PRINTED: 06/20/2017 FORM APPROVED • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER· 144040 OMB NO. 0938-0391 COMPLETED A BUILDING--------- c 6. WING 06/08/2017 STREET ADDRESS, CITY, STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION .. A 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE AOOO Without confirming or denying the truth, accuracy and completeness of An Investigation was conducted 06/08/17 for Complaint# IL00093947/172433 and IL00093757/172418. The Hospital was not in compliance with the Condition of Participation of 42 CFR 482.13, Patient Rights for Hospitals as evidenced by: A 115 482.13 PATIENT RIGHTS A hospital must protect and promote each patient's rights. the items set forth in the Statement of Deficiencies, the provider submits the following Plan of Correction. The Statement of Deficiencies was received by the provider on 6/23/2017. Therefore, this Plan of Correction is being submitted timely." A 115 lA !..C (A)( The polity 7/1/2017 AllS the hospjtal ptotect•d and promoted p.aUent•s rlchtsand wfety by: tntit~ Checks WIS Py the S.loty Officer or Dostcn••· and auditod lorcomplotlon. Any del...ienctos ••• roportod to 1dministr1Uon~ Mtd monthly complianCe Is reported to the S1fety Commitcee 1nd Perfo rmanc• Improvement Committee tntervteW, It WaS determined fOr 7 Of 7 Inpatient This wiP bo mon"Os Cool of 100% compliorou,The person psychiatric units (Adolescent, General Adult, Dual ultlmotolyrosponsibloforthisoctionlsthoS.fotyOffker · · W [A 144 (BI( The Doflcioncy noted In A1•4 (B) wos discow;tddurin& an obsorvot~nal tour of tho Adoltsachocl of 10 ( Pts #1 2 3 4 5 and 7) clinical records boon recontly ploced thoro!>'( tho conttoctor. When units undorco mointtMncO, th S.fetyOffi.Wookly InfectionCOntrol. S.loty. •"" Rlst. Rcunds porformod by the lnfoctlon • • • • • 0 , • 1 • ' 1 1 " 1 • • CMO Findings include: Control RN, Safety Officer• .and the Oiftctor of Rfsk Man~em.nt~ wil1 monitor for continued CGiftP~nca. All rswes wll M reported 'o the S.Jifety OHicer for immed iate resolution The per"'n ultrm.ately respo nsiblt for 1hls 1Unds 1 Th H "tal f "I d • f t "t h k shells !SnMnutochtckdocumontot.onwosrevisod odcl;rcofi«ldlordocumontinlthatflNStoffwJl perforrnat - e ospl ate lO ~nsure sa e y U~l c ec srnlnlm~mono!Smlnutochocbper shilt. A>woll, R~Stoffw~r••lowdocumontatlonfor complotlon, Jnd conflrrntho were conducted, as requIred. See deficiency at completion of the form .. ,h •hilt. Audits will be perforMed so medlc:ol record• monthly to ensurefullond accurate A-144A. completion oilS minute rounds shoots. The results will be oeported to the PtrformafiCelmprovomont Committoo.This Gf1 win tJe. monitOft-d for four (:Ot'lse(Utift months with .a menurtment of success toal of lOOK compliance , Administr~tion will do periodic random comp•.a ntt reviews to ensure compliance with patient roundfn1. Tht~ revit ws will occ:uf wte•ly 2. The Hospital failed to ensure a plastic bag wasonoRactlvepetient cor..roosforfourconsocutlvomonths. TllopeuonultlmotelyrosponslblelorthluctionisthoChlof not in a patient bathroom. See deficiency at Hvrsmcofficor. (A 168 (AJ) Restr•int •nd Sec\asion Order Fotm wu revised. approved. and re·eduuted to all RN 1t•ff bv June 22. 2017 A-1448 o PhvsLclans were inrormtd about chanc•s in documentation. Tht u pdated Order Form rtqulrtd that eac h sepa rate •nttttvenUon. 3 Th H "t 1f "led t f ty ovenilportolono....,t,requlrod~sownordorform.AIRNit•ff-roeducetedonthtl\oSj)iQ po.Kydofini"'SI<.W...n ' e . OSpi a at 0 ensure sa e . .. •seeluslon litho involuntoryconlirlernont oh patlontolone ... oroom Of ••ulromwhich the pationt is physically precaUtiOnS were COnducted every 15 mtnutes, as provontrd from looviOJ. 