Saint Anthony Hospital

“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: 40079 Based on document review, and interview it was determined that for 1 of 5 patients’ clinical records (Pt.#1) reviewed for monitoring, the hospital failed to ensure that the behavioral rounding sheets included the patients ordered precautions to ensure patients were monitored for the appropriate precautions. Findings include: 1. The hospital’s policy titled, “Observation Status and Precaution Levels” (revised 06/23/2021) was reviewed and required, “To provide safe care for individuals who, due to their symptomology, may require increased ongoing observation... Individuals admitted to an inpatient psychiatry unit require some form of ongoing monitoring to ensure their safety and the safety of others. When an individual is initially assessed, he or she is evaluated for precautionary status. Types of precautions include, but are not limited to: Suicidal, Assaultive, Elopement ... Fall risk ... the level of assessed risk (low/moderate/high) will dictate the precaution level... Low Risk to Moderate Risk will be observed through 15-minute precaution rounds... Change in Status ... Physician/LIP (Licensed Independent Practitioner) progress notes will additionally confirm the levels of risk and the need...” 2. The clinical record of Pt.#1 was reviewed on 02/04/26. Pt.#1 presented to the Emergency Department (ED) on 12/12/25 with a chief complaint of overdose. The clinical record included the following: -History & Physical (Behavioral Health Unit) dated 12/16/25, “Admitted to psychiatric unit medical floor due to mood disorder ... subsequent concern for n/v (nausea and vomiting) fever, leukocytosis (elevated white blood cells that may indicate infection), aggression/agitation. Followed by ID (Infectious Disease) and psychiatric service. Medically stabilized, improved mentation during stay, with episodic agitation demanding to leave, redirected as needed ... psych services recommended inpatient psychiatric admission.” -Physician Order dated 12/16/25, “Precautions: 15-Minute Safety Rounds, Elopement, Suicide, Assault, Fall.” -The Patient Observation Flowsheets dated 12/16/25 to 12/21/25 were reviewed. The observation flow sheets from 12/16/25 to 12/19/25, indicated “Monitoring Level: Check every 15 minutes; Precaution Type (check all that apply) the following precautions were checked - Suicide, Assault, Elopement, Fall.” The flow sheets from 12/20/25 to 12/21/25, indicated that the Precaution Type (check all that apply) only Suicide was checked. The clinical record did not include a Physician’s order to discontinue precautions for Assault, Elopement, Fall. -Nurse Progress Notes and Daily Assessments dated 12/16/25 to 12/21/25, were reviewed. The progress notes indicated that (Pt.#1) was complaint with their medications, attending groups and interacting with staff and peers. There were no indicators to increase level of observation documented from 12/18/25 to 12/21/25. There were no indicators to increase the level of observations, however there was no physician order to discontinue precautions for elopement, assault, or falls. 3. An interview was conducted with the Manager of BH (E#1) on 02/04/26 at 11:12 AM. E#1 confirmed that for (Pt.#1) the observation flow sheets dated 12/20/25 to 12/21/25 did not include elopement precautions, and there were no orders to discontinue elopement precautions.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36774 Based on document review, observation, and interview, for 13 expired patients (Pt. #1, and Pt. #11 through Pt. #22), the hospital failed to ensure that the Chief Nursing Officer (CNO/E #1) supervised the process and care regarding handling and management of human remains. Findings include: 1. On 6/17/2025, the hospital’s “Job Description - Chief Nursing Officer” (revised 05/21/25) was reviewed and required, “Provides clinical leadership and executive management for the Nursing Division, provides executive leadership for Clinical Excellence, Patient Safety, and Case Management ... Assumes responsibility for knowing and maintain established hospital and departmental objectives, polices/procedures ...” 2. On 6/17/2025, the hospital’s policy titled, “Care and Management of the Expired Patient” (reviewed by the hospital 06/2023) was reviewed and included, “Purpose to provide guidelines for the removal of the deceased from the unit to the morgue and for release from the morgue ... 3. The Nurse, Hospital Operations Administrator (HOA), or Physician is responsible to review all deaths ... V. Notify HOA of death ... assists the nurse in determining if patient meets criteria for ... notification/jurisdiction ... 2. In cases when the family has not selected or identified the funeral home: i. the nurse presents instructions to the family as to how to contact the HOA ...” 