7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 (X1) (X2) MULTIPLE (X3) DATE SURVEY STATEMENT OF CONSTRUCTION COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AN PLAN 0 144946 A- 3 65/17/2619 CORRECTION 3 awms I NAME OF PROVIDER OR SUPPLIER 3STREET ADDRESS, CITY, STATE, ZIP CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 60016 HOSPITAL .m ?man.? 1.. - .. sou ?mm, -. .. I I ?mu?rm" For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 6060 Initial Comments Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation LABORATORY DIRECTOR 3 OR 3 TITLE 3" (er DATE REPRESENTATIVES SIGNATURE 3 . 3 CMS-2567 (02/99) Previous Versions Obsolete 1/10 7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAEID SERVICES OMB NO. 0933?0391 (X2) MULTIPLE (X3) DATE SURVEY STATEMENT OF . CONSTRUCTION COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CHICAGO BEHAVIORAL HOSPITAL STREET ADDRESS, CITY, STATE, ZIP 144940 A- BUILDING 05/17/2919 3555 WILSON LANE, DES PLAINES, IL, 59615 For information on the provider' 5 plan to correct this deficiency, please contact the provider or the state survey agency. E46979 investigation was conducted on 5/17/19 for ?Complaint The Hospital was not -in compliance with the Condition of Participation, 342 CFR 482.13 Patient Rights, as evidenced by: .An Immediate Jeopardy (ID) was identified on 55/17/19, due to the Hospital?s failure to ensure Ethat patients that are placed in the :seclusion room and/or quiet room on the Behavioral gHealth Units (ITU - Intensive Treatment Unit - 1 West, TCU - Transitional Care Unit - 2 West and 2 South) were protected from risk of causing serious self?harm/injury. The was identified and announced on 5/17/19 at 1:24 PM, during a meeting with the Director of .Nursing, Assistant Director, Director of Performance .Improvement/Risk Management, and the Chief Executive EOfficer of the Hospital. The was not removed by gthe survey exit date of 5/17/19. A9115 Patient Rights 482.13 Corrected On: 86/07/2619 Any deficiency statement ending with an: asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homesl the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited an approved plan of correction is requisite to continued program participation LABORATORY OR TITLE DATE SIGNATURE FORM OMS-2567 (02199) Previous Versions Obsolete 2/10 7/17/2019 Survey Report for 144040 CENTERS FOR MEDICARE a. MEDICAID SERVICES OMB N0. 0933-0391 (xn x2 STATE ENT 0 PROVIDERJSUPPLIERICLIA COMPLETED DEFICI ENCIES IDENTIFICATION NUMBER AN PLAN OF I 144646 3- 95/17/2919 CORRECHON i I- oP PROVIDER oR SUPREIERM CITY STATE ZIP "mm CHICAGO BEHAVIORAL I 555 WILSON LANE, DES PLAINES, IL, 60016 HOSPITAL I I For information on the provider 5 plan to correct this deficiency, please contact the provider or the state survey agency. ?weundenmwuw ?an I4eo79 Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that patients that were placed in the seclusion room and/or quiet room were protected Sfrom causing self-harm/injury. This potentially places all future patients with Iof self-harm/injury at risk for serious harm. As a Eresult, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance. Findings include: 1. The Hospital failed to ensure that a patient placed in the seclusion room and/or quiet room was protected from causing self?harm. An Immediate Jeopardy (13) was identified on 5/17/19, due to the Hospital's failure to ensure that patients that are placed in the seclusion room and/or quiet room on the Behavioral Health Units (ITU - 1 West, TCU - 2 West and 2 South) were protected from risk of causing serious self-harm/injury. The was identified and announced on 5/17/19 at 1:24 PM, during a meeting with the Director of Nursing, Assistant Director, Director of Performance Improvement and Risk Management, and the Chief Executive Officer of the Hospital. The IJ was not removed by the survey exit date of 5/17/19. Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation LABORATORY OR TITLE (X6) DATE REPRESENTATIVES SIGNATURE FORM OMS-2567 (02/99) Previous Versions Obsolete 3/10 7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 X1 x2 MULTIPLE (X3) DATE SURVEY STATEM NT 0 EOLSTRUCTION COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AND PLAN 144646 egg-gm? 05/17/2019 CORRECHON su?pEliEE CIHZTEE if?? CHICAGO BEHAVIORAL $555 WILSON LANE, DES PLAINES, IL, 66016 HOSPITAL i For information on the provider?s plan to correct this deficiency, please contact the provider or the state survey agency. A6144 Patient Rights: Care In Safe Setting Corrected On: 66/67/2619 40079 Based on document review, observation, and interview, it was determined that for 3 of 7 Behavioral Health Units Nest, TCU- 2 West and 2 South), the Hospital failed to ensure that patients that are placed in the seclusion room and/or quiet room were protected from risk of causing serious self?harm/injury. Subsequently, a patient?s (Pt. injury followed. Findings include: 1. The HOSpital's policy titled, "Restraint and/or Seclusion (effective 11/14), was reviewed and included, 3. Seclusion is the involuntary confinement of a patient alone in a room or may be used for management of violent or self-destructive The use of restraint/seclusion is justified to iprevent the patient from causing physical harm to ?himself or The patient in restraint/seclusion shall be monitored by continuous in-person observation by a staff member who is trained and competent in the care of a patient in restraint/seclusion.. 2. The clinical record for Pt #1 was reviewed on 5/14/19. Pt 1 was a 22 year old male admitted to the Hospital on 5/7/19 at 6:45 AM through 5/7/19 at Any deficiency statement ending with arf asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes. the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved pian of correction is requisite to continued program partICIpatIon LABORATORY OR 1 TITLE (X6) DATE SIGNATURE EORM OMS-2567 Previous VerSIons Obsolete .html 4/10 7/1Tl2019 participation 1 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES 0MB NO. 0938-0391 . X1 X2 MULTIPLE X3 DATE SURVEY STATEMENT OF ERROVIDERJSUPPLIERICLIA CONSTRUCTION COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AN LAN 0F 144949 351555301? 95/17/ 2919 CORRECTION g, - assume CHICAGO BEHAVIORAL 3555 WILSON LANE, DES PLAINES, IL, 56616 HOSPITAL i For information on the provider's plan: to correct this deficiency, please contact the provider or the state survey agency. 8 E36 7PM, with the diagnOses of ?Belief "psthofic Edisorder and suicidal ideation. - The Initial Nursing Assessment dated 5/7/19 at ,16:66 AM, was reviewed and included, "Body ;Check/Safety Search Performed By: two Registered Nurses; No bruises, or lacerations were -A physician's order dated 5/7/19 at 8:35 AM, included, "Type of Restraint: Seclusion - Start time 8:35 AM Stop time 12 16 Reason for Restraint/Seclusion - Physical threatening behavior, suggestive of imminent harm to self or others." ?The Restraint/Seclusion Monitoring sheet dated 5/7/19 from 8:35 AM to 12:16 PM was reviewed and included, "Restraint Type (Seclusion), Behavior P1 (Physical Aggression), V1 (Yelling), A2 (Agitation-expression of verbal distress), Signs of Injury - (yes) at 8:56 AM to 12:16 PM, Release - (No) from 8:35 AM to 12:65 AM - A Clinical Note entered by a Registered Nurse dated 5/7/19 at 1:66 PM, was reviewed and included, "Staff reported to NOD (nurse on duty) that the patient (Pt lost his balance and was ,moving/walking backwards and hit his back against fthe door of the seclusion room and patient (Pt fended up on the floor. Patient (Pt stood up gagain and started walking, bumping on the wall and Enoted with facial bumps, swelling/redness on both ?eyebrows and upper lip (MD made aware Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. {See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes. the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program LABORATORY OR PROVIDERISUPPLIER TITLE 3- (XB) DATE REPRESENTATIVES SIGNATURE i FORM OMS-2567 (02/99) Previous Versions Obsolete 5110 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE SERVICES OMB NO. 0938-0391 X1 X2 MULTIPLE X3 DATE SURVEY STATE ENT 0 7 LROVIDERISUPPLIERICLIA COLISTRUCTION DEFICIENCIES IDENTIFICATION NUMBER AND PLAN OF 144040 95/17/2919 CORRECHON ERORSUPPEIER 3 STREET ADDRESS, CITY, STATE, ZIP CHICAGO BEHAVIORAL 3555 WILSON LANE, DES PLAINES, IL, 60016 HOSPITAL i ..Lm . "mam,? .s For information on the provider's plari to correct this deficiency, please contact the provider or the state survey agency. dated s7r71??a? If 39 AM, was reviewed and included, "Patient is a 22 year old male with history of substance abuse Ito the Hospital after he presented