Loretto Hospital

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 32741 Based on document review and interview, for 3 of 3 clinical records (Pt. #1, Pt #2, Pt #8) reviewed for sexually acting out behavior, the Hospital failed to have a sexual abuse policy/protocol that would detail procedures to follow in the event of a sexual abuse allegation or inappropriate sexual behavior. Findings include: 1. On 8/11/2025, a sexual abuse policy/protocol was requested. The facility could not provide a sexual abuse policy/protocol that would include procedures to follow in the event of a sexual abuse allegation (protection of patient, offering of a sexual assault kit, examination, notification to the required parties, etc.) 2. An incident report (dated 6/26/2025), documented by the 3 East Behavioral Health RN (E #5) was reviewed on 8/11/2025. The report included, “ ...Behavioral incident: Patient found in a compromising position with a ...peer. Location: 3 East. At about 1050 [AM] while staff [E #4] were doing rounds found patient [Pt #1] in Rm 359 standing by the bed in a compromising position with [Pt #1’s] gown up to [Pt #1’s] waist with a ...peer [Pt #2] still with clothes on ran towards the bathroom. When approached [Pt #1] stated, ‘My doctor said I am the only one who could have sex with anyone, and yes, I did have sex with [Pt #2] and it feels so good, I was stressed out and it calmed me down. I did it with [Pt #2’s] roommate last night too!’ referring to patient [Pt #8]. I [E #5] talked to patient [Pt #2] and [Pt #2] stated, ‘We were about to finish when [staff member] knocked and opened the door!’ both patients admitted that it was consensual. Talked to [Pt #8] [Pt #8] did state that, ’[Pt #1] came to my room last night pulled my shirt up and we did it!’. I [E # 5] asked patient [Pt #8] if it was consensual, [Pt #8] replied ‘yes!’. 3. The 3 East & 3 West “Community Rules” (Behavioral Health units), included, “No touching, hugging, kissing or sexual contact...” 4. On 8/11/2025, Pt. #1’s clinical record included the following: - Pt #1 presented to the ED on 6/22/2025, voluntarily, for a psychiatric evaluation. - The ED physician note (dated 6/22/2025), included, “Reason for visit: Suicidal ideation ...history of major depression complains of suicidal ideation with no specific plan ...Review of past medical records reveal several different diagnoses bipolar disorder, schizophrenia as well as schizoaffective disorder [serious mental illnesses] ...Psychiatric: Denies any visual auditory hallucinations or +suicidal ideation+ depression ...Discharge/Disposition: Inpatient Admission ...” - ED nursing note (dated 6/22/2025 at 5:22 AM), indicated that Pt #1 was transported/admitted to 3 East (co-ed behavioral health unit). - The Psychiatric Evaluation (dated 6/22/2025), documented by the Advanced Practice Nurse (APN #2), included, “ ...admitted voluntarily ...brought in for suicidal ideation without a plan, depression and medical non-compliance ...behavior: cooperative, anxious, guarded, impulsive, isolated. Insight poor, Judgement poor ...Plan: Patient will be admitted to locked unit ...” - Nursing notes from 6/22/2025-7/1/2025, were reviewed and included the following notes: - 6/22/2025 at 6:40 AM: (Admission note): “ ...admitted to the behavioral health unit with a diagnosis of schizophrenia ...patient is alert, coherent and oriented X3 [person, place, time] ...patient will be placed on SP [suicidal] and AP [assault] precautions ...” - 6/26/2025 at 5:06 PM, documented by a RN (E #5), “At about 10:50 [AM] patient was found in RM 359 standing by the bed in a compromising position with [Pt #1’s] gown up to [Pt #1’s] waist with a ...peer. When approached patient [Pt #1] stated, ‘My doctor said I am the only one who could have sex with anyone and yes I did have sex with [Pt #2] and it feels so good. I was stressed out and it calmed me down, I did it with [Pt #2’s] roommate last night too!’ Attending physicians made aware orders received, noted and carried out. Patient was placed on SAO [sexually acting out precautions], placed on 1:1 [sitter within arm’s length] for safety.” - 6/27/2025 at 7:00 AM: APN #1’s orders for STI testing (HIV, RPR, Hepatitis) offered. Refused by patient (Pt #1). Pt #1’s record did not include an examination or offer of sexual assault kit. 5. Pt #2’s clinical record included that Pt #2 was admitted to 3 East on 6/25/2025, for self-reporting of suicidal ideation. Pt #2’s physician orders indicated that Pt #2 was on assault and suicide precautions on admission. SAO precautions were initiated and marked on the rounding sheets, after the 6/26/2025 incident. Pt #2 was moved to a different unit (3 West/Behavioral Health unit-male unit) due to the 6/26/2025 incident with Pt #1. STI testing was ordered and completed on 6/27/2025. Pt #2’s record did not include an examination or offer of sexual assault kit. 6. Pt #8’s clinical record included that Pt #8 was admitted to 3 East on 6/24/2025 for psychiatric evaluation, due to aggressive and combative behavior. Pt #8’s physician orders indicated that Pt #8 was on assault precautions on admission. SAO precautions were initiated and marked on the rounding sheets, after the 6/26/2025 incident. Pt #8 was moved to a different unit (3 West/Behavioral Health unit-male unit) due to the 6/26/2025 incident with Pt #1. STI testing ordered and completed on 6/26/2025. Pt #8’s record did not include an examination or offer of sexual assault kit. 7. On 8/12/2025 at 10:00 AM, an interview was conducted with the Chief Nursing Officer (E #11). E #11 stated that E #11 was made aware by the Behavioral Health Director, of an incident involving Pt #1 and 2 other patients (Pt #2, Pt #8). E #11 stated that a Mental Health Specialist (E #4) found Pt #1 and Pt #2 in a compromising position. E #11 stated that E #11 immediately began investigating to determine if there was actual witnessed sexual intercourse. E #11 stated that E #4 did not witness the patients in the physical sexual act, just the implied positioning of the 2 patients. E #11 stated that both Pt #2 and Pt #8 were interviewed regarding the allegation of engaging in sexual activity with Pt #1. E #11 stated that although it was documented that Pt #8 engaged in sexual activity with Pt #1 (on 6/25/2025), E #11 stated that when Pt #8 was interviewed again, Pt #8 denied it. E #11 stated that this incident was taken seriously, as even consensual sex is not allowed on the unit. 8. On 8/11/2025 at 1:40 PM, a phone interview was conducted with the Lead Mental Health Specialist (E #4). E #4 stated that while doing every 15 minutes rounds, E #4 entered Pt #2’s and Pt #8’s room. E #4 stated that Pt #1 was found bent over in a “compromising position” with Pt #2 behind Pt #1. E #4 stated Pt #2 yelled out “hey!” and then ran into the bathroom. E #4 stated that Pt #2’s roommate (Pt #8) was also in the room when E #4 entered, but there was no interaction between Pt #1 and Pt #8 at that time. E #4 stated that E #4 then left out of the room to inform the assigned nurse (E #5) about the incident. E #4 stated E #5 then came in and questioned both Pt #2 and Pt #8 about the occurrence. All three patients stated that sexual activity was consensual. E #4 stated that originally Pt #1 was on assault and suicide precautions, but later SAO precautions were added due to the incident. E #4 stated that Pt #1 was moved to a private room closer to the nurse’s station. E #4 stated Pt #1 was also put on 1:1 (sitter). 9. On 8/12/2025 at 2:30 PM, an interview was conducted with the Attending Psychiatrist (MD #1). MD #1 stated that no one complained that Pt. #1 was violated. MD #1 stated that, therefore, there was no indication that a rape kit should have been offered for Pt. #1. MD #1 stated that the protocol for sexual abuse allegation is that a rape kit would be offered. MD #1 stated that 1:1 monitoring was done for Pt. #1 following the incident. 10. On 8/12/2025 at 2:45 PM, an interview was conducted with the Director of Quality (E #1). E #1 confirmed and acknowledged that the Hospital does not have a sexual abuse protocol or policy. E #1 stated that the Hospital has a policy on reporting sexual abuse allegations to the State, but does not have a policy or protocol on the steps/process required for a sexual abuse allegation.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 4 of 4 patients’ (Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding care planning, the hospital failed to ensure that the patients participated in the development of interdisciplinary treatment (IDT) plans. 1. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital’s psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). On 7/26/2024, IDT plan was developed for Pt. #1. The IDT plan of care or the clinical record did not indicate that Pt. #2 participated in the development of the treatment plan. 2. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital’s psychiatric unit with a diagnosis of schizophrenia. On 7/29/2024, an IDT plan was developed for Pt. #3. The IDT plan or the clinical record did not indicate that Pt. #3 participated in the development of the treatment plan. 3. On 8/05/2024, the clinical record for Pt. #4 was reviewed. On 7/28/2024, Pt. #4 was admitted to the hospital’s psychiatric unit with a diagnosis of schizoaffective disorder. On 7/28/2024, an IDT plan was developed for Pt. #4. The IDT plan or the clinical record did not indicate that Pt. #4 participated in the development of the treatment plan. 4. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital’s psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). On 7/30/2024, an IDT plan was developed for Pt. #5. The IDT plan or the clinical record did not indicate that Pt. #5 participated in the development of the treatment plan. 5. On 8/05/2024, the hospital’s policy titled, “Interdisciplinary Plan of Care [IPC], Treatment and Services” (9/2022) was reviewed and included, “... Definitions: 1. Patient Plan of Care - The patient’s plan of care and goals are developed with the patient/family and reflect individualized care and treatment approved by the multidisciplinary team... Policy... 3... The IPC includes actual problem/measurable goals/needs pertinent admission. It also includes input and preferences from the patient and family/significant others...” 6. On 8/05/2024 at approximately 11:00 30 AM, findings were discussed with E #3 (Director Of Patient Care Services, Psychiatry). E #3 stated that there were no patients’ signatures or documentation that the patients participated in the development of the IDT plans.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 4 of 4 patients’ (Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding the right to make informed decision, the hospital failed to ensure that the consent to administer psychotropic medication was completed, as required. Findings include: 1. On 8/05/2024, the hospital’s policy titled, “Consent to Administer Psychotropic Medication” (9/2021) was reviewed and included, “... It is the policy of (Name of the hospital)... in accordance with... the Illinois Mental Health Code have access to psychotropic medication... that it is prescribed in a clinically appropriate manner... The physician or LIP (licensed independent practitioner) shall advise the recipient in writing of the side effects of the medication and his right to refuse a psychotropic drug... Procedure: 1. When an order for scheduled psychotropic medication is initiated, a consent from the patient must be obtained... 3. The patient and physician must sign the “Psychotropic Notice and Consent” form and have it witnessed by the registered nurse...” 2. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital’s psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). On 7/31/2024 at 9:00 PM, Olanzapine (psychotropic medication) 10 mg (milligram) tablet was given as a scheduled bedtime dose to Pt. #2. There was no “Psychotropic Medication Notice and Consent Form” completed for Pt. #2. 3. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital’s psychiatric unit with a diagnosis of schizophrenia. On 7/30/2024, 7/31/2024, and 8/01/2024, Paliperidone (psychotropic medication) 6 mg tablet was given as a scheduled daily dose to Pt. #3. There was no “Psychotropic Medication Notice and Consent Form” completed for Pt. #3. 4. On 8/05/2024, the clinical record for Pt. #4 was reviewed. On 7/28/2024, Pt. #4 was admitted to the hospital’s psychiatric unit with a diagnosis of schizoaffective disorder. On 7/29/2024, 7/30/2024, and 7/31/2024, Fluoxetine (antidepressant) 10 g tablet was given as a scheduled daily dose to Pt. #4. There was no “Psychotropic Medication Notice and Consent Form” completed for Pt. #4 5. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital’s psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). On 7/30/2024, 7/31/2024, and 8/01/2024, Haldol (psychotropic) 10 mg tablet as a scheduled every 12-hour dose was given to Pt. #5. There was no “Psychotropic Medication Notice and Consent Form” completed for Pt. #5. 