3. On 6/17/2025, the hospital’s policy titled, “Expired Patient (no next of kin)” (reviewed by the hospital 05/20/25) was reviewed and required, “Procedure: 1. Patient Access must contact the Office of the Cook County Public Administrator in every instance in which expiration has no next of kin. This includes cases in which there are friends listed as emergency contacts who are willing to bury ... In every instance, you must call the investigation office ... This procedure ensures that a proper investigation is started to search for family members, assess, and burial arrangements.” 4. On 6/17/2025, the hospital policy titled, “Human Remains, Care and Disposal of” 96/2023) included, “This procedure is designated to accurately document the movement of the human materials (bodies, limbs, stillborn) into and out of the morgue ... Since such material is of human origin, its dignity must be maintained by responsible and accurate control ... Originating Nursing Unit... 5. Register the item in the logbook ... indicating the name, date, time of delivery into the morgue, and signature of person delivering material ... 5. On 6/17/2025, the clinical record for Pt.#1 was reviewed on 06/17/25. Pt.#1 was admitted to the hospital on 10/28/24 and expired on 11/02/24. The clinical record included the following: -Face Sheet/Demographic information, did not include name or contact information of “Person to Notify/Next of Kin, or Medical Power of Attorney.” -State of Illinois Certificate of Death, “Decedent Name (Pt.#1) Date of Death: 11/02/2024 at 11:06 AM ... Cause of Death: a. Cardiac Arrest b. Cardiogenic Shock ...” -Case Management Note (LSW/E#13), dated 11/02/24 at 3:58 PM, “(Pt.#1) passed away after cardiac arrest. SW (social worker) attempted to contact next of kin per previous SW note: (name of cousins) ... but number is not in service. SW spoke with (Pt.#1’s) friend (Pastor) from church ... stated that (Pt.#1) has nephews in Illinois but they have never been involved and (Pt.#1) did not have any communication with them ... in past (Pt.#1) requested they (cousins) visit (Pt.#1), however they declined ... (Pastor) does not have any contact information for any family ... stated is agreeable to assist with any decisions needed to be made and can be contacted for any questions/concerns ... SW spoke with MD and nurse regarding above information. SW (E#13) spoke with Legal Services and verified friend (Pastor) can make decisions regarding burial arrangements given circumstances that there is no other next of kin and no POA. Per legal services if (Pastor) doesn’t want to be involved then pastoral care should be contacted and family would have up to 30-days to contact coroner. SW endorsed information to nurse.” -Nurse Note (E#14) dated 11/02/24 at 5:19 PM, “ ... (Pastor) was notified of death by doctor and CC (Case Manager/E#13). CC verified (Pt.#1) did not have next of kin ... HOA (House Operations Administrator/E#12) aware of issue, staff is waiting on (Pastor) to call back regarding (Pt.#1’s) wishes regarding body. (Pt.#1) off the floor at 1600 (4:00 PM) with belongings of clothes ...” - The clinical record did not include documentation that the HOA followed up by requesting from Pastoral Services to follow up with (Pt.#1’s) friend regarding arrangements. The HOA did not report the case to the Public Administrator for further investigation for family or next kin. 6. On 6/18/2025 from approximately 12:45 PM through 1:30 PM, observational tour of the hospital’s morgue was conducted with E #2 (Director of Security) and E #16 (Director of Quality and Accreditation). The following were observed: - One round opaque plastic container with contents inside. The plastic container had a label, indicating the name of the mother, medical record number, as well as the mother’s date of birth. The morgue log indicated that the container was delivered to the morgue on 6/10/2025. - Two grey containers were also observed inside the morgue. Each of the grey container measures about two feet long, three feet wide, and one foot deep. One of the grey containers had three labels (pathology letter) taped on the outside. The labels had names of patients’ fetuses (Pt. #11, Pt. #12, and Pt. #13). The dates on the labels were from June 4, 2025, May 16, 2025, and February 12, 2025, respectively. Approximate age of the fetuses was between 13 weeks to 15 weeks. When the grey container was opened, four smaller containers were found. The smaller containers had labels and contents inside. Second container also had three labels taped on the outside. The labels had names of patients’ fetuses (Pt. #14, Pt. #15, and Pt. #16). The dates on the labels were from October 20, 2024, July 26, 2024, and August 31, 2024, respectively). Approximate age of the fetuses was between 13 weeks to 18 weeks. When the grey container was opened, eight smaller containers were found. The smaller containers had labels and contents inside. - The morgue log inside the room did not include Pt. #11 through Pt. #16. 