South Shore Hospital

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 34411 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services. Findings include: 1. The hospital failed to ensure that policy was adhered in order to prevent the patient from eloping from the ED (emergency department). 2. The hospital failed to ensure that staff adhered to the hospital’s policy on elopement precautions that were put in place to prevent patients from eloping. See deficiency at A-1104 (B). 3. The hospital failed to ensure that the hospital’s elopement policy was adhered to, following a patient’s (Pt #1) elopement.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 34411 A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) patient who presented to the hospital’s emergency department (ED) for a psychiatric evaluation, the hospital failed to ensure that policy was adhered in order to prevent the patient from eloping from the ED (emergency department). Findings include: 1. The hospital’s policy titled, “Patients Requiring Psychiatric Evaluation (dated 8/2024), was reviewed, and required, “...Implement elopement prevention precautions per policy and procedure. Utilize restraints when needed, per policy and procedure...” 2. The hospital’s policy titled, “Use of Restraint Policy & Procedure” (dated 9/2022), was reviewed and required, “ ...Guidelines ...In an emergency, the nurse may apply restraints for period not to exceed 1 hour ...Physical hold (manual restraint) is only used on an emergency basis when a patient’s behavior pose an imminent risk of physical harm to self or others and less restrictive strategies have not achieved safety. Emergency use must meet the following conditions: Imminent intervention must be needed to protect the patient or others from imminent risk of physical harm ...” 3. A policy on treatment of aggressive/agitated patients who present to the hospital’s ED, was requested. The hospital was unable to provide a policy. 4. The clinical record of Pt #1 was reviewed on 1/13/2025. Pt #1 presented to the ED (emergency department) on 8/15/2024 at 7:14 PM, as a transfer from the nursing home. Pt #1 eloped from the hospital’s ED on 8/15/2024 at 7:40 PM. Pt #1’s clinical record included: - A “Petition for Involuntary Admission” (dated 8/15/2024), included, “Resident [Pt #1] has diagnoses of Schizophrenia and Schizoaffective Disorder [serious mental illness] and presents with extreme agitation, delusions and threatening behavior and is unresponsive to redirection. These behaviors have persisted over the course of the afternoon and are not subsiding. A psychiatric evaluation is warranted for safety purposes ...” -The ED Provider Note (dated 8/15/2024 at 7:28 PM), documented by the ED Attending Physician (MD #1), included, “Patient was brought to the emergency room for psych [psychiatric] evaluation...Alert, Oriented X3 [person, place, time]. Patient is aggressive and agitated ...” - The Triage Note (dated 8/15/2024 at 7:32 PM), documented by the ED Paramedic/Technician (E #5), included, “Chief Complaint: Psychiatric Complaint ...Mode of Arrival: Ambulance ...Involuntary Petition. Patient received with an Involuntary Petition: Y[es] ... Pt sent from NH [nursing home] for psych eval for aggressive behavior ...Hx [history] Psychiatric Problems: Y[es] ...” The clinical record lacked the triage assessment completed by a RN [registered nurse]. - A Patient Note (dated 8/15/2024 at 7:40 PM), documented by the ED Charge Nurse (E #4), included, “Security and I [E #4] were in Room 9 to have [Pt #1] undress. Patient refusing. Patient took off running out the room and on 2nd attempt broke the ER [emergency room] door and ran off down the street. [Local police department] immediately called.” - Pt #1’s physician orders included an emergency IM (intramuscular) medication. Lorazepam (anti-anxiety medication) that was entered on 8/15/2024 at 7:42 PM (after Pt #1 eloped). The clinical record did not include any documentation that the medication was administered prior to Pt #1 elopement.. Pt #1’s clinical record lacked any documentation of attempted physical restraint in order to prevent the patient from imminent danger (elopement). According to staff interviews, the clinical or security staff did not physically attempt to prevent Pt #1 from eloping from the ED, due to the patient’s size. 5. An Incident Report (dated 8/15/2024), regarding Pt #1, included, “Date & Time Occurred: 8/15/2024 [at] 8:30 PM ...Narrative: On the date and time above, I [Director of Security/E #9] received a call from Supervisor [E # 8], who notified me of a patient who had absconded (eloped) from the ER [emergency room]. A nurse and [E #8] attempted to pursue the patient, but their efforts were unsuccessful. I [E #9], instructed [E #8] to call the MOD [manager on duty], inform them of the situation, and call the police...” 