to ED (Emergency gDepartment) with si/sx (suicidal ideation lconsistent with acute is in need of immediate hospitalization due to risk of harm to self and others Status Examination General appearance, Attitude and Behavior: a. Clothes/Hygiene: naked, bumping into walls in his room being redirected, eyes half closed picking at the air -The High Risk Patient Precautions Records sheet dated 5/7/19 from 12:20 PM to 8:50 PM, was reviewed and indicated that Pt #1 was in the quiet room with a sitter. - A Clinical Note entered by #8 dated 5/7/19 at 2:00 PM, was reviewed and included, "Patient (Pt is still restless and walking into the wall, needs redirection. Pt #1 is not cooperative with nursing #1 is still bumping his shins on his bed." 3. Video recording of the ITU Seclusion Room on 5/7/19 between 8:30:35 AM to 12:07:40 PM was reviewed on 5/15/19 at approximately 11:00 AM, with the Director of Performance Improvement (E ?At 8:30:35 AM, Pt #1 was escorted by staff into the seclusion room and after the door was closed, Pt #1 picked at the walls and the floor, as if trying to grab small objects. The outside view of the seclusion room showed staff observing Pt #1 through Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation LABORATORY 0R PROVIDERISUPPLIER TITLE (X6) DATE REPRESENTATIVES SIGNATURE i 2 5 FORM OMS-2567 (02/99) Previous Versions Obsolete .html 6/10 7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0933-0391 STATEM ENT OF PROVIDERISUPPLIERICLIA CONSTRUCTION COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AND OF I 144949 95/17/2919 CORRELTION I - I Elseeta;as?;?c??vfgm??;2;; I CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 69915 HOSPITAL i w- .- dun?: For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. the window as? the" doOr du rui ng time ?Pt #14 was in the seclusion room. -At 8:41:16 AM, Pt #1 is seen getting down on his knees and begins to take Of his clothes. Pt #1 stands up and is pacing back and forth, walks to the wall, faces the wall and moves his body from side to side repeatedly. From this angle Pt #1's body, from the shoulders above, was out of view of the camera. -At 16:11:36 AM, Staff including #4 (Director of Nursing), #8 (Registered Nurse), #13 (Mental Health Technician), and #15 (Mental Health Technician) entered the seclusion room to administer medication to Pt Pt #1 continued with same behavior of pacing, at times losing his balance and walking into the wall, and rubbing his body (face forward) against the wall until he was taken out of the seclusion room at 12:67:26 PM. The video surveillance for the quiet room for 5/7/19 between 12:67:46 PM to 4:61:36 PM, was reviewed. ?At 12:67:46 PM, Staff escorted Pt #1 to the quiet room. Staff was observed monitoring the patient while in the quiet room. ?At 12:13:36 PM to 4:61:36 PM, Staff entered the quiet room several times, during this time Pt #1 was observed pacing, going towards the wall and window. Pt #1 was observed walking towards foot of the bed several times, and at one point, Pt #1 was observed flopped forward onto the bed. The MHT (Mental Health Technician) assigned to observe Pt #1was trying to steer and direct the patient away from the wall and Any deficiency statement ending with an' asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation LABORATORY OR PROMIDERISUPPLIER TITLE (X6) DATE SIGNATURE 1 FORM CMS-ZSET (02l99) Previous Versions Obsolete .html TM 0 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB N0. 6938-0391 X1 X2 MULTIPLE X3 DATE SURVEY STATEM ENT 0F DEFICIENCIES IDENTIFICATION NUMBER AN LAN OF 144949 3- WEDING 95/17/2919 CORRECTION 1 - PROVIDERDR CHICAGO BEHAVIORAL 2555 WILSON LANE, DES PLAINES, IL, 66616 HOSPITAL i For information on the provider's plan: to correct this deficiency, please contact the provider or the state survey agency. the bed . .1 WW 1W. -At 4:61:36 PM, Staff placed Pt #1 in mechanical restraints (soft wrist restraints on both arms and legs) and brought a vital signs machine into the quiet room. 4. On 5/14/19 between 16:36 AM to 11:16 AM an observational tour of 2 West and 2 South - STransitional Care Unit was conducted. There were six 5(6) patients on suicidal ideation precautions. No Epatients on restraints or seclusion or on one?to-one monitoring (1:1 - constant line of vision observation by a single observer who is able to .provide immediate intervention of any self-injurious behaviors). On 2 South, there were six (9) patients on suicidal ideation precautions; however, there were no patients on restraint or seclusion or on 1:1 constant line of vision Observation by a single observer who is able to provide immediate intervention monitoring. The seclusion room was unpadded. 