Insight Hospital and Medical Center Chicago

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 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. #10 and Pt. #11) grievances reviewed, the hospital failed to provide the required written response for resolving grievances. Findings include: 1. On 10/15/2024, the hospital’s policy titled, “Patient Complaints and Grievances” (2/2023) was reviewed and included, “... V. Procedure... F. Written Response to Grievance. 1. Grievances are responded to in writing using the (Name of the Hospital’s) Grievance Response Letter Template... 3. The Complaint Coordinator sends the complainant a written response to the grievance that includes the following elements: a. Steps taken on behalf of the patient to investigate the grievance. b. The hospital’s decision/results of the investigation. c. Date of completion. d. Name of Hospital’s contact person...” 2. On 10/15/2024, the hospital’s grievance log was reviewed. The log included the following: - On 7/15/2024, Pt. #10 filed a grievance to the hospital regarding seeing a primary care physician and making Pt. #10 feel that, “(Pt. #10) is a problem.” There was no written response provided to Pt. #10 regarding resolution of the grievance. - On 8/27/2024, Pt. #11 filed a grievance to the hospital regarding dissatisfaction of the service received from the hospital, e.g., tests completed were unnecessary and felt being experimented on. There was no written response provided to Pt. #11 regarding resolution of the grievance. 3. On 10/15/2024 at approximately 3:00 PM, findings were discussed with MD #1 (Chief Medical Officer). MD #1 could not provide the written responses to Pt. #10 and Pt. #11. MD #1 added that response letters should have been provided to both patients by the patient advocate.”

“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: 40079 Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed, the hospital failed to ensure the patient’s power of attorney (POA) was informed of the patient’s change in health status after a patient (Pt. #1) sustained a fall and on a later date sustained unexplained bruising. Findings include: 1. The hospital’s policy titled, “Patient Rights and Responsibilities” (revised 01/2024) was reviewed and included, “ ... 4. The patient (or the patient’s legal representative) has the following rights: ... Information and Communication ... his/her representative has the right to make informed decisions regarding care ... informed of his/her health status, diagnosis and prognosis; being involved in the care planning and treatment; and being able to request or refuse treatment ...” 2. On 10/10/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the hospital’s emergency department (ED) on 08/15/24 via ambulance from nursing home for evaluation for agitation and discharged back to the nursing home on 08/29/24. The clinical record included the following: -Power of Attorney (POA) for Health Care, dated 01/01/23, signed by (Pt. #1) and witness, and (name of POA/daughter). -History & Physical dated 08/15/24 at 10:00 PM, “Chief Complaint: Psych [psychiatric] Evaluation ... No medical concerns, all labs are WNL (within normal limits), vital signs stable (heart rate/HR 81 bpm (beats per minute), and blood pressure 138/91 mmHg (millimeter of mercury) [reference range [HR 60-80 bmp and BP 90/60mmHg to 140/90 mmHg], patient is admitted to psych with medicine on consult as patients is unable to ambulate. -Physician Progress Note (Nurse Practitioner -NP/E #6) dated 08/20/24 at 10:06 AM, “(Pt. #1) with sitter at bedside ... noted with a bump on the head, per staff (Pt. #1) had a fall overnight due to constantly trying to get out of bed ... continues to be restless ... received Haldol (anti-psychotic) 2mg (milligrams) IM (intramuscularly) as well as Ativan (anti-anxiety) 1mg IM yesterday due to restlessness and constantly trying to get out of bed ...V/S (vital signs) from flow sheet 8/20/24 at 7:15 AM, Blood Pressure 134/87, Pulse (HR) 102 ...” -Physician Progress Note (Internal Medicine/MD #1) dated 08/25/24 at 9:30 AM, “Called by house supervisor ... with a request for IM (Internal Medicine) to assess (Pt. #1) as supposedly has bruises all over ... (Pt. #1) was examined at bedside ... has a large bruise to right upper anterior chest/shoulder as well as a bruise over left anterior submental region on jaw. These bruises are consistent with injuries. Informed Supervisor who was at bedside to ensure bedrails are padded ... does have bruising over arms but this is also consistent with healing stages of ecchymosis (bruise) from IV (intravenous) insertions and blood draws ... No active concerns. Please pad bed rails and consider constant sitter if is prone to injuries ...” The Physician Progress notes, and the clinical record did not include documentation that (Pt. #1’s) POA was contacted or attempted to be contacted to inform of (Pt. #1’s) fall or unexplained bruising. 