7. On 6/17/2025, the Hospital’s” HOA Morgue Logs” (03/2024 through 06/17/2025) were reviewed. Pt.#1 was listed in the log as taken to morgue on 11/02/24 at 1547 (3:47 PM). The log did not indicate that (Pt.#1) was picked up. The log included an additional entry for Pt.#1, that indicated that (Pt.#1) was picked up on 05/30/25 (approximately 6 months from when Pt. #1 was taken ot the morgue). 8. The hospital provided a “Cremation Authorization Form” signed by Chief Nursing Officer (CNO/E#1), dated 05/30/2025, and included, “Name of Deceased (Name of Pt.#1) Date of Death 11/02/2024 ... Place of Death (name of hospital) ... Date of Authorization 05/30/2025, I/We (hospital) hereby authorize and request in accordance with the subject rules and regulations and any applicable state laws or regulation, for (name of funeral home) ... to cremate the above-named human remains and arrange for the final disposition of the cremated remains. The customary 30-day waiting period will be reached on 06/30/25 from the date of death and no family member has claimed the responsibility of final disposition ... Except in cases of extreme neglect, if the authorizing agent fails to sign or agree to sign a cremation authorization within 90 days of first contact or awareness of death, a cremation will be performed under the authorization of the institution ...” (form was initiated approximately 6 months and 28 days after the patient expired). 9. On 6/17/2025, interviews were conducted with the Chief Nursing Officer (E#1) on 06/17/25 at 9:25 AM and 2:00 PM. E#1 stated that late in May of 2025, it was discovered that a body (Pt. #1) was in the morgue since November of 2024, the body should have been picked up within 72 hours of arrival to the morgue. E#1 stated that when (Pt.#1) was discovered in the morgue sometime in May, the hospital notified the Public Administrator and arranged for cremation after 30 days if no one claims (Pt.#1). E #1 stated that E #1 oversee the handling and management of human remains in the morgue. E #1 state that the human remains should be picked up by the funeral home within 3 days. E #1 stated that E #1 was not aware that there were still fetuses stored inside the morgue. E #1 stated that the hospital’s process of handling human remains is fragmented. 10. On 6/17/2025 at approximately 1:45 PM, an interview wad conducted with E #17 (Lead Histology Technician). E #17 stated that after the physician is done examining the fetus, a pathology letter will be written, and they will reach out to E #11 (Manager of Pastoral Services) to get an approval for burial. Afterwards, E #17 stated that they will bring the fetuses down to the morgue. E #17 stated that the way they keep track of the fetuses brought down to the morgue is by keeping track of the pathology letter (and parish record of death). E #17 did not say that a logbook will be completed when human remains are brought to the morgue. At approximately 2:00 PM, E #17 provided 12 patients’ pathology letters with parish records of death. The 12 letters included Pt. #11 through Pt. #16. E #17 stated that the 12 patient’s letters correlate with the number of patients’ fetuses sent down to the morgue. 11. On 6/17/2025 at approximately 4:10 PM, E #16 (Director of Quality and Accreditation) verfied that the 12 patients’ (Pt. #11 through Pt. #22) fetuses were not recorded in the logs for both the HOA Morgue log and the one kept inside the morgue.”

“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 2 of 2 patients’ (Pt. #7 and Pt. #8) clinical records reviewed regarding use of violent and/or self-destructive restraints, the hospital failed to ensure that the care plan was modified to reflect use of restraint as an intervention. Findings include: 1. On 5/30/2024, the hospital’s policy titled, “Restraint Use of and Alternative Measures for Violent and/or Self-Destructive Patients” (7/2021) was reviewed and indicated, “... Assessment/Monitoring/Reassessment... 3. The Restraint... Order... Assessment... Alternative... to be part of the patient’s plan of care...” 2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness) On 5/23/2024, Pt. #7 was placed in restraints due to violent and/or self-destructive behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention. 3. On 5/30/2024, the clinical record for Pt. #8 was reviewed. On 5/11/2024, Pt. #8 was admitted to the hospital due to suicidal ideation. On 5/14/2024, Pt. #8 was placed in restraints due to violent and/or self-destructive behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention. 4. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 could not provide documentation that the patients’ care plans were modified to reflect use of restraints. E #6 did not know the modification of care plan was required after use of restraint.”