6. The Security Event log (8/2024) was reviewed. The log included Pt #1’s event (dated 8/15/2024), “S/O [security officer/E #8] was called to ER for a patient. The patient broke out the emergency door and ran all the way to [local street] that’s where we stopp[ed] running after [Pt. #1].” 7. On 1/13/2025 at 2:40 PM, a phone interview was conducted with the Security Supervisor (E #8). E #8 stated that Pt #1 came in agitated stating that Pt #1 was not going to stay there and wanted to leave. E #8 stated that E #8 and another officer (E #10) were called in the ED when Pt #1 was being aggressive. E #8 stated that Pt #1 charged at the exit door with Pt #1’s shoulder once and then the 2nd time, Pt #1 was able to break the lock and run out of the ED. E #8 stated that E #8 and the other officer E #10, were not able to physically restrain Pt #1 and did not touch the patient physically. E #8 stated that due to E #8’s and E #10’s age, and the size of the patient, it would not have been safe to physically restrain the patient. E #8 stated that E #8 and a nurse (E #11), both ran after Pt #1, for a couple of blocks. E #8 stated that Pt #1 got away, and E #8 and E #11 returned to the hospital. 8. On 1/14/2025 at 11:45 AM, an interview was conducted with the ED Attending Physician/Chairperson (MD #1). MD #1 stated that Pt #1 was the medical clearance needed prior to being admitted to the behavioral health unit. MD #1 stated that Pt #1 was an involuntary admission, who presented from the nursing home, with violent behavior and agitation. MD #1 stated that MD #1 put in medication orders for Pt #1 due to agitation. MD #1 stated that current elopement precautions in the ED, include having a locked door and security present. MD #1 stated that if a patient is attempting to elope, precautions/interventions would include administering emergency medications or physically restraining the patient. MD #1 stated that it would be easier to medicate the patient to calm them down versus restraining them. MD #1 stated that Pt #1 was about 200 pounds and would have been difficult to restrain Pt #1. MD #1 stated that an intervention that would potentially prevent a patient from eloping in the future, would include installing heavier security doors or having a different type of lock on the door that could prevent a patient from breaking through it. 9. On 1/15/2025 at 10:15 AM, an interview with the ED manager (E #2) was conducted . E #2 stated that regarding preventing Pt #1’s elopement, a physical hold would not have been safe for the staff due to the patient’s weight and body build. E #2 stated that Pt #1 was physically a bigger patient around 200 pounds. E #2 stated that E #2 feels as though the staff did everything they needed to do. E #2 stated that the ED does not use sitters/1:1. E #2 stated that if a patient is presenting with aggression/agitation, then a staff member should remain at the bedside. 10. On 1/16/2025 at 10:35 AM, an interview was conducted with the Security Officer (E #10). E #10 stated that E #10 and the other officer (E #8), got called back to the ED to assist with a patient (Pt #1). E #10 stated that when E #10 and E #8 went back to the ED, Pt #1 was still in Room 9, and they were talking with Pt #1 trying to calm the patient down. E #10 stated that Pt #1 was disgruntled and argumentative. E #10 stated that while they were talking with Pt#1, Pt #1 walked through another room (Room 10) and then proceeded to the exit doors. E #10 stated that at that point, there were 4 of them at the exit door with Pt #1. E #10 stated that Pt #1, then grabbed at the metal magnet piece at top of the door, broke it off, and then started