3. An interview was conducted with the Nurse Practitioner (E #6) on 10/15/24 at 1:10 PM. E #6 stated that E #6 saw Pt. #1 daily. E #6 stated that Pt. #1 had was assigned a sitter during the patient’s admision it was started in the ED and continued throughout (Pt. #1’s) admission for safety. E #6 stated that the first notice of bruises was on the 8/20/24. The staff reported that the bruise resulted from a fall on the previous shift. E #6 stated that a few days later on Monday (8/26/24) after the weekend E #6 asked staff about the new bruising, but no one knew what was going on or how (Pt. #1) got the bruises, E #6 was told that (Pt. #1) was restless over the weekend and tried getting out of bed. E #6 stated that (Pt. #1’s) medication was adjusted. E #6 stated that E #6 spoke to POA before the fall, does not recall any other conversations.”

“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, observation, and interview, it was determined that for 4 of 4 (Pt #1-Pt #4) clinical records reviewed for monitoring, the hospital failed to ensure that fall preventive measures were in place and hourly rounding was documented, as required for patients at high fall risk. Findings include: 1. The hospital’s policy titled, “Fall Risk Assessment & Prevention Program” (dated 2/23), was reviewed, and required, “ ...The Fall Prevention Program has been developed to minimize patient falls and potential injuries from a fall ...In addition to universal fall interventions implemented, any patients with Morse scale equal to or higher than 45 (high risk) should be given the following interventions ... Maintain within arm’s reach during high risk activities... Activate bed/chair alarm appropriately ...” 2. The RN (Registered Nurse) and Certified Nurse Assistant Skills Validation Packet (orientation competency checklist) indicates that patient hourly rounds are required part of documentation. 3. The clinical record of Pt. #1 was reviewed. (Pt. #1’s) Morse Fall Risk Scores were reviewed and on 08/18-08/19/24 the Morse Fall Score was 50 (high risk), on 08/24/24 score was 60 (high risk), and on 08/28/24 the score was 75 (high). The Hourly Rounding Flowsheets dated 08/16/24 to 08/29/24 were reviewed and indicated that the hourly round was not conducted on the following dates as ordered by the Physician on 08/16/24: -08/18/24 from 6:56 PM to 08/19/24 at 12:11 AM (5 hours and 7 minutes). -08/19/24 at 2:02 AM to 04:03 AM (2 hours 1 minute) - 06:08 AM, 2:00 PM (1 hour 52 minutes) to 4:00 PM. 6:00 PM (2 hours) to 8:00 PM (2 hours). -08/24/24 at 11:01 PM to 08/25/24 at 1:07 AM (2 hours and 6 minutes), and 08/25/24 at 1:07 AM to 7:45 AM (7 hours and 38 minutes). -08/28/24 at 8:07 PM to 10:09 PM (1 hour 58 minutes) to 08/29/24 at 12:02 AM (2 hours and 7 minutes) to 2:04 AM (2 hours 2 minutes) to 4:01 AM (2 hours 3 minutes) to 7:00 AM (2 hours and 59 minutes). 4. The clinical records of Pt #2, Pt #3, Pt #4, were reviewed. The patients’ Morse Fall Risk scores were reviewed. Pt #2’s fall risk score was 70 (high risk). Pt #3’s and Pt #4’s fall risk score was 45 (high risk). 5. On 10/10/2024 at 9:55 AM, an observational tour of the 7N/7S Medical/Surgical Telemetry unit was conducted. During the tour, Pt #2, Pt #3, and Pt #4, rooms were checked for fall preventive measures in place including bed alarms. The three patients who are high fall risk, did not have bed alarms set. - Following the observation, the clinical records were reviewed for the required hourly rounding and the records including the following: Pt #2’s last hourly rounding was documented on 10/10/2024 at 2:56 AM (lacking rounds from 4:00 AM-10:00 AM). Pt #3’s last hourly rounding was documented on 10/9/2024 at 5:46 PM (lacking rounds from 6:00 PM-10/10/2024 at 10:00 AM). 6. On 10/10/2024 at 11:05 AM, an interview was conducted with the 7N Charge Nurse (E #2). E #2 stated that the RNs and CNAs rotate charting on hourly rounds and that they should be documented in the computer. E #2 confirmed that Pt #2, Pt #3, and Pt #4’s bed alarms were not set while the patients were laying in the bed. E #2 stated that fall prevention measures include bed alarms, yellow socks, yellow non-skid socks, and chair alarms.”

