2/28/2019 Survey Report for 144040

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8. MEDICAID SERVICES 0MB N0. 0933-0391
(XI) X2 MULTIPLE X3 DATE SURVEY
STATEMENT OF 
DEFICIENCIES IDENTIFICATION NUMBER
AND PLAN 144949 5' 3- 98/92/2918
CORRECTION I - A

 

 

 

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 60616

 

 

HOSPITAL J-
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)
0069 Initial Comments



Any deficiency statement ending with ani asterisk denotes a de?ciency which the institution may be excused from correcting
providing it" Is determined that other safeguards provide suf?cient protection to the patients. (See reverse for further Instructions.)
Except for nursing homes, the findings s'tated 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 3

 

LABORATORY OR PROVIDERISUPPLIER TITLE I (X6) DATE
REPRESENTATIVE SIGNATURE i

m. I 
FORM OMS-2567 (02/99) Previous Verifions Obsolete
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1/13

 

 

2/28/2019 Survey Report for 144040 5"

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

 

 

 

CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391
3 (X1) -- (X2) MULTIPLE (X3) DATE SURVEY
STATE 0 CONSTRUCTION COMPLETED
DEFICIENCIES IDENTIFICATION NUMBER
AN PLAN OF 144640 08/02/2618
CORRECTION 
0F 6E EJPELER Eu;
CHICAGO BEHAVIORAL 555 LSON LANE DES PLAINES IL, 66016
HOSPITAL
Eor information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
336774

 

.An investigation was conducted on 68/2/18 for
icomplaint . The Hospital was not
jin compliance with the Condition of Participation,
g42 CFR 482.13, Patient Rights, as evidenced by:

I

An immediate jeopardy (IJ) was identified on 8/2/18,
:for the Hospital's failure to ensure sexual abuse
allegations of a patient by an employee were
?thoroughly investigated. This failure placed all
patients with sexaual abuse allegations
Eat risk for serious harm. An was announced on
.8/2/18 at 3:29 PM, during a meeting with the Chief
=Executive Officer, Senior Vice President of Clinical
Services, and Director of Performance Improvement
'and Risk Management. The immediate jeopardy was not
~removed by the survey exit date of 8/2/18.

 

A0115 ?Patient Rights
M82.13
Corrected On: 68/20/2918

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 I TITLE 1? (X6) DATE

REPRESENTATIVES SIGNATURE 

 

- I
i I

FORM CMS- 2567 (02l99) Previous Versions Obsolete
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2/28/201'9

HOSPITAL

Survey Report for 144040

 

DEPARTMENT OF HEALTH AND HUMEAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAEID SERVICES OMB NO. 0933-0391
(X1 X2 MULTIPLE X3 DATE SURVEY
STATE PREDVIDERISUPPLIERICLIA (CONSTRUCTION 
DEFICIENCIES IDENTIFICATION NUMBER
AN LAN 0F 144040 2 3- 68/02/2818
CORRECTION NAME OF PROVIDER SUPPLIER ESTREET ADDRESS, CITY, STATE, ZIP
CHICAGO BEHAVIORAL I555 WILSON LANE, DES PLAINES, IL, 60616

mum ?u "1l- um? um-u nu. man mm mum . 

 

For information on the provider' 5 plan to correct this deficiency, please contact the provider or the state survey agency.

E36774

Based on document review and interview, it was
determined that the Hospital failed to ensure
patients' rights were protected. This has the
potential to affect all current and future patients
with sexual abuse allegations at risk for harm. As a
result, the Condition of Participation, 42 CFR
482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure the grievance
process was followed, as required (A-6118).

2. The Hospital failed to ensure allegations for
sexual abuse were thoroughly investigated, to ensure
patients are free from abuse 

An Immediate Jeopardy (IJ) began on 16/15/17 for the
Hospital's failure to thoroughly investigate Pt.

5 sexual abuse allegations by an employee 
Ethus potentially placing all patients
Ewith sexual assault allegations at risk for serious
Eharm.