6. On 8/05/2024 at approximately 11:30 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the Psychotropic Medication Notice and Consent form should be completed.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 3 of 4 patients’ (Pt. #2, Pt.#3, and Pt. #5) clinical records reviewed regarding notification of admission, the hospital failed to ensure that the patients’ right to notify a family member or representative regarding their admission to the hospital was provided. Findings include: 1. On 8/05/2024, the clinical record of Pt. #2 was reviewed. On 7/26/2024, Pt. #2 was admitted to the hospital’s psychiatric unit with a diagnosis of schizoaffective disorder (type of mental disorder). Pt. #2’s “Application for Voluntary Admission” form was not complete, to indicate that Pt. #2’s right to notify a family member or representative regarding their admission to the hospital was provided. 2. On 8/05/2024, the clinical record of Pt. #3 was reviewed. On 7/29/2024, Pt. #3 was admitted to the hospital’s psychiatric unit with a diagnosis of schizophrenia. Pt. #3’s “Application for Voluntary Admission” form was not complete, to indicate that Pt. #3’s right to notify a family member or representative regarding their admission to the hospital was provided. 3. On 8/05/2024, the clinical record for Pt. #5 was reviewed. On 7/29/2024, Pt. #5 was admitted to the hospital’s psychiatric unit with a diagnosis of bipolar disorder (type of mental disorder). Pt. #3’s “Application for Voluntary Admission” form was not complete, to indicate that Pt. #3’s right to notify a family member or representative regarding their admission to the hospital was provided. 4. On 8/06/2024, the hospital’s policy titled, “Patient Rights and Responsibilities” (10/2022) was reviewed and required, “... A patient at (Name of the hospital), you have... The right to have a family member or representative of his or her choice... notified promptly of his or her admission to the hospital...” 5. On 8/05/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the “Application for Voluntary Admission” forms were not complete to indicate that the patients’ right to notify a family member or representative regarding their admission to the hospital was provided.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 34411 Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 (Pt #1) patients reviewed for elopement, the hospital failed to fully implement measures to ensure safety of patients in the psychiatric unit following Pt #1’s elopement. Findings include: 1. The hospital’s policy titled, “Patient Rights and Responsibilities” (dated 10/12/2022), was reviewed, and required, “...As a patient at [Hospital], you have the right to...receive care in a safe setting...” 2. On 8/06/2024, the clinical record for Pt. #1 was reviewed. On 7/05/2024, Pt. #1 was an involuntary transfer from a local hospital. Pt. #1 was voluntarily admitted to Hospital’s 3W Behavioral Health Unit with a diagnosis of Paranoid Schizophrenia (type of mental disorder). - The Psychiatric Evaluation dated 7/5/2024, documented by E #12 (Nurse Practitioner), included, “ ...voluntary admission brought in for bizarre and erratic behavior. Aggressive and threatening ... Presents as a danger to self and others ... Past Psychiatric History: Schizophrenia, Paranoid ...Plan. 1. Patient will be admitted to locked unit. 2. Patient will participate in individual, group and milieu therapy. 3. Medication management. 4. Risk of not having treatment explained. 5. Medical service for completing H&P [History and Physical] and to evaluate, monitor and manage medical issues. 6. Education. 7. Social Worker for aftercare. 8. Estimated LOS [length of stay]; 5-7 days.” - Pt. #1’s Physician orders from 7/5/24-7/6/2024 was reviewed on 8/6/2024. The orders included assault precautions (require every 15-minute checks). - The High-Risk Precaution Observation sheets from 7/5-7/6/2024, were reviewed. The sheets indicated that Pt. #1 was on assault precautions, and the required 15-minute checks were completed. The last documented observation check was done on 7/6/2024 at 12:15 PM. - Pt #1 eloped from the 3 West Behavioral Health Unit on 7/6/2024 at 12:24 PM. 3. The incident report regarding Pt #1 was reviewed on 8/5/2024. The incident report dated 7/6/2024 at 12:30 PM, documented by the 3 West RN (E #13), included, “This