“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: 40079 Based on document review and interview it was determined that for 1 of 1 clinical record (Pt. #1) with an allegation of abuse, the hospital failed to follow the process for the reporting and investigation of an allegation of abuse. This could potentially affect all current and future patients at the hospital who report an allegation of abuse. Findings include: 1. On 10/10/24 the hospital’s policy titled, “Reporting of Abuse/Neglect Allegations” (revised 12/2023) was reviewed and required, “Definitions: IDPH (Illinois Department of Public Health) ... V. Procedure: A. Allegations of Abuse ... 1. Any personnel who have reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report ... 3. Upon receiving a report, the hospital shall promptly conduct an internal review to ensure the alleged victim’s safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital’s administrator and shall include, but are not limited to, removing suspected violators from further patient contact during the hospital’s internal review ... B. 1. All internal hospital reviews shall be conducted by a designated hospital employee or agent who is qualified to detect abuse and is not involved in the alleged victim’s treatment ... to determine if the allegation is substantiated or unsubstantiated ... All internal review findings shall be documented ... shall be made available to the Department upon request ...” 2. On 10/10/24, the hospital provided a “Safety Event” report and included, “Date Received: 08/25/24, Date of Event: 08/25/24 ... Location: 7N/Telemetry ... Significance: 5 - Event patient temporary harm ... LPN (licensed practical nurse/E #7) entered the room and noted that (Pt. #1) had multiple bruises on left and right upper arms and a large bruise on left jaw. According to staff that worked yesterday (Pt. #1) did not have any of these bruises. No report was given from night shift RN (registered nurse). Only SBAR (Situation, Background, Assessment, & Recommendation) hand off to writer by charge nurse ... Dr. made aware ... (Pt. #1) with new bruises and scratches to arms and face after night shift on Saturday (08/24/24). Written statements from sitters determined occurred on Saturday night. Patient restless and agitated, scratching and hitting self throughout night. (Pt. #1) was medicated ... bruising not noted on the night shift, but documented on Sunday AM by staff ... Discussion in huddle regarding documentation on bruising and scratching and any events that have occurred...” 3. On 10/10/24, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the hospital’s emergency department (ED) on 08/15/24 via ambulance from nursing home for psychhiatric evaluation for agitation and discharged back to the nursing home on 08/29/24. The clinical record included the following: -ED History & Physical dated 08/15/24 at 7:20 PM, “(Pt. #1) ... past medial history including dementia, Alzheimer’s, alert and oriented x1 (to person) at baseline, generalized anxiety presenting to the ED via EMS (emergency medical services) for agitation ... Skin: Warm, dry, grossly intact, no obvious rashes ...” Admission to general medical floor.” -Nurse Progress Note, dated 08/19/24 at 4:12 PM, “High-risk Skin Assessment ... (Pt. #1) with complex medical history ... dementia/Alzheimer’s, restlessness, unsteady gait, lack of coordination, cognitive communication deficit ... being seen for high-risk skin assessment - no alterations in skin integrity related to pressure or moisture. -Physician Progress Note (Internal Medicine/MD #2) dated 08/25/24 at 9:30 AM, “Called by house supervisor ... with a request for IM (Internal Medicine) to assess (Pt. #1) as supposedly has bruises all over ... Reviewed the chart, not on any antiplatelets or anticoagulants. Current meds (medication) unlikely to predispose to bleeding ... (Pt. #1) was examined at bedside ... has a large bruise to right upper anterior chest/shoulder as well as a bruise over left anterior submental region on jaw. These bruises are consistent with injuries. Informed Supervisor who was at bedside to ensure bedrails are padded ... does have bruising over arms but this is also consistent with healing stages of ecchymosis (bruise) from IV (intravenous) insertions and blood draws ... No active concerns. Please pad bed rails and consider constant sitter if is prone to injuries ... Wound care nurse consult placed due to multiple abrasions over arms.” 4. The “Time-Sheets” for E #8 (Registered Nurse) and E #9 (Sitter) from 08/24/24 to 10/15/24, were reviewed. The timesheets indicated that E #8 and E #9 continued to work at the hospital through 9/21/24. On 9/25/24, E #8 and E #9 were suspended due to unsatisfactory work performance. As of 10/16/2024, remain on suspension. 