5eeil.lslon mly only bo used fortho manuement of violent Ofsolf·destructivo bohovior", from required by policy. See deficiency at A-144C. poW cv "RosUoint and/or SOcius on".Hospi~lloadouhip developed. po•t-ewnt review process to evaluoto •• uses of restrH'It aM ~e,luiion. This review ptocen includes dOOHMntatton ev1luaUon, c:hart ftYttw. and "''" tducaUon wheft needed Resulu. of the reviews 1re presen te-d to the Pttfon-nanu lm prcwtmtnt Commlttte. The ptrson ultimately res onsible for the aetiol'l Is the Chltr Nursin& Officet. TITLE , (XGlDATE &-JJ ilVJ 70610812017 Any deficiency statement endi with an a 1sk (•) de otes a de iency which the institution may be excused from correcting providing it is determined that ot" ~afeguards provide s tent protection to the patients. (See instructions.) Except for nurs~ng homes. the findings stated above are disclosable 90 days f<. •19 the date of sutVey whether or not a plan of correction is provided. For nurs1ng 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 FORM CMS·2567(02·99) Previous Versions Obsolete Event ID· XOR911 Facility lO- lL HOSP5915 If continuation sheet Page 1 of 13 STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION OMB NO (X 1l PROVlDERJSUPPLIERICLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION 0938~0391 (X3) DATE SURVEY COMPLETED A BUILDIN G - - - - - - - - - c B. WING 144040 06108/2017 STREET ADDRESS, CITY. STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG PRINTED: 06/20/2017 FORM APPROVED .-~· DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES DES PLAINES,IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PlAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG [XSl COMPLETION DATE (A 169) A.tstr~•nt and Sec:luslo tt Otder Form was re~lsed, approved, and re·tduc.attd to all ftN staH by June 22, 2017. A 115 Continued From page 1 4. Tthe Hospital failed to ensure a physician's order was written for a patient placed in restraint/seclusion. See deficiency at A-168. 5. The Hospital failed to ensure restraints were not ordered as a PRN (as needed). See deficiency atA~169 . PhysKJans were Informed about chan&ts In documentation. Tht updated Ordtr Form requir~ that each sep.~r1te ln,tNtfltlon, ewn cf part of onc even,, teq\llted iU own order form Tht wo rdin& on the documer~t w~s revised to remove tht statement • If nuded for emeraenc:v m1 n11tment, restralnt/s.dude for-·"· Re-eduuUon was provided to d RN stiff by June- 21. 2017 on the hospiQI policy ~rohibitinc 'he use of l'testrl int/S.cluston orders o~s PRNi from poltcy •R•stt1 int Hd/Of S.ctuslott• Ho.1plta.l t.Hershipdevetopcd,. post-event review ptOCISS to lt'Y~Iu1te 111 uses of ttstrl•n• and seduston. This review process W.cludes documentaUOn evt~ lut1ion, cNrt review, 1nd staff eduutO n when needed Results o f the reviews 1re Pfe$tnttd to the P~otrnance fmptovement Com nMUre. The person u ltilmately responsible for action b Nunlnc Officer. (A 171) RestrM!t 1nd seclusion Order Form was reviHd~ 1pprowd, and ,...duc.ltltd t o II RN staff by Jun. 22, 2017. PhysiciJ.ns were informed about chancu.,. documentation. TN updatH Otchr Form requited that uch se~rlte 6M~t~, ev•n if p1rt of one event, required its own ordH fort~~~. Ttw otder Jorm sti lts the maximum t"-e pe< bosod off oct tho RN ~· ....... by June 30. 2017 to provide oversl&ht t(> •mure thlt t imes ue .c:cur1tdv docu~ltd. and t hat W.te~"Ventions do not exceed max.IMum tir'lvs perst1tellw. Hospitlllndershlp d..wloped a post·ew nl rtvtew proceu to ev1 \J1te II VHsof rutr~lntal\d seclusion. This review PfOC.ISS iftcludes doc:urnent1tfon evalut~tic>n, chart r~w, 1nd staH .duation when tlw tlw Chlof lnte,..ntlonsunbe •ppHed. st•tolow, of of potlont. ro·oduutod 6• The Hospital failed to ensure patientS Were notnoedod. _ leResults of tlwrtvlowsoroP CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION (X 1) PROVIOERJSUPPLIER/CUA IDENTIFICATION NUMBER OMB NO 0938-0391 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. B U I L D I N G - - - - - - - - c B. WING 144040 NAME OF PROVIDER OR SUPPLIER 555 WIL.SON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)10 PREFIX TAG 06/08/2017 STREET ADDRESS, CITY. STATE. ZIP CODE DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUll REGUlATORY OR LSC IDENTIFYING INFORMATION} A 168 Continued From page 6 PROVIDER'S PlAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG tn ) COMP\.ETION OAU A 168 2. On 6/7/17 at 1:25PM, Pt. #3's clinical record was reviewed. Pt. #3 