writer made hourly rounds at 12:00 PM. Patient is observed in the hallway by the dayroom. Writer came to the nursing station. An MHS [Mental Health Specialist] was doing rounds at 12:30 [PM] and realized the patient cannot be found. The MHS came to tell writer in the nursing station that patient cannot be found. Charge nurse [E #14] notified. Writer and other staff went to check every patient’s room and every other place on the unit. Code Gold (Emergency Response for Patient Elopement) called. Nursing supervisor came on the unit. Patient’s family member called, but no one (picked up the call. Nursing supervisor made aware that no one (picked up the phone). Unit director made aware. E #12/NP made aware.” 4. A video of Pt #1’s 7/6/2024 incident, was reviewed on 8/5/2024, with the Chief Nursing Officer (E #2) and the Vice President of Patient Experience and Engagement (E #10). The following was observed on 7/6/2024 on 3 West unit, the stairway, and the outside of Hospital: At 12:24:16 PM, a MHS (Mental Health Specialist/E #4) opened the stairway door on 3 West, to escort a patient (Pt #12) out that was being discharged. As E #4 and Pt #12 left the unit through the stairway door, the door was left ajar and unsecured. Therefore, Pt #1, who was standing by the door when E #4 and Pt #12 exited, was able to exit out of that door at 12:24:50 (24 seconds behind E #4 and Pt #12). There was no staff monitoring the hallway when Pt #1 exited the stairway door. At 12:25:33 seconds, Pt #1 was seen walking through the alley outside of the hospital. 5. The Root Cause Analysis/RCA regarding Pt #1’s incident (dated 7/10/2024) was reviewed on 8/5/2024. The RCA included: - “MHS [E #4] staff opened the exit door and walked out in front of the patient [Pt #12] being discharged, therefore not securing the door behind [E #4]. Action item: Staff [E #4] was suspended pending investigation. Staff was terminated 7/18/24.” - Pt #1 was able to elope from a locked unit. The RCA did not include any action items indicating that staff were re-educated on precautions to prevent a patient from eloping in the future. The hospital did not provide any in-services or sign-in sheets of re-education to staff of policy review, following Pt #1’s event. 6. On 8/6/2024 at 10:15 AM, an interview was conducted with the Charge Registered Nurse (E #14). E #14 stated that Pt. #1 was seen around 12:15 PM and was calm and cooperative. E #14 stated that around 12:30 PM E #6 asked E #14 if Pt. #1 was off the unit for any reason. E #14 stated that this was not the case. E #14 and E #6 then began to search the entire unit for Pt. #1 between 12:30 PM-12:40 PM. Pt. #1 was not found, and a “Code Gold” (emergency response for elopement) was called at 12:40 PM. E #14 stated that E #14 also made E #12 aware that Pt. #1 had eloped. E #14 was able to verbalize the protocol for Code Gold and Elopement. E #14 stated that there is signage posted throughout the unit to make sure staff are keeping the doors closed. E #14 stated that E #14 did not receive any additional education regarding Code Gold or Elopement. 7. On 8/6/2024 at 11:05 AM, an interview was conducted with the Director of Patient Care Services (E #3). E #3 stated there has not been any formal in-services or re-education after Pt #1’s incident, just staff huddles. E #3 stated that there will be a meeting coming up this Thursday (8/8/2024) to discuss events from July.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 patients’ (Pt. #9) clinical records reviewed regarding use of restraints or seclusion due to violent or aggressive behaviors, the hospital failed to ensure that the care plan was modified to reflect the use of restraint or seclusion as an intervention. Findings include: 1. On 8/05/2024, the hospital’s policy titled, “ Use of Restraints and Seclusion” (9/2021) was reviewed and included, “... Healthcare providers and staff will use restrains and seclusion consistent with the following... E. Documentation of Restraint... Every episode of restraint use must be documented in the patient’s medical record... 7. Plan of Care based (POC) on an assessment and evaluation of the patient which reflects the use of a restraint or seclusion intervention...” 