5. An interview was conducted with the Director of Nursing (DON/E #1) on 10/10/24 at 2:58 PM. E #1 stated that E#1 did get a call about some bruising and scratches on (Pt. #1) on 08/29/24 by nursing home staff. (Pt. #1) had just been discharged back to the SNF (Skilled Nursing Facility). The SNF’s DON called and told E #1 they had a concern about abuse to (Pt. #1). E #1 stated that when E #1 had received the call, there had been an investigation already started about a hospital staff reporting bruising on (Pt. #1), however the hospital did not view this incident on 08/25/24 as abuse and did not investigate it as abuse. E #1 stated that a Midas event (electronic safety event reporting system) was entered prior to this call, by the nurse (E #7) on the day shift of 8/25/24. E #1 stated that the hospital was gathering more information to be able to investigate what happened. E #1 stated that he did a chart audit, staff interviews, however from their internal investigation their results came back inconclusive and did not suspect abuse. E #1 stated that there has not been any further investigation that E #1 is aware of. E #1 stated that after the call on 08/29/24 from the SNF, E #1 did not report this call as an allegation of abuse to Risk Manager, or administrators, and did not report to IDPH (Illinois Department of Public Health). 6. An interview was conducted with the Vice President of Safety (E #5) on 10/10/24 at 3:20 PM. E #5 stated that their investigation conducted for 08/25/24, was inconclusive, the hospital has the names of staff (E #8 and E #9) involved in the care of (Pt. #1) on the prior evening of 08/25/24. Staff were interviewed and they all stated that they did not see anything happen to (Pt. #1). Some of the staff stated that (Pt. #1) was scratching self. On one occasion (08/25/24), the medical team saw the patient and recommended that they pad the rails. E#5 stated that the hospital has not identified that there was any type of abuse, so the hospital has not done anything further. E #5 stated that in early October, the hospital hired a third party (name of law firm) to help them with their investigation. E #5 stated that the two staff identified as working on the shift that they suspect were providing care when the incident occurred have been suspended as of 09/25/24. E #5 stated that this incident was not reported to IDPH (Illinois Department of Public Health). Additionally, E #5 stated that the hospital does not have any documentation to show what has been done about this incident, E #5 stated that the investigation is still ongoing as of 10/10/24.”

“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. #8) clinical records reviewed regarding use of restraints, the hospital failed to ensure that a physician’s order for the application of violent restraints was obtained, as required. Findings include: 1. On 10/15/2024, the hospital’s policy titled, “Restraint and Seclusion” (2/2024) was reviewed and included, “... Obtaining physician’s order for... behavioral restraints... See Table 1... Order time limit... Behavioral Restraints. Age: Age 18 and older - four (4) hours... Order renewal... Within the required timeframe...” 2. On 10/15/2024, the clinical record for Pt. #8 was reviewed. On 7/20/2024, Pt. #8 was admitted with a diagnosis of paranoid behavior. On 7/22/2024 at 3:15 PM, a physician’s order was made to place Pt. #8 in violent restraints for four hours (order expired at 7:15 PM). Pt. #8’s restraints continued until 8:20 PM, however, a physician’s order was not obtained, as required, when the restraints order expired at 7:15 PM. 3. On 10/15/2024 at approximately 10:30 AM, findings were discussed with E #1 (Director of Nursing). E #1 stated that a physician’s order should have been obtained at 7:15 PM and not 8:20 PM.”