5. On 5/14/19 between 2:66 PM to 2:15 PM an observational tour of 1 West Intensive Treatment Unit was conducted. 1 West has a capacity of 16 patients with a census of 9 patients. The unit was staffed There :were no patients on restraints or seclusion or 1:1 :monitoring. The seclusion room was unpadded. 6. On 5/14/19 at approximately 2:16 PM, an interview was conducted with the Director of Nursing (DON #4 stated that, if the patient is unable to be re-directed, the patient will then have to be Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation i LABORATORY OR TITLE REPRESENTATIVES SIGNATURE . I ?a a FORM OMS-2567 (02/99) Previous Versions Obsolete I 1 CVisit1 .html 8/10 7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 X1) X2 MULTIPLE (X3 DATE SURVEY STATEM ENT 0 IJROVIDERISUPPLIERICLIA IZIOIISTRUCTION COIVIPLETED DEFICIENCIES NUMBER AN PLAN OF 144646 a 65/17/2619 CORRECTION - .. . . .. sways? mm .1. a .nwi w. NAME OF PROVIDER OR SUPPLIER 3 STREET ADDRESS, CITY, STATE, ZIP CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 66616 HOSPITAL For information on the provider? 5 plan to correct this deficiency, please contact the provider or the state survey agency. j'placed i'n restralnts #4 stated that, after Pt #1 iwas medicated and did not reSpond or show improvement, the next step should have been to place Pt. #1 in mechanical restraints or send out for a medical evaluation. 7. On 5/16/19 at approximately 16:18 AM, an interview was conducted with an MHT (E #14 stated, work 2nd shift, I was assigned as one?t0- one with Pt when he was in the quiet room. The door was kept open for direct observation. Pt #1 was talking to himself, walking into the walls, his behavior was not normal. As Pt #1 was walking he was tripping and stumbling with the bed, his balance was not stable. Pt #1 was bruising his face, eyes, and the side of his face and the lips by walking into the wall, not too forcefully but repeatedly. Pt #1 ;s face kept making contact with the wall, he was not slamming into it but he kept making same constant movements and hitting same spots which caused the bruising. I notified the nurse that the patient kept hurting himself, and was not re-directable. Pt #1 had to be placed in restraints for less than an hour, and after taking Pt #1 off restraints, Pt #1 continued same behavior. Pt #1 continued to try to walk and had poor balance and I had to keep watching him so he would not fall. I had to sit with him until he was transferred. The nurse on duty came in to check on the patient, and checked the vital signs and bruises." 8. On 65/17/19 at approximately 12:45 PM, and interview was conducted with the Director of Performance Improvement and Risk Management (E #12 stated that, when a patient is in the Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it Is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are citedI an approved plan of correction is requisite to continued program participation LABORATORY 8 OR TITLE (X6) DATE SIGNATURE I J- I FORM CMS -2567 I02I99I Previous Versions Obsolete .html 9/10 7/17/2019 Survey Report for 144040 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0933-0391 X1 (X2) MULTIPLE X3 DATE SURVEY STATEMENT OF CONSTRUCTION DEFICIENCIES IDENTIFICATION NUMBER AND PLAN OF 144049 65/17/2619 CORRECHON . we seam"sags:I CHICAGO BEHAVIORAL E555 LANE, DES PLAINES, IL, 63016 HOSPITAL For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. seclO?iOh and/Or adiEt 5504. they (the stafr) there to protect them the patients) from getting hurt or hurting others. #12 stated that Pt #l's situation was very tricky because Pt #1 was not responding to the medication that was given. #12 stated, ?Staff should have done something else to protect Pt #1 after the medication given was not preventing the patient from Pt #l's behavior Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation LABORATORY OR TITLE (X6) DATE REPRESENTATIVES SIGNATURE 3' i FORM CMS-2567 (02/99) Previous Versions Obsolete 10/10