2. On 8/06/2024, the clinical record for Pt. #9 was reviewed. On 8/02/2024, Pt. #9 was admitted to the hospital with a diagnosis of psychosis (deviation from reality). On 8/03/2024, the clinical record indicated that Pt. #9 was placed in 4 -point restraints due to violent/aggressive behavior from 3:00 AM through 5:00 AM. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention. 3. On 8/06/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that the care plan should be modified to indicate the use of restraint as an intervention.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 patients’ (Pt. #10) clinical records reviewed regarding use of restraint or seclusion due to violent or aggresssive behaviors, the hospital failed to ensure that a physician’s or licensed practitioner’s order regarding use of seclusion was obtained. Findings include: 1. On 8/05/2024, the hospital’s policy titled, “Use of Restraints and Seclusion” (9/2021) was reviewed and included, “... Orders for Restraint or Seclusion... Restraint and Seclusion Order for Violent/Self-Destructive Patients... 4. The order should be entered before the initiation of restraint or seclusion...” 2. On 8/06/2024, the clinical record for Pt. #10 was reviewed. On 7/22/2024, Pt. #10 was admitted to the hospital with a diagnosis of schizophrenia (type of mental disorder). On 7/25/2024 from 2:40 PM through 6:30 PM (3 hours and 50 minutes), Pt. #10 was placed in seclusion due to violent/aggressive behavior. There was no physician or licensed practitioner’s order regarding the use of seclusion. 3. On 8/06/2024 at approximately 11:00 AM, findings were discussed with E #3 (Director, Patient Care Services, Psychiatry). E #3 stated that an order should be obtained when a restraint or seclusion is used as an intervention.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to complete a physician certification regarding the medical benefits and risks of transfer. See deficiency A-2409-A. 2. The hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient. See deficiency A-2409-B. 3. The hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the patients’ emergency condition. See deficiencyA-2409-C. 4. The hospital failed to ensure the transfer was through qualified personnel and transportation equipment. See deficiencyA-2409-D.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40079 A. Based on document review and interview, it was determined that for 2 of 8 patients’ (Pt. #1 and Pt. #8) clinical records reviewed for transfer, the hospital failed to complete a physician certification regarding the medical benefits and risks of transfer. Findings include: 1. On 05/14/2024, the hospital’s policy titled, “Transfer of the ED Patient” (revised 09/2021) was reviewed and required, “Due to various reasons, patients may require transfer to another hospital ... All transfers will be in accordance with ED EMTALA policy ... A decision may be made to transfer a patient if ... 4. The services needed by the patient are not available at (Hospital A) ... 1. Physician will determine the need for transfer and the appropriate transfer facility ... 7. The Transfer Form will be completed and signed by Emergency physician ...” 2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder (type of mental disorder). A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked a physician certification regarding the medical benefits and risks of transfer. 3. On 5/15/2024, the clinical record of Pt. #8 was reviewed. On 4/25/2024, Pt. #8 was brought to the ED due to schizoaffective disorder. On 4/26/2024, Pt. #8 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked a signed physician certification regarding the medical benefits and risks of transfer. 4. An interview was conducted with the ED Manager (E #3) on 05/15/2024 at approximately 10:30 AM. E #3 confirmed that the physician certification for transfer was not completed for Pt. #1 and Pt. #8. B. Based on document review and interview, it was determined that for 1 of 8 (Pt. #1) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient. Findings include: 1. On 05/14/24, the hospital’s policy titled, “Transfer of the ED Patient” (revised 09/2021) was reviewed and required, “ ... All transfers will be in accordance with ED EMTALA policy ... 6. It has been confirmed that the receiving hospital has the space and personnel to receive the transfer and they agree to the transfer... 2. ED Physician will speak directly with the physician who will accept the transfer. 