“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. #8) clinical records reviewed regarding use of violent restraints, the hospital failed to complete the required face-to-face assessment within one hour after the initiation of restraints. Findings include: 1. On 10/15/2024, the hospital’s policy titled, “Restraint and Seclusion” (2/2024) was reviewed and included, “... Face-to-Face Evaluation for Violent or Self-Destructive Behavior. 1. Patients placed in restraint... for violent or self-destructive behavior, a face-to-face evaluation is performed between the LIP (licensed independent practitioner), qualified RN... The purpose... is to determine if the use of these measures is justified... 2. The LIP conducting the face-to-face evaluation... must include an assessment of the following issues and must be documented the findings in the medical record: a. The patient’s immediate situation. b. The patient’s reaction to the intervention. c. The patient’s medical and behavioral condition...” 2. On 10/15/2024, the clinical record for Pt. #8 was reviewed. On 7/20/2024, Pt. #8 was admitted with a diagnosis of paranoid behavior. On 7/22/2024 at 11:15 AM, violent restraints were applied to Pt. #8. The clinical record lacked the required face-to-face evaluation within one hour of placing the violent restraints...” 3. On 10/15/2024 at approximately 10:30 AM, findings were discussed with E #1 Director of Nursing). E #1 stated that the required face-to-face evaluation was not documented in the clinical record.”

“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: 50702 Based on the observation, document review, and interview, it was determined that for 2 of 2 patients (Pt. #3 and #4), the hospital failed to label IV (intravenous) dressings when the dressings were applied/changed. Findings include: 1. On 9/3/2024 at 9:50 AM, a tour of the Medical-Surgical Telemetry unit (7-South) was conducted, 2 of 2 patients (Pt. #3 and Pt. #4) were observed with peripheral IV’s with dressings on their left/right forearms which were not labeled with insertion date, time, and initial. 2. The policy titled “Intravenous Therapy- (Patient Care Services)” (dated 1/2021) was reviewed and required “Post insertion guidelines:...label IV dressing with date, time, gauge of catheter, and initials...” 3. On 9/3/2024 at 10:10 AM, an interview was conducted with the Charge Nurse (E#9) on (7-South). E#9 stated that all patients’ IV lines should be labeled with date, time, size of the gauge, and initials.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 1 of 4 clinical records (Pt. #2) reviewed for discharge planning, the hospital failed to ensure that the patient’s family was included included in discharge planning and notified regarding the patient’s discharge, per policy. Findings include: 1. The hospital’s policy titled, “Discharge Planning Process” (Origination date: 06/2021) was reviewed on 9/3/2024 and required, “... The patient or representative and family/support person/caregiver are active participants in... post discharge care 2. On 9/3/2024, the hospital’s policy titled, “Transfer of Emergency Department Patients to other Facilities” (Origination date - 6/2021) was reviewed and indicated that, “...V. Procedure...10. The patient’s family will be given information regarding the receiving facility (name, address, contact information, directions.)” 2. On 9/3/2024, Pt. #2’s clinical record (dated 3/15/2024 to 3/16/2024) was reviewed. Pt. #2 presented to the ED (Emergency Department) on 3/15/2024. -The ED - H & P (History and Physical) by MD#1 included, “Patient ... with past medical history of dementia, psychosis, anxiety, adjustment disorder, MDD [Major depressive disorder], syncope presents from nursing home for psychiatric evaluation. On evaluation patient is hemodynamically stable, afebrile, nontoxic-appearing, is calm, concern for worsening dementia versus underlying mood disturbance, patient was aggressive at the nursing home he will need evaluation by psychiatric team and inpatient therapy. H & P indicated that Pt.