was a 43 year old male, admitted on 3/17/17, with a diagnosis of schizophrenia. Pt. #3's "Restraint/Seclusion Order Sheet" dated 3/19/17 at 10:10 PM, included a "manual hold", because "patient attacked statr'. However, a "RN Progress Note" dated 3/20/17 at 3:05AM , included, that on 3/19/17 "...At 9:45 PM, Patient lunged at and made physical contact with Mental Health Technician. Patient placed on manual hold ... Patient escorted to seclusion room ... Patient remained in seclusion room with door open, being monitored by staff until1 0:05 PM. Patient offered water and snacks ..." Pt. #3 returned to his room, but "after 30 minutes patient remains confused. Placed in quiet room for the remainder of the shift..." 3. On 6/7/17 at 2:20PM, an in interview was conducted with the Director of Performance Improvement and Risk {E #3} and the Director of Nursing (E #6). E #6 stated that Pt. #3 was not in seclusion because the seclusion room door was left open and the Nurse documented the incident incorrectly. 4. The clinical record of Pt #5 was reviewed on 6/7/17 at approximately 1:50PM. Pt #5 was a 16 year old female admitted on 4/15/17 with a diagnosis of disruptive mood dysregulation disorder. Pt #S's clinical record contained a Restraint/Seclusion Order Sheet dated 4/21/17 that included a physician's order for manual hold and 4 point mechanical restraints. Documentation indicated that Pt #5 was placed in a manual hold on 4/21/17 from 3:55PM to 4:12 PM and then 4 point leather restraints from 4:31 FORM CMS-2567(02-99) Previous Versions Obsole1e Even11D XQR911 Facility ID: IL HOSP5915 If continuation sheet Page 7 of 13 PRINTED: 0612012017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAl D SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPUERICLIA IDENTIFICATION NUMBER OMB NO 0938-0391 A. BUILDIN G - - - - - - - - NAME OF PROVlDER OR SUPPLIER 0610812017 STREET ADDRESS, CITY, STATE, ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL PREFIX TAG c B. WING 144040 {X4) ID (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTI~N DES PLAINES,IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 168 Continued From page 7 PM to 5:30 PM (19 minutes later). The clinical record lacked a second physician order for the placement of the mechanical restraints following the manual hold. PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) COMPLETION DATE A 168 5. Pt #S's clinical record contained a RestrainUSeclusion Order Form dated 5/1/17 that required 4 point mechanical restraints. The order form indicated that Pt #5 was placed into a manual hold prior to the mechanical restraints without a physician's order. 6. An interview was conducted with the Director of Performance Improvement and Risk (E #3) and the Director of Nursing (E #6) on 6/7/17 at approximately 2:20 PM. E #3 and E #6 stated that there should have been a second order for the restraints because of the time lapse and there was no order for the patient to be placed in a manual hold. A 169 482.13(e){6) PATIENT RIGHTS: RESTRAINT OR SECLUSION A 169 Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This STANDARD is not met as evidenced by: Based on document review and interview, it was determined that for 3 of 5 clinical records (Pts #2, 4, and 5) reviewed of patients in restraint, the Hospital failed to ensure that restraint orders did not include a PRN (as needed} component. Findings include: 1. The Hospital policy entitled, "Restraint and/or Seclusion," (Effective date:11/14} reviewed on FORM CMS-2587(02·99) Previous Versions Obsolete EveotiD· XOR911 Facility 10: ll HOSP59t 5 If continuation sheet Page 8 of 13 PRINTED: 06/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1) PROVIDERISUPPLIER/CliA IDENTIFICATION NUMBER: OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING 144040 NAME OF PROVIDER OR SUPPliER 06/08/2017 STREET ADDRESS, CITY, STATE. ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION DES PLAINES,IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 169 Continued From page 8 6/6/17 at approximately 11 :00 AM required, "Policy ... G. No PRN or standing orders for restraint or seclusion are permitted." PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE A 169 6/26/2017 A 169 Restraint and Seclusion Order Form was revised, approved, and re-educated to all RN staff by June 22, 2017. Physicians 2. The clinical record of Pt #2 was reviewed on 6/7/17 at approximately 1:40 PM. Pt #2 was a 14 year old female admitted on 4/5/17 with a diagnosis of major depressive disorder. Pt #2's clinical record contained Restraint/Seclusion Order Sheets dated 4/17/17, 4/18/17 at 2:26PM and 2:50AM, and 4/19/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management. restraint/seclude for ... " were informed about changes in documentation. The updated Order 3. The clinical record of Pt #4 was reviewed on 6/7/17 at approximately 1:45 PM. Pt #4 was a 28 year old female admitted on 3/21/17 with a diagnosis of schizoaffective disorder. Pt #4's clinical record contained Restraint/Seclusion Order Sheets dated 4/6/17 and 4/30/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management, restraint/seclude for ..." education when needed. Results of the reviews are presented Form required that each separate intervention, even If part of one event, required its own order form. The wording on the document was revised to remove the statement "If needed for emergency management, restraint/seclude for .. .". Re-education was provided to all RN staff by June 22, 2017 on the hospital policy prohibiting the use of Restraint/Seclusion orders as PRN, from policy "Restraint and/or Seclusion". Hospital leadership developed a post-event review process to evaluate all uses of restraint and seclusion. This review process includes documentation evaluation, chart review, and staff to the Performance Improvement Committee. The person ultimately responsible for the action is the Chief Nursing Officer. 4. The clinical record of Pt #5 was reviewed on 6/7/17 at approximately 1:50 PM. Pt #5 was a 16 year old female admitted on 4/15/17 with a diagnosis of disruptive mood dysregulation disorder. Pt #5's clinical record contained Restraint/Seclusion Order Sheets dated 4/21/17, 4/26/17. and 4/29/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management, restraint/seclude for... " 5. The Director of Nursing (E #6) stated, during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID XOR911 Facility ID: IL HOSP5915 If continuation sheet Page 9 of 13 PRINTED:- 06/20/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1) PROVIOERISUPPLIERICLIA IDENTIFICATION NUMBER OMS NO 0938-0391 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING _ _ _ _ _ _ __ c B. WING 144040 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 06/08/2017 STREET ADDRESS. CITY. STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} A 169 Continued From page 9 an interview on 6/7/17 at approximately 2:30PM. that the order did indicate that restraint/seclusion could be used as PRN. A 171 482.13(e)(8) PATIENT RIGHTS: RESTRAINT OR SECLUSION PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (XSI COMPLETION DATE A 169 A 171 6/30/2017 A171 Unless superseded by State law that is more restrictive-(i} Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; Restraint and Seclusion Order Form was revised, approved, and This STANDARD is not met as evidenced by: Based on document review and interview, it was determined that for 3 of 5 (Pts #2, 4, and 6) clinical records reviewed of patients with restraint usage. the Hospital failed to ensure patients were not restralned longer than allowed. includes documentation evaluation, chart review, and staff re-educated to all RN staff by June 22, 2017. Physicians were informed about changes in documentation. The updated Order Form required that each separate intervention, even if part of one event, required its own order form. The order form states the maximum time interventions can be applied, per state law, based off of age of the patient. RN Supervisors were re-educated by June 30, 2017 to provide oversight to ensure that times are accurately documented, and that interventions do not exceed maximum times per state