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.

ST BERNARD HOSPITAL 326 W 64TH ST CHICAGO, IL 60621 Aug. 24, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) grievance records reviewed, the Hospital failed to ensure that a written notification regarding the resolution of the grievance was provided, as required.

Findings include:

1. On 8/22/28 at approximately 9:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male admitted on [DATE] with diagnoses of homicidal ideation and acute psychosis. Pt. #1 was discharged from the hospital on [DATE].

2. On 8/22/18 at approximately 9:55 AM, the Incident Report of E #6 (Security Officer) was reviewed. The incident report included, "... Type of incident: alleged cell phone damage... Date of incident: 7/18/18... discharged patient (Pt. #1) came to the main lobby asking to file a complaint... E #8 (Patient Advocate) got all the patient information, and told him (Pt. #1) she (E #8) will be in contact..."

3. On 8/22/18 at approximately 10:00 AM, the Complaint and Grievance Report made by E #8 (Patient Advocate) was reviewed and included, " ... Date (Received) 7/18/18... Date Closed (7/30/18/Investigation completed per E #8) ... Security Officer reports that (Pt. #1) was brought in with hand cuffs ... (Pt. #1) was wheeled to the bed ... jumped up and pushed pass (E #1/Registered Nurse) and attempted to run. At this time ... (the Hospitals) officers stopped (Pt. #1) and assisted (E #1) with the (application of) restraint. (Pt. #1's) belongings were removed ... (Pt. #1) had a cracked phone, and a lighter... (E #1) stated that he (E #1) didn't see security officer(s) do any damage to (Pt. #1's) cell phone and that he (E #1) was present the entire time ..."

4. On 8/22/18 at approximately 2:10 PM, the Hospital's policy titled, "Patient Complaint/Grievance Policy" (revised 3/17) was reviewed and included, " ... A patient grievance is a formal or informal written/verbal complaint that is made to the hospital by a patient ... when a patient issues cannot be resolved promptly by a staff member ... Procedure... If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient ... that the hospital is still working to resolve the grievance ... 6. The patient shall receive written notification of the resolution of the grievance.

5. On 8/22/18 at approximately 2:05 PM, findings were discussed with E #8 (Patient Advocate). E #8 said, "Grievance can be a verbal complaint that could not be resolved at the time of the complaint." E #8 added, "I should have sent (Pt. #1) a letter regarding the resolution of the grievance."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on document review and interview, it was determined that for 1 of 5 (Pt. #6) behavioral (violent) patients with restraints, the Hospital failed to complete the "Notice Regarding Restriction of Rights" document, to ensure appropriate use of restraints, as required.

Findings include:

1. On 8/22/18 at approximately 10:15 AM, the Hospital's policy titled, "Utilization of Human Restraint" (reviewed 2/17) was reviewed and required, "... Care of the Patient in Physical Restraint... 12. Whenever restraint and/or seclusion are used... A "Notice Regarding Restriction of Rights"... form will be completed... The original will be placed in the patient's medical record..."

2. On 8/23/18 at approximately 12:00 PM, the clinical record of Pt. #6 was reviewed. The clinical record indicated that Pt. #6 was placed in 4 point locked restraints (both wrists and legs) on 7/27/18. However, the clinical record lacked documentation that the "Notice Regarding Restriction of Rights" was completed.

3. On 8/23/18 at approximately 1:45 PM, findings were discussed with E #14 (Director of Nursing). E #14 stated that the Notification Regarding Restriction of Rights Form should have been completed. At approximately 3:45 PM, E #13 (Vice President, Nursing Services) stated that the restriction of rights form could not be found.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 3 of 5 (Pt. #3, #5, and #6) behavioral (violent) patients with restraints, the Hospital failed to ensure that the use of restraints were in accordance with a physician's order.

Findings include:

1. The Hospital's policy titled, "Utilization of Human Restraint" (last reviewed 2/2017), was reviewed on 8/23/18 and required, "Each use of physical restraint or seclusion requires a written physician's order... which shall include the type of restraint employed, specific time limits and the clinical justification for usage, as well as alternatives attempted prior to restraint seclusion..."

2. The clinical record of Pt. #3 was reviewed on 8/23/18. Pt. #3 was a [AGE] year old female, admitted on [DATE] with a diagnosis of acute psychosis. The clinical record indicated that Pt. #3 was in 4 point (both wrists and legs) locked restraints on 7/20/18 from approximately 12:21 PM to 6:30 PM. However, a physician's order, dated 7/20/18 at 4:32 PM, did not include the type of restraints to be utilized.

3. The clinical record of Pt. #5 was reviewed on 8/23/18. Pt. #5 was a [AGE] year old female, who (MDS) dated [DATE] with possible alcohol intoxication. The clinical record indicated that Pt. #5 was in restraints on 7/24/18 from 11:55 AM to 6:55 PM. The clinical record included a physician's order for restraints for 4 hours on 7/24/18 at 3:55 PM. However, the clinical record lacked an initial physician's order for restraints at 11:55 AM.

4. The clinical record of Pt. #6 was reviewed on 8/23/18. Pt. #6 was a [AGE] year old male, who (MDS) dated [DATE] with agitation. The clinical record indicated that Pt. #6 was in restraints from 10:15 AM to 5:00 PM. However, the physician's order, dated 7/27/18 at 2:00 PM, did not include the type of restraints to be utilized.

5. During an interview on 8/23/18 at approximately 1:45 PM, the Director of Nursing (E#14) stated that the type of restraints should be marked on the physician's order. Also E#14 could not find the initial order for restraints (on 7/24/18 at 11:55 AM) in Pt. #5's clinical record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 5 (Pt. #3 and Pt. #6) behavioral (violent) patients with restraints, the Hospital failed to ensure that the patient's physical condition was monitored per policy.

Findings include:

1. The Hospital's policy titled, "Utilization of Human Restraint" (last reviewed 2/2017), was reviewed on 8/23/18 and required, "The restrained patient's pulse and respiration will be assessed every two hours..."

2. The clinical record of Pt. #3 was reviewed on 8/23/18. Pt. #3 was a [AGE] year old female, admitted on [DATE] with a diagnosis of acute psychosis. The clinical record indicated that Pt. #3 was in 4 point (both wrists and legs) locked restraints on 7/20/18 from approximately 12:21 PM to 6:30 PM. The "Observation / Restraint Flow Sheet" included that pulse and respirations (vital signs) were last assessed between 3:00 PM to 4:00 PM. The clinical record lacked documentation that another set of vital signs were completed within 2 hours (by 6:00 PM).

3. The clinical record of Pt. #6 was reviewed on 8/23/18. Pt. #6 was a [AGE] year old male, who (MDS) dated [DATE] with agitation. The clinical record included a physician's order for 4 point locked restraints on 7/27/18 at 10:15 AM. The close observation record indicated that Pt. #6 was in restraints from 10:15 AM to 5:00 PM. However, the "Restraint Flow Sheet" indicated that monitoring for Pt. #6 did not begin until 11:45 AM (an hour and 30 minutes later).

4. During an interview on 8/23/18 at approximately 1:45 PM, the Director of Nursing (E#14) stated that vitals should have been completed and documented every two hours. E#14 also stated that restraint checks should be conducted and documented every 15 minutes.