#2 is verbal and alert x 1 (aware of self). “Addendum to the ED H & P by MD#2 indicated that there is no reason for medical admission. Patient is safe for inpatient psychiatric care. For agitation anxiety, patient given 2.5 mg of p.o. [by mouth] Zyprexa (antipsychotic). A psychiatric consult was ordered, and MD #3 was the consulting psychiatrist. -The Behavioral Health Progress Note by Crisis Coordinator (E#7), dated 3/16/2024 at 8:38 AM, included, “Per [MD #3 - consulting psychiatrist] direction, [Pt #2] to be transferred out. [E #7] contacted [psychiatric referral service] ... referred to Neuropsych ... clinical [records] faxed. E #7’s note, dated 3/16/2024 t 11:07 AM, included, “Received call from ... NeuroPsych reporting [Pt #2] was accepted under [accepting psychiatrist’s name] in [City name] location in the 200 unit. [neuro-psychiatric hospital in a different state - approximately 45 minutes from the hospital]. ED charge [nurse] updated with information.” -The RN Discharge Note by (E#16) on 3/16/2024 at 1:25 PM, indicated that Pt.#2 was discharged to [psychiatric hospital] and was transferred by ambulance and medical records were sent with the patient. The clinical record did not include any documentation indicating that Pt #2’s family was notified by the Crisis Worker or Nurse of Pt #2’s discharge/transfer. 3. On 9/4/2024 at approximately 9:50 AM, an interview was conducted with discharge planner (E#13). E#13 stated that discharge planning is initiated right after admission so as to give ample time to make arrangements for post-hospital discharge needs, services and care. E#13 stated that patients and family members are always involved in the discharge planning process and would be informed of the discharge plan. E#13 stated that if the patient is being discharged/transferred to a SNF (skilled nursing facility), the discharge planner will inform the patient’s family. If the patient will be discharged/transferred to another hospital, the nurses will inform the patient’s family. E #13 stated that E #13 did not recall Pt. #2 and did not know why the family was not notified.”

“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 ensure appropriate disposition of patients’ visits on the ED log. See A-2405. 2. The hospital failed to provide a medical screening examination, to determine if Pt. #1 was experiencing a psychiatric medical emergency. See A-2406 A. 2. The hospital failed to ensure that the “Bylaws of the Medical Staff “included the person qualified to perform a medical screening examination. See A-2406 B. 3. The hospital failed to complete a physician certification regarding the benefits and risks of transfer. See A-2409.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 3 of 22 patients’ (Pt. #1, Pt. #21, and Pt. #22) clinical records reviewed for patients seeking care in the ED (emergency department), the hospital failed to ensure appropriate disposition of patients’ visits was included on the ED log. Findings include: 1. On 7/03/2024, the hospital’s policy titled, “EMTALA Compliance” (1/2022) was reviewed and included, “... II. It is the policy of (Name of the Hospital) to provide medical evaluation and stabilizing treatment to all persons presenting to the Emergency Department... V. Procedure... K. Record Keeping and documentation. 1. Maintain a log of all patients who present to the Emergency Department...” 2. On 7/2/2024, the clinical record for Pt. #1 was reviewed. On 3/20/2024 at 11:24 AM, Pt. #1 was in the hospital’s ED for psychiatric evaluation. Pt. #1 was checked out at 11:27 AM. The incident report for Pt. #1 indicated that on 3/20/2024, Pt. #1 was refused treatment in the ED. However, the ED log indicated that Pt. #1 was “Incorrectly Registered.” 3. On 7/3/2024, the clinical record for Pt. #21 was reviewed. On 3/20/2024 at 7:04 PM, Pt. #21 was in the hospital’s ED due to head hurting. Pt. #21 was checked out at 7:25 PM. The ED log indicated that Pt. #21 was “Incorrectly Registered.” 4. On 7/3/2024, the clinical record for Pt. #22 was reviewed. On 6/18/2024 at 2:51 PM, Pt. #22 was in the hospital’s ED due to left leg pain. Pt. #22 was checked out at 3:47 PM. The ED log indicated that Pt, #22 was “Incorrectly Registered.” 