I

EThe 13 was identified and announced on 8/2/18 at

3 26 PM, during a meeting with the Chief Executive
EOfficer, Senior Vice President of Clinical Services,
Eand the Director of Performance Improvement and Risk
gz?Management. The was not removed by the survey
,exit date of 8/2/18.

i

Any deficiency statement ending wi?1 ari 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 OR PROVIDERISUPPLIER . TITLE DATE

REPRESENTATIVE SIGNATURE i i

 

r?I. . nm?r? _j

FORM (02/99) Previous Verisions Obsolete

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3/13

2/28/2019 Survey Report for 144040

 

DEPARTMENT OF HEALTH AND HU MAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0933-0391

(x2) MULTIPLE (X3) DATE SURVEY

STATEMENT OF PROVIDERISUPPLIERICLIA CONSTRUCTION COMPLETED
DEFICIENCIES IDENTIFICATION NUMBER
AN PLAN OF 144949 I 08/02/2618
CORRECTION I 
O: STREET ADDRESS, CITY, STATE, ZIP
CHICAGO BEHAVIORAL ?555 WILSON LANE, DES PLAINES, IL, 66616
HOSPITAL

 

For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

 

 

A6118 Patient Rights: Grievances


ICorrected On: 08/26/2618

I

36774

'Based on document review and interview, it was
determined that the Hospital failed to follow the
Igrievance process for 2 of 4 allegations (Pt. 
ifor sexual abuse, as required.

 

IFindings include:

I
I1. On 7/31/18 at approximately 10:30 AM, the

Eclinical record of Pt. #1 was reviewed. Pt. #1 was a
$46 year old female admitted on 5/22/18 with a
idiagnosis of schizoaffective disorder, depressive
type On 5/23/18 the dally nur51ng progress notes

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

 

LABORATORV DIRECTOR 5 OR PROVIDERISUPPLIER 3 TITLE (X6) DATE
REPRESENTATIVE SIGNATURE i I I

i 

FORM CMS- 2567 (02199) Previous Versions Obsolete

I
CVisit1 .html 4/13

2/28/201 9

Ear information on the provider?s plan to correct this deficiency. please contact the provider or the state survey agency.

participation 3

Survey Report for 144040

DEPARTMENT OF HEALTH AND SERVICES FORM APPROVED

 

CENTERS FOR MEDICARE 8. MEDICAID SERVICES 0MB NO. 0938-0391
X1 X2 MULTIPLE X3 DATE SURVEY
STATEM NT 0 (COIJNISTRUCTION 

IDENTIFICATION NUMBER
AND PLAN OF 144040 3- 08/02/2018
CORRECTION - 

OF PRJVIDER 0R SUPPLIER STREET mm WM I

CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 60016

HOSPITAL

 

gm.? .. mum?c . n- nun-mum 

 

?of #6 (Registered Nurse/RN Pt #1 RR on
5/23/18). 1 indicated, ?Thought Process: Continues
ito say outloud that she was sexually approached by
'male staff the last time I (Pt. was here. 
EHowever, a follow- up investigation regarding Pt.
allegation was not available.

I

2. On 7/31/18 at approximately 10:45 AM, the
Grievance and Complaint Log from 2/2018 to 7/29/2018
was reviewed. The log did not include Pt. #1'5
allegation of sexual abuse.

3. An incident report dated 10/15/17, for Pt. #1'5
hospitalization from 10/7/17 to 10/16/17 due to
unspecified schizophrenia, was received from the
Hospital on 8/1/18. The incident report written by
the Nursing Supervisor (E #13) indicated, ?Godmother
of (Pt. called this writer (E #13) stating that
her daughter was here and had recently accused
someone of raping her(.) (B)ut godmother states she
later found that to be untrue. She continued the
conversation stating there was a staff member
here(,) her daughter had been intimately involved.
She said her daughter (Pt. had been here before
and wanted to come back here. Her mother stated once
previously while out at her home the staff she
called (E #16) (a bald, black man in his 50's with
the same birthday as [Pt. had called (Pt. 
cell phone at 3 AM. When mother asked why was he
calling her patient (Pt. state(d) "he was just
checking on me." Mother also said patient said they
#1 and staff) had had consensual sexual
iintercourse two times previously. She says that (Pt.
also was given phone by the person who
?allowed her to text and call her mother. Per



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 3 0R 3 TITLE (X6) DATE
REPRESENTATIVEI SIGNATURE 7.. u?na-m?ll- n.