law. Hospital leadership developed a post-event review process to evaluate all uses of restraint and seclusion. This review process education when needed. Results of the reviews are presented to the Performance Improvement Committee. The person ultimately responsible for the action is the Chief Nursing Officer. Findings include: 1. The Hospital policy entitled, "Restraint and/or Seclusion,'' (effective date:11/14) rev!ewed on 6/6/17 at approximately 11 :00 AM required, "Policy...J. restraints/seclusions orders ...4 hours for adults {18 years and older), 2 hours for children and adolescents age 9 17...Procedures ... 12. Completes required documentation regarding patients in restraint including ..." FORM CMS-2567(02-99) PreviOus Vers10ns Obsolete EventiO· XOR911 FaCility ID: IL HOSP5915 If continuation sheet Page 10 of 13 PRINTED: DEPARTMENT OF-HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . (X1) PROVIDER/SUPPLIER/Cl.IA IDENTIFICATION NUMBER: -06/2~/2017 FORM APPROVED OMB NO 0938-0391 {X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING----- --- c B WING 144040 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE , ZIP CODE 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)10 PREFIX TAG 06/08/2017 DES PLAINES,IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 171 Continued From page 10 2. The clinical record of Pt #2 was reviewed on 7/7/17 at approximately 1:40 PM . Pt #2 was a 14 year old female admitted on 4/5/17 with a diagnosis of major depressive disorder. Pt #2's clinical record contained Restraint/Seclusion Order Sheets dated 4/19/17 and 4/20/17 at 9:00 AM and at 4:25PM that indicated Pt #2 had been placed into 4 point mechanical restraints. The order forms lacked either the time Pt #2 was placed into restraints and/or removed, to assure Pt #2 was not restrained longer than the policy allowed. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE A 171 3. The clinical record of Pt #4 was reviewed on 6/7/17 at approximately 1:45PM. Pt #4 was a 28 year old female admitted on 3/21 /17 with a diagnosis of schizoaffective disorder. pt #4's clinical record contained Restraint/Seclusion Order Sheets dated 3/22/17 at 7:30AM, 10:45 AM, and 4:30PM and 3/25/17. The orders failed to include the maximum hours allowed , as required by the order form. 4. The Director of Nursing (E #6) stated, during an interview on 6/7/17 at approximately 2:30PM, that the documentation did not indicate the time of restraint usage. A 395 482.23(b)(3) RN SUPERVISION OF NURSING CARE A395 A registered nurse must supervise and evaluate the nursing care for each patient. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for ordering of medications, the Hospital failed to ensure medications were FORM CMS-2587(02-99) Previous Ve1$ions Obsolete Event IO·XOR911 Facility lO- ll HOSP5915 If continuation sheet Page 11 of 13 PRINTED: 06/20/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STAtEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1l PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER. FORM APPROVED OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION A BUILDING-------- c B WING 144040 NAME OF PROVIDER OR SUPPLIER 06/08/2017 STREET ADDRESS. CITY, STATE. ZIP CODE 655 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED DES PLAINES, IL 60016 SUMMARY STATEMENT OF DEFICIENCrES (EACH DEFIC1ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)' A 395 Continued From page 11 obtained and administered as ordered. PROVIOER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPlET!ON DATE A395 6/26/2017 A395 Findings include: Policy entitled " Physician Orders" was amended to reflect 1. The Hospital policy entitled, "Written Medication Orders," (reviewed December 2015) reviewed on 6/7/17 at approximately 1:15PM required, "... B. Nursing ...2. Nursing forwards the written order copy to the pharmacy in a timely manner." 