5. On 7/3/2024 at approximately 1:30 PM, interviews were conducted with E #6 (Director of Inpatient Care Services) and E #8 (Vice President of Patient Care and Safety). E #6 and E #8 could not explain why Pt. #21 and Pt. #22 were incorrectly registered. E #6 and E #8 stated that the hospital does not review the ED log to ensure the disposition has been documented appropriately on the log. On 7/5/2024 at approximately 1:30 PM, E #8 stated that the hospital does not have a formalized process of identifying/defining the different dispositions used in the ED.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48264 A. Based on document review and interview, it was determined that for 1 of 1 patient’s (Pt. #1) clinical records reviewed with psychiatric complaints seeking care in the emergency department (ED), the hospital failed to provide a medical screening examination (MSE), to determine if Pt. #1 was experiencing a psychiatric medical emergency for two separate presentation to the ED on the same day. Subsequently, Pt. #1 returned to the ED by ambulance, police, and CFD (Chicago Fire Department) with petition for psychiatric evaluation. Findings include: 1. On 7/02/2024, the hospital’s policy titled, ‘EMTALA (Emergency Medical Treatment and Active Labor Act) Compliance’ (01/2022) was reviewed and included, “ ...Policy: ...it is the policy of (the hospital) to provide medical evaluation and stabilizing treatment to all persons presenting to the Emergency Department ...V. Procedure: ...A. All persons who request examination or treatment in the Emergency Department shall receive an appropriate and prompt medical screening by an Emergency Physician or Emergency Department Mid-Level Provider to determine whether the person has an emergency medical condition ...” 2. The “ED (Emergency Department) Activity Log” for 3/20/2024 was reviewed and indicated that Pt. #1 presented to the ED at 11:24 AM. The log indicated that Pt. #1’s ED encounter ended at 11:27 AM.(a duration of three minutes). The disposition for the encounter was noted as “incorrectly registered” (not treated by the emergency department). 3. On 7/02/2024, Pt. #1’s clinical record for the ED visit on 3/20/24 at 11:24 AM was reviewed. Pt.#1 chief complaint was psychiatric evaluation. The clinical record included: - On 3/20/2024 at 11:34 AM, the Charge Registered Nurse’s (E #1) ‘Clinical Discharge Summary’ indicated that Pt. #1 checked into the hospital at 11:24 AM for a psychiatric evaluation and discharged at 11:27 AM. No triage assessment or medical screening exam was available for review. 4. On 7/02/2024, Pt. #1’s clinical record for the ED visit on 3/20/2024 at 4:45 PM was reviewed. Pt. #1 presented to the ED by EMS (Emergency Medical Services) and CPD (Chicago Police Department) for a psychiatric evaluation. The clinical record included: -On 3/20/2024 at 4:47 PM, the Physician’s ‘History and Physical’ included, “...presenting to the ER (Emergency Room) ...for psychiatric evaluation ...petition filled out by CPD ...review of systems: ...unable to obtain due to: uncooperative patient ...workup: ...will obtain psychiatric screening labs. Anticipate psychiatric admission versus transfer ...awaiting psychiatric evaluation, transfer at this time ...”. A psychiatric evaluation was not available for review. -On 3/22/2024 at 10:04 AM, the Physician’s ‘History and Physical’ included, “...summary: (Pt. #1) presents ER with agitated combative behavior warranting inpatient psychiatric care ...(Addendum): discussed with (Psychiatrist /MD #5), states hospital cannot accomodate (Pt. #1’s) complex medical and psychiatric needs ...needs higher level of care, agrees with transfer, case accepted at (outside hospital) ...”. A psychiatric evaluation was not available for review. 5. On 7/02/2024, the hospital’s ‘Safety Events’ for Pt. #1, dated 3/22/2024, was reviewed and included, “ ...No: (Safety Event number) 24-859 ...Comments: 3/22/2024 at 3:30 PM by (anonymous source) ... (Pt. #1) arrived for (psychiatric evaluation) at 11:20 AM, due to recent admission ED charge nurse (E #1) had (Pt. #1) escorted out by security without being evaluated by doctor. The safety event report indicated that the event was investigated, and findings included that (Pt. #1) was seen in the ED three times that day and 5 times over the week for the same concerns, discharged from (hospital) on 3/20/2024 and (Pt. #1) called EMS (emergency medical services) and brought back to (hospital) for “no just cause” and since (Pt. #1) was already seen and discharged, (Pt. #1) did not need another evaluation as Pt. #1 was just malingering (falsification or profound exaggeration of illness). The investigation report noted that (Pt. #1) was homeless, wanted placement, and was violent and aggressive to staff, EMS, and CFD. (Pt. #1) was petitioned by CFD, admitted to psychiatry unit. Pt. #1 was discharged after 48 hours. No other follow-up or documentation of event was available for review. 