FORM OMS-2567 (02/99) Previous Versions Obsolete

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2/28/2019 Survey Report for 144040

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8. SERVICES OMB NO. 0938-0391
X1 X2 MULTIPLE X3 DATE SURVEY
STATEM NT 0 

DEFICIENCIES IDENTIFICATION NUMBER
AND PLAN OF 144646 3- $31?le a8/62/2618
CORRECHON 

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP

CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 56016

HOSPITAL

For information on the provider's plan to correct this deficiency. please contact the provider or the state survey agency.

 

told her she only had five minutes. When mom asked
who that was, patient told mother that was him. I 
#13] told mother I would investigate this further
and go and talk to her. I #13] went and spoke to
patient and she denied stating they had sex. She
(Pt. said, this man was checking in on her at
night, but she felt ok because someone else would
come right in after him and check on her. She also
said she could not remember his name. She said she
didn't want to be bothered with him and just wanted
to go home. I #13] asked her to describe the
person and she said he was tall, bald, black and big
but not fat."

4. On 7/31/18 at approximately 11:60 AM, the
HOSpital's policy titled, "Grievances and the
Patient Advocate" (effective 11/2614) was reviewed
and indicated, "Policy: (The Hospital) will provide
an effective mechanism for handling 
grievances as an important part of providing quality
,care and services to our 2.
iIt is the responsibility of each staff member to
irespond to any concern or grievance voices
iby 3. When a patient voices a complaint,
ithe patient may be encouraged to discuss the
:complaint with their physician or unit nursing
istaff. The staff nurse supervisor may be 
i4. An issue becomes a grievance if it involves an
iallegation of the facility staff
ishould listen to the patient's grievance, consider
ithe circumstances and context of the issue, assure
ithe patient that their concerns will be
6. The Risk Manager should be made
iaware of all serious patient 

is 7 . 

Any deficiency statement ending with ari 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 0R i TITLE i (xe) DATE
REPRESENTATIVES SIGNATURE I i
__ic I. _m is 7 i 
FORM OMS-2567 (02/99) Previous Verisions Obsolete
i

6/13

 9

Fir-mm ?nu-me my. would-Im< 


Survey Report for 144040

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0933-0391
X1 X2 MULTIPLE X3 DATE SURVEY
STATEMENT OF (COIJNISTRUCTION (COLIPLETED
DEFICIEN Cl ES IDENTIFICATION NUMBER
AN PLAN OF I 144049 3- 68/92/ 2618
CORRECTION i - i
0F PROVIDER SEEGEPLIERE 1- 
CHICAGO BEHAVIORAL 555 WILSON LANE DES PLAINES, IL, 69616
HOSPITAL

 

 

 

 

For information on the provider's plan to correct this deficiency. please contact the provider or the state survey agency.



E5. On 7/31/18 at approximately 11:39 AM, the
Hospital's policy titled, "Patient Abuse and
Neglect" (effective 11/2614) was reviewed and
included, All allegations of patient abuse or
neglect will be thoroughly 
Definitions: Class 1 B. Any sexual assault
or sexual exploitation involving an employee..

6. On 8/1/18 at approximately 10:39 AM, the
Hospital's document titled, "Position Description,
Staff Nurse" (October 2617) was reviewed and
included, 3. Act as the
patient?s advocate and assure that patient rights
are 7. Follow facility, departmental and

personnel policies and procedures.?

7. On 8/1/18 at approximately 9:52 AM, an interview
was conducted with #6 (Registered Nurse/RN-Pt.
#l's RN on 5/23/18). #6 admitted to writing the
documentation for Pt. #1 in the nursing progress
notes on 5/23/18. #6 stated, took it as
.something that happened in the past and that had
already been investigated the last time she (Pt. 
;was In hindsight, I should have gotten
reported to the nursing 
'made an incident report." When asked how she (E 
would know if the allegation happened in the past, 
said, would not know unless I went ahead and
Edo the (follow?up) report."