pushing at the door with Pt #1’s shoulder. E #10 stated that once Pt #1 removed the metal piece from the door, Pt #1 was able to physically push through the door and run out. E #10 stated that none of the staff tried to physically stop the patient from leaving. E #10 stated that Pt #1 was tall (approximately 5 feet’8’’ inches). E #10 stated that staff would have physically intervened if Pt #1 was trying to physically harm one of them. E #10 stated that the security staff receive SECURE (de-escalation) training annually and they are taught how to properly intervene physically, with an aggressive patient. B. Based on document review and interview, it was determined that for 1 of 4 (Pt #1), clinical records reviewed for elopement, the hospital failed to ensure that staff adhered to the hospital’s policy on elopement precautions that were put in place to prevent patients from eloping. Findings include: 1. The hospital’s policy titled, “Elopement Prevention” (dated 7/2023), was reviewed, and required, “Purpose: To reduce the risk of elopement for emergency department patients on involuntary psychiatric holds and to delineate the reporting process if an elopement occurs. Patient arriving to the Emergency Department with Petition for Involuntary Admission ...during their emergency department visit related to psychiatric complaints will have elopement precautions implemented ...Elopement Prevention ...During completion of the triage assessment, the nurse will answer ‘yes’ to the screening question ‘Patient with Petition for Involuntary Admission?’ which will trigger a flag in EMR [electronic medical record] to signify possible elopement risk. The Emergency Department RN [registered nurse] will complete the elopement risk screening tool in the EMR ...” 2. The clinical record of Pt #1 was reviewed on 1/13/2025. Pt #1 presented to the ED [emergency department] on 8/15/2024 at 7:14 PM, as a transfer from the nursing home. Pt #1 eloped from the hospital’s ED on 8/15/2024 at 7:40 PM. Pt #1’s clinical record included: - A “Petition for Involuntary Admission” (dated 8/15/2024). - The Triage Note (dated 8/15/2024 at 7:32 PM), documented by the ED Paramedic/Technician (E #5), included, “Chief Complaint: Psychiatric Complaint ...Mode of Arrival: Ambulance ...Involuntary Petition. Patient Received with an Involuntary Petition: Y[es] ... Pt sent from NH [nursing home] for psych eval [psychiatric evaluation] for aggressive behavior ...Hx Psychiatric Problems: Y[es] ...” - A Patient Note (dated 8/15/2024 at 7:40 PM), documented by the ED Charge Nurse (E #4), included, “Security and I [E #4] were in Room 9 to have [Pt #1] undress. Patient refusing. Patient took off running out the room and on 2nd attempt broke the ER [emergency room] door and ran off down the street. [Local police department] immediately called.” Pt #1’s clinical record lacked the elopement risk screening assessment by the RN (registered nurse) and lacked the triage assessment completed by a RN (registered nurse), as required per policy. 3. On 1/15/2025 at 10:15 AM, an interview was conducted with the ED Manager (E #2). E #2 stated that the elopement risk screening assessment should be done by the triage nurse. E #2 acknowledged that Pt #1’s clinical record lacked an elopement risk screening assessment. C. Based on document review and interview, it was determined that for 1 of 4 (Pt #1), clinical records reviewed for elopement, the hospital failed to ensure that the hospital’s elopement policy was adhered to, following a patient’s (Pt #1) elopement. Findings include: 1. The hospital’s policy titled, “Patient Leaving Without Notification and/;or Authorization Absconded Patient” (dated 7/2023), was reviewed, and required, “When a patient is found missing from his/her room there will be a concerted effort to locate the patient and the incident will be documented ...Locating the patient: Security will be responsible for further documentation and follow-up until the patient is located ...” 2. The clinical record of Pt #1 was reviewed on 1/13/2025. Pt #1 presented to the ED (emergency department) on 8/15/2024 at 7:14 PM, as a transfer from the nursing home. Pt #1 eloped from the hospital’s ED on 8/15/2024 at 7:40 PM. Pt #1’s clinical record included: - A “