6. On 7/03/2024 at approximately 11:28 AM an interview with the Director of Quality (E #7) was conducted. E #7 stated (E #5/Previous Director of Emergency Services) performed the investigation for the event but is no longer a hospital employee. E #7 stated that E #5 did not provide any documentation of the investigation. E #7 stated that EMTALA was discussed at a manager meeting in April 2024, but no further investigation or interventions have been implemented since Pt. #1’s event. 7. On 7/05/2024 at 8:55 AM an interview with the Chief Medical Officer (MD #1) was conducted. MD #1 stated that every person that presents to the ED is required to receive a medical screening evaluation. 36774 B. Based on document review and interview, it was determined that the hospital failed to ensure the “Bylaws of the Medical Staff “included the person qualified to perform a medical screening examination. Findings include: 1. On 7/2/2024, the hospital’s ‘Bylaws of the Medical Staff’ (adopted in June 2021) was reviewed. The Bylaws did not include who had been deemed qualified to perform medical screening exams in the Emergency Department (ED) 2. On 7/2/2024 at approximately 12:15 PM, an interview was conducted with MD #1 (Chief Medical Officer). MD #1 stated that the qualified person allowed to conduct medical screening examination is in the hospital’s policy and not in the Bylaws. 3. On 7/3/2024 at approximately 1:30 PM, E #8 (Vice President of Patient Care and Safety) also confirmed that the qualified persons allowed to conduct medical screening examination is not in the Bylaws. E #8 stated that the Bylaws are approved by the hospital’s governing body.”

“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: 36774 Based on document review and interview, it was determined that for 2 of 5 patients (Pt. #4 and Pt. #6) clinical records reviewed for transfers, the hospital failed to complete a physician certification regarding the risks and benefits of transfer. Findings include: 1. The hospital’s policy titled, “EMTALA Compliance” (1/2022) was reviewed and included, “... V. Procedure... A physician certifies in writing that... patient should be transferred because the medical benefits of the transfer outweigh the risk to the patient...” 2. On 7/2/2024, the clinical record for Pt. #4 was reviewed. On 7/1/1024, Pt. #4 was brought to the hospital’s ED (emergency department) due to lightheadedness and palpitations. The clinical record indicated that Pt. #4 had atrial fibrillation (irregular rapid heart beat) with rapid ventricular response (irregular heart rhythm) and a test showing aortic dissection (a tear in a large blood vessel). The clinical record indicated that Pt. #4 required a higher level of care to stabilize Pt. #4’s emergency medical condition. The clinical record lacked a physician certification regarding the risks and benefits of the transfer. 3. On 7/2/2024, the clinical record for Pt. #6 was reviewed. On 6/18/2024, Pt. #6 was brought to the ED due to gastrointestinal bleeding. The clinical record indicated that Pt. #6 required a higher level of care to stabilize Pt. #6’s emergency medical condition. The clinical record lacked a physician certification regarding the risks and benefits of the transfer. 4. On 7/5/2024 at approximately 9:00 AM, findings were discussed with E #8 (Vice President of Patient Care and Safety) and MD #1 (Chief Medical Officer). E #8 confirmed that Pt. #4 and Pt. #6’s clinical record did not include physician certification regarding the risks and benefits of transfer. MD #1 stated that the ED attending physician is responsible to make sure that the certification of the risks and benefits of transfer is completed.”