 

.8. On 8/1/18 at approximately 11:25 AM, an interview
Ewas conducted with #2 (Director of Performance
EImprovement and Risk Management). #2 stated that
Ehe (E is normally made aware of any allegation

M?iAny deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correctirig
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
par?tICIpatIon

1111111. I 1. .1- 

LABORATORY DIRECTORI 8 OR PROVIDERISUPPLIER TITLE
REPRESENTATIVES SIGNATURE 3 i;

I 1 
FORM CMS-2567 (02199) Previous Verfsions Obsolete

.htmi 7/13

2/28/2019 Survey Report for 144040

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAEID SERVICES OMB NO. 0938-0391
77 X1 X2 MULTIPLE (X3 DATE SURVEY
STAT 0 IDRIIDVIDERISUPPLIERICLIA CONSTRUCTION COIVIPLETED
DEFICI NC IES IDENTIFICATION NUMBER
AND PLAN OF 144646 3- 68/62/2618
CORRECHON II 
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP
CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 66616
HOSPITAL

For information on the provider's plar?I to correct this deficiency, please contact the provider or the state survey agency.

_Tof abuse. #2 stated that he (E was not made 
Iaware of Pt. #1'5 allegation in May 2618, so an
ginvestigation was not conducted. When shown #6'5
?documentation on 5/23/18, #2 said, "As soon as
they [staff] are told, they should report to the
{Nurse do a full that
Ishould have been reported.

 

 

 

39. On 8/1/18 at approximately 2:66 PM, when the
gincident report from 16/15/17 was presented,
jinterviews were conducted with #1 (Chief Executive
IOfficer), #2 (Director of Performance Improvement
Iand Risk), and #14 (Senior Vice President of
IClinical Services). #14 stated that the incident
Ireport filed by the Nursing Supervisor (E #13) on
i16/15/17 was not fully investigated. #14 added
Sthat normally, the report should have been forwarded
Ito Risk Management. #14 stated that the incident
?report was filed without proper investigation and
that the Hospital's policy was not followed.

 

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 0R TITLE I (X6) DATE
REPRESENTATIVES SIGNATURE ?3 I

,c_m_mWiLm_ii_cmm_inn I
FORM OMS-2567 (02l99) Previous Versions Obsolete
I
8/13

Survey Report for 144040

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8: MEDICAEID SERVICES OMB NO. 0938-0391
X1 X2 MULTIPLE X3 DATE SURVEY
STATE 0 EREVIDERISU PPLIERIC LIA EIOENISTRUCTION 
DEFICIENCIES IDENTIFICATION NUMBER
AN LAN 144949 3- 68/62/2618
CORRECTION i 
ENAME oE EIEWM 
CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 66616
HOSPITAL

u- E-I-m-u-ew murmuu?AWHW mes-1-: .

For information on the provider's plan: to correct this deficiency, please contact the provider or the state survey agency.

 

A6145 Patient Rights: Free From Abuse/Harassment

Corrected On: 68/26/2618

36774

Based on document review and interview, it was
determined that the Hospital failed to ensure
allegations of sexual abuse were thoroughly
investigated, to ensure patients are protected from
abuse. This has the potential to affect an average
daily census of 112 patients in the Hospital.

Findings include:

1. On 7/31/18 at approximately 16:36 AM, the
clinical record of Pt. #1 was reviewed. Pt. #1 was a
46 year old female admitted on 5/22/18 with a
diagnosis of schizoaffective disorder, depressive
type. On 5/23/18, the daily nursing progress notes
of #6 (Registered Nurse) indicated, "Thought
Process: Continues to say outloud that she was
sexually approached by male staff the last time I

Any deficiency statement ending with an? asterisk denotes a deficiency which the institution may be excused from correcting
providing it is determined that other safe?guards provide sufficient protection to the patients. (See reverse for further Instructions.)
Except for nursing homesI the findings stated above are 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

metmxe

 

LABORATORY 0R PROEIDERISUPPLIER :1 TITLE
REPRESENTATIVES SIGNATURE I 


 

