicidal ideation. Patient aggressive and non compliant upon arrival at ER."
- Physician Addendum, dated 7/6/2021 at 6:36 AM, "When patient awakened he asked about going upstairs. He was told it would be a little while longer. He became very upset, violent and belligerent. Patient ran out the door and was unable to be stopped. We tried calling him and reasoning with him but he began walking down the street, He refused to come back. Patient absconded."
- The medical record did not indicate if Pt. #15 had a 1:1 sitter; however, the ED assignment sheet dated 7/5/2021 indicated that a sitter was assigned to monitor the psychiatric patients including Pt. #15.
3. An interview was conducted with the ED Nurse Manager (E#1) on 11/9/2021, at approximately 1:15 PM. After reviewing Pt. #15's record, E#1 stated that Pt. #15 was not ready to be discharged upon leaving the ED. E#1 stated that Pt. #15 was cleared medically but needed to be evaluated by psychiatry. E#1 stated that the psychiatrist will determine if the patient needs to be admitted or transferred. E#1 stated that the record did not indicate that Pt. #15 was ever seen by a Psychiatrist. E#1 stated that when a patient is petitioned and certified (for involuntary admission), the expectation is to keep the patient in the Hospital for the patient's and/or other's safety until an psychiatric evaluation is completed. E#1 stated that for patients with SI and HI, the staff will attempt to redirect and deescalate the patient. E#1 stated that a sitter is always assigned to monitor the psychiatric patients. E#1 stated that as a last resort, staff can use chemical or physical restraints to hold the patient. E#1 stated that Pt. #15 was somehow able to get past staff and security and leave the ED.
4. An interview was conducted with ED Physician (MD#2) on 11/9/2021, at approximately 2:15 PM. MD#2 stated that a patient is petition and certified for involuntary admission if they are a potential harm to themselves or others and are in need of psychiatric evaluation and/or hospitalization . MD#2 stated that a petition and certificate gives legal power to hold the patient until a psychiatric evaluation can be done to determine if the patient needs to be admitted , transferred, or is safe for discharge. The ED Physicians are responsible for medically clearing the patients prior to the psych evaluation. MD#2 stated that while a patient is awaiting the psych evaluation, the ED staff are responsible for securing the patient's safety and others as well. MD#2 stated that when a patient is petitioned and certified, they cannot just leave the Hospital against medical advice. MD#2 stated that, "It's not okay for them to just leave if they are petitioned and certified. MD#2 stated that there is always a sitter present to monitor all psychiatric patients in the ED. First we'd try to calm them down and may have to give medication if necessary. If they still try to leave and become aggressive, we may have to call security and use some force to prevent them from leaving."