“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. #7) clinical records reviewed regarding use of violent and/or self-destructive (locked) restraints, the hospital failed to ensure that use of restraint was in accordance with the physician’s order. Findings include: 1. On 5/30/2024, the hospital’s policy titled, “Restraint Use of and Alternative Measures for Violent and/or Self-Destructive Patients” (7/2021) was reviewed and indicated, “... Violent and/or Self-Destructive Restraint Use - When patient is currently exhibiting dangerous behavior that is harmful to him/herself/others and/or destructive to property... Policy... 7. A restraint order must be obtained from LIP (Licensed Independent Practitioner) for each restraint episode...” 2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness). On 5/23/2024, Pt. #7 was placed in locked restraints due to violent and/or self-destructive behavior from 11:15 AM through 1:15 PM (two hours). The LIP order lacked the type of restrained to be used for Pt. #7. 3. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 stated that the LIP restraint order should indicate the type of restraint to be used.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. 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. #7) clinical records reviewed regarding use of violent and/or self-destructive (locked) restraints, the hospital failed to ensure that the physician or trained personnel conducted a face-to-face evaluation 1 hour after initiation of the restraints. Findings include: 1. On 5/30/2024, the hospital’s policy titled, “Restraint Use of and Alternative Measures for Violent and/or Self Destructive Patients” (7/2021) was reviewed and indicated, “... Violent and/or Self-Destructive Restraint Use - When patient is currently exhibiting dangerous behavior that is harmful to him/herself/others and/or destructive to property... Policy... 11... d... the LIP (Licensed Independent Practitioner) or trained HOA (Hospital Operations Administrator)... must see the patient face-to-face to do the evaluation within 1 hour of initiation of restraints and document the specific need for restraints...” 2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness). On 5/23/2024, Pt. #7 was placed in locked restraints due to violent and/or self-destructive behavior from 11:15 AM through 1:15 PM (two hours). The clinical record lacked documentation that a face-to-face evaluation by or HOA was conducted within 1 hour of initiation of restraints. 3. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 could not provide documentation that a 1-hour face to face evaluation was conducted for Pt. #7. E #6 stated that one hour face to face should be conducted.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 3 patients (Pt. #5 and Pt. #6) clincal records reviewed regarding discharge of ambulatory surgery patients, the hospital failed to ensure that the patients were discharged to a responsible adult, as required. Findings include: 1. On 5/30/2024, the hospital’s policy titled, “Admision and Discharge of Amublatory Surgery Patients” (5/2021) was reviewed and included, “... To... initiate an appropriate care plan for admission and discharge from the Ambulatory Surgery Unit... Discharge Procedure... l. Patient is dicharged to a responsible adult...” 2. On 5/30/2024, the clinical record for Pt. #5 was reviewed. On 5/28/2024, Pt. #5 underwent a colonoscopy (visualization of the large intestine and anus) procedure as an outpatient. The clinical record lacked documentation that Pt. #5 was discharged to a responsible adult. 3. On 5/30/2024, the clinical record for Pt. #6 was reviewed. On 5/29/2024, Pt. #6 underwent a colonoscopy procedure as an outpatient. The clinical record lacked documentation that Pt. #6 was discharged to a responsible adult. 4. On 5/30/2024 at approximately 1:00 PM, findings were discussed with E #2 (Director Surgical Services). E #2 stated that the practice is to discharge post-colonoscopy patients to a responsbile adult. E #2 could not provide documentation that Pt. #5 and Pt. #6 were discharged to a responsible adult after the procedure. 5. On 5/31/2024 at approximately 9:40 AM, a telephone interview was conducted with MD #2 (Gastro-Intestinal Specialist). MD #2 stated that patients should be accompanied by a responsible adult when discharged from the hospital.”