FORM OMS-2567 (02/99) Rrevious Versions Obsolete



i

 

v.1 .mi nu ma

9/13

2/28/2019 Survey Report for 144040

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAEID SERVICES OMB NO. 0938-0391
X1 X2) MULTIPLE (X3) DATE SURVEY
STATEMENT OF PROVIDERISUPPLIERICLIA CONSTRUCTION COMPLETED
DEFICIENCIES IDENTIFICATION NUMBER
AND PLAN OF 144040 08/02/2018
CORRECTION I 
NAME OF PROVIDER OR SUPPLIER STREET AEDRESS, CITY, STATE, ZIP
CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 60016
HOSPITAL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
?1 (Pt. was here. However, a fellow? up ?7 
_investigation regarding Pt. allegation was not

 

Econducted by the Hospital.



An incident report dated 10/15/17 was received
Efrom the Hospital on 8/1/18. The incident report
jwritten by the Nursing Supervisor (E #13) indicated,
?"Godmother of (Pt. called this writer (E #13)
3:stating that her daughter was here and had recently
iaccused someone of raping her(. (B)ut godmother
jstates she later found that to be untrue. She
icontinued the conversation stating there was a staff
?member here(,) her daughter had been intimately
jinvolved. She said her daughter (Pt. had been
ihere before and wanted to come back here. Her mother
?stated once previously while out at her home the
?staff she called (E #16) (a bald, black man in his
550's with the same birthday as [Pt. had called
3(Pt. cell phone at 3 AM. When mother asked why
'was he calling her patient (Pt. state(d) "he was
just checking on me." Mother also said patient said
they (Pt. #1 and staff) had had consensual sexual
?intercourse two times previously. She says that (Pt.
also was given phone by the person who
lallowed her to text and call her mother. Per
ipatient's mother he was standing next to her and he
told her she only had five minutes. When mom asked
,who that was, patient told mother that was him. I 
i#13] told mother I would investigate this further
land go and talk to her. I #13] went and spoke to
Epatient and she denied stating they had sex. She
2(Pt. said, this man was checking in on her at
?night, but she felt ok because someone else would
Ecome right in after him and check on her. She also
Esaid she could not remember his name. She said she

 

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 PROVIDERISUPPLIER TITLE 1 (X6) DATE
REPRESENTATIVE SIGNATURE i a
I- I mm? 5 
FORM CMS -2567 ((12/99) Previous Versions Obsolete


10/13

2/28/2019 Survey Report for 144040

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8. SERVICES OMB NO. 0938-0391
I EX1 7 X2 MULTIPLE X3 DATE SURVEY
STATEMENT OF 5 ISOINISTRUCTION 
DEFICIENCIES IDENTIFICATION NUMBER
AND PLAN OF 144646 88/92/2018
CORRECTION - 
NAME OF PROVIDER ORMSUPPLIER STREET ADDRESS, CITY, STATIETZIP mm? m7
CHICAGO BEHAVIORAL 555 WILSON LANE, DES PLAINES, IL, 66016
HOSPITAL

 

 

 

.. - . mum. 

For information on the provider's plan to correct this de?ciency, please contact the provider or the state survey agency.

sea just wanted 
Eto go home. I #13] asked her to describe the
iperson and she said he was tall, bald, black and big
?but not fat."

i

i3. On 7/31/18 at approximately 11:08 AM, the
gHospital's policy titled, ?Grievances and the
Patient Advocate" (effective 11/2914) was reviewed
and required, "Policy: (The Hospital) will provide
an effective mechanism for handling 
grievances as an important part of providing quality
care and services to our 2.
It is the responsibility of each staff member to
respond to any concern or grievance voices
by 3. When a patient voices a complaint,
the patient may be encouraged to discuss the
complaint with their physician or unit nursing
staff. The staff nurse supervisor may be 
4. An issue becomes a grievance if it involves an
allegation of the facility staff
should listen to the patient's grievance, consider
the circumstances and context of the issue, assure
the patient that their concerns will be
6. The Risk Manager should be made
aware of all serious patient 

4. On 7/31/18 at approximately 11:36 AM, the
Hospital's policy titled, "Patient Abuse and
?Neglect" (effective 11/2914) was reviewed and
Iincluded, All allegations of patient abuse or
Ineglect will be thoroughly 
EDefinitions: Class 1 B. Any sexual assault
Eor sexual exploitation involving an 

I
g5. On 8/1/18 at approximately 9:52 AM, an interview

Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting
providing it is determined that other safejguards provide sufficient protection to the patients. {See reverse for further instructions.)
Except for nursing homes, the findings Stated above are 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 .