2. The Hospital policy entitled, hAtter Hours Procurement of Medications," (reviewed December 2015) reviewed on 6/7/17 at approximately 1:20 PM required, "I. Policy: The pharmacy shall maintain a limited supply of commonly used drugs in a specially designated location for urgenVemergent use." that medicati on orders are hand delivered or faxed to the pharmacy. RN Staff was re-educated by June 22, 2017 by the Chief Nursrng Officer to clarify the policy. The person ultimately responsible for this action Is the Director of Pharmacy. 6/26/2017 A395 The Director of Pharmacy/Designee is available 24 hours daily, to 3. The clinical record of Pt #1 was reviewed on 6/6/17 at approximately 10:15 AM. Pt#1 was a 14 year old female admitted on 4/19/17 with diagnoses that included, major depression and suicide ideation. Pt #1's clinical record included physician's admitting orders dated 4/19/17 at 11 :00 PM that included, Pt #1 's home medication record that included: home medications - Zoloft (anti-depressant) and Melatonin {hormone used for sleep) and the last time taken was 4/18117. Documentation included that the physician's order was faxed to the pharmacy on 4/21/17. ensure that all medications ordered have been dispensed per Pt #1 's clinical record included a Medication Administration Record with the initial date of 4/21/17. The record indicated that Pt#1's Zoloft (Sertraline) 125 mg was started on 4/20/17; however, the first documented dose was on 4/21/17. Pt #1 's Melatonin 5 mg was started on 4/21/17. This audit will be reported to the Pharmaceuticals and FORM CMS-2567(02-99) Previous Versions Obsolete Event 1D:XOR9tt physician's order, in a timely manner. Pharmacy Director/Designee ensures that medications are stocked and available during off hours, per policy. Ongoing compliance is being monitored via weekly pharmacy, storage, and medication room inspections. Ongoing audits are completed to ensure all medications ordered were received by the pharmacy within four hours of transcription. RN Staff were re educated by June 22, 2017 about the process for obtaining medication s on off hours. This includes use of the night cabinet, obtaining medications from a local pharmacy, or contacting the Director of Pharmacy/Designee for guidance. Therapeutics Committee, and the Performance Improvement Committee. The person ultimately responsible for this action is the Director of Pharmacy. Fa~rlity 10: IL HOSP591 5 If continuation sheet Page 12 of 13 PRINTED: 06/2012017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X 1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER· OMB NO 0938-0391 A. B U I L D I N G - - - - - - - - c B. WING 144040 06/08/2017 STREET ADDRESS. CITY. STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 555 WILSON LANE CHICAGO BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION DES PLAINES,IL 60016 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUlATORY OR LSC IDENTIFYING INFORMATION) A 395 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A395 4. MD #1 stated during the inteJView on 6/6/17 at approximately 1:00 PM, "When a patient is admitted, the way medications are ordered is through the med reconciliation. I check continue home meds or discontinue the meds. I continued the home meds of the patient (Pt #1 }." 5. A registered nurse (E #4} stated during the inteJView on 6/7117, "When a patient is admitted and we get orders from the doctor, the home medications are reviewed and the physician decides which ones to keep. The order is then sent to the pharmacy." 6. On 617117 at approximately 12:15 PM, the Pharmacist (E #5) was inteJViewed. E #5 stated, "When a patient is admitted at night and is in need of medications, there is a night cabinet available for use. In the morning, we would get the form and the order from the cabinet and fill the order. Looking at my computer, I see the first medication that was sent from the pharmacy was on 4/21/17. There is no documentation in the night cabinet book to indicate the patient received a dose upon admission. The order for the medication is dated 4/19/17 at 11:00 PM and signed by the doctor on 4/20/17 at 10:00 AM but was not faxed to us until4/21/17." FORM CMS-2567(02·99) Prev,ous Versions Obsolete EveniiD· XOR911 Facility ID· IL HOSP5915 If continuation sheet Page 13 of 13