3. ED staff will contact accepting facility for available bed. 4. Nurse to Nurse report will be given prior to transfer.” 2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that the ED staff contacted facilities for bed availability and acceptance of (Pt. #1). 3. On 05/15/2024 at 1:35 PM, an interview was conducted with a Crisis Worker (E #2). E #2 stated that normally the Crisis Worker evaluates patients after they are medically cleared to help determine if the patient requires admission. The Crisis Worker would discuss the findings with the ED physician and if the assessment determines that the patient requires to be admitted but we cannot admit here to closed unit, we call different hospitals for bed availability. Once the hospital accepts the patient, the Crisis Worker will notify the nurse and the physician. This is documented in the clinical record including the names of facilities that were contacted and whether there is availability or not. E #1 stated this was not done for Pt. #1 because E #2 did not complete an assessment. C. Based on document review and interview, it was determined that for 2 of 8 (Pt. #1 and Pt. #5) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the patients’ emergency condition. Findings included: 1. On 05/14/24, the hospital’s policy titled, “Transfer of the ED Patient” (revised 09/2021) was reviewed and required, “ ... All transfers will be in accordance with ED EMTALA policy ... 6. A copy of the patient chart, including all lab and imaging data is to accompany patient ...” 2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that copies of pertinent medical records were sent to the receiving hospital. 3. On 5/16/2024, the clinical record of Pt. #5 was reviewed. On 5/06/2024, Pt. #5 was brought to the hospital’s ED due to suicidal ideation and psychiatric evaluation. On 5/07/2024, Pt. #5 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that copies of all pertinent medical records were sent to the receiving hospital. 4. An interview was conducted with the ED Manager (E #3) on 05/15/2024 at approximately 10:30 AM. E #3 confirmed that the clinical records for (Pt. #1 and Pt. #5) lacked documentation that medical records were sent to the receiving hospital. D. Based on document review and interview, it was determined that for 1 of 8 (Pt. #1) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the transfer was through qualified personnel and transportation equipment. Findings include: 1. On 05/14/24, the hospital’s policy titled, “Transfer of the ED Patient” (revised 09/2021) was reviewed and required, “ ... All transfers will be in accordance with ED EMTALA policy ... 5. ...primary nurse will arrange for transfer with appropriate level of support and appropriate equipment.” 2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with a Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record included the following: -A Nurse’s (E #4) note dated 03/09/24 at 11:53 PM, “(Pt. #1) being discharged back to CPD. (Pt. #1) given discharge instructions. (Pt. #1) discharged to CPD. Name of Transporting Ambulance: Left with Chicago Police Department.” -An “Arrestee Medical Clearance Report” (completed and signed by MD #1) dated 03/09/24 at 11:28 PM, “Name of Examining Physician (name of MD #1) ... I have examined the arrestee and find him/her in need of hospitalization. Female psych unit at (Hospital A) is undergoing renovation. CPD to transport (Pt. #1) to another psych facility (Hospital B).” -A “Police Release Form”, dated 03/09/24 at 11:30 PM, “(Pt. #1) has been examined at (Hospital A) ED and has been: Treated & Released.” 3. On 05/15/24 at 12:45 PM, an interview was conducted with the ED Physician (MD#1). MD #1 stated that MD #1 did not recall (Pt. #1) stating they were suicidal. However, MD #1 recalls that (Pt. #1) was aggressive and smelled of alcohol and was banging (Pt. #1’s) head on window (triage area). (Pt. #1) required to be transferred due to the female psychiatric unit at (Hospital A) was not available. MD #1 stated that it is not appropriate to transfer psychiatric patients or patients with suicidal ideation via Chicago Police Department. Patients requiring transfer should be transferred via ambulance with appropriate personnel and equipment. This (Pt. #1) was not transferred via ambulance, (Pt. #1) was transported by the Police Officers.”