111.. 


 

LABORATORY 0R TITLE (X6) DATE
REPRESENTATIVES SIGNATURE i i

?m mm. 

FORM OMS-2567 (02I99) Previous Ver?tions Obsolete



11/13

2/28/2019 Survey Report for 144040

 

 

DEPARTMENT OF HEALTH AND HUMIAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF Ixs?vmemsuppuemu. 

DEFICIENCIES IDENTIFICATION NUMBER i I
AN PLAN OF 144949 A- BUILDING 98/92/2918
CORRECTION 

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP

CHICAGO BEHAVIORAL 555 LANE, DES PLAINES, IL, 69916

HOSPITAL

 

 

For information on the provider' 5 plan to correct this deficiency please contact the provider or the state survey agency.

was conducted with #6 admitted to writing
,the documentation for Pt. #1 in nursing progress
Inotes on 5/23/18. #6 stated, took it as
isomething that happened in the past, and that had
Ialready been investigated the last time she (Pt. 
was In hindsight, I should have gotten
reported to the nursing 
Imade an incident report." When asked, how she (E 
would know if the allegation happened in the past. 
#6 said, would not know unless I went ahead and
do the (follow?up) report."

 

 

 

46. On 8/1/18 at approximately 11:25 AM, an interview
Iwas conducted with #2 (Director of Performance
IImprovement and Risk Management). #2 stated that
Ihe (E is normally made aware of any allegation
Iof abuse. #2 stated that.he (E was not made
Iaware of Pt. #1's allegation in May 2918, so an
Iinvestigation was not conducted. When shown 
Idocumentation on 5/23/18, #2 said, "As soon as
Ithey [staff] are told, they Should report to the
INurse do a full that
Ishould have been reported."

I

7 On 8/1/18 at approximately 2: 86 PM, when the
Iincident report from 16/15/17 was presented,
{interviews were conducted with #1 (Chief Executive
?Officer), #2 (Director of Performance Improvement
Iand Risk), and #14 (Senior Vice President of
IClinical Services). #14 stated that the incident
Ireport filed by the Nursing Supervisor (E #13) on
{19/15/17 was not fully investigated. #14 added
Ithat normally, the report should have been forwarded
Ito Risk Management. #14 stated that the incident

Ireport was filed without proper investigation and

I
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 PROVIDERISUPPLIER TITLE I (XS) DATE
REPRESENTATIVES SIGNATURE I I

 

FORM CMS -2567 (02I99) Previous Versions Obsolete
i

12/13

2/28/5201 9

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Survey Report for 144040

FORM APPROVED

CENTERS FOR MEDICARE MEDICAEID SERVICES

STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION

NAME OF PROVIDER OR SLIPPLIER

CHICAGO BEHAVIORAL
HOSPITAL



OM NO. 0938-0391

(x1) (x2) MULTIPLE (x3) DATE SURVEY
PROVIDERISUPPLIERICLIA CONSTRUCTION COMPLETED

A. BUILDING
144040 ,BJch 68/62/2818

.f

STREET ADDRESS STATE, ZIP

555 WILSON LANE, DES PLAINES, IL, 69016

-""Ilm?m mun. m- t-wn-m wen-nu.- mun-.m-

 

?For ihfoi?mation on the provider's plan: to correct this deficiency, please contact the provider or the state survey agency.

that the Hospltal pollcy has not followed

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 suf?cient 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

REPRESENTATIVES SIGNATURE

(X6) DATE

FORM EMS-2567 (02f99) Previous Versions Obsolete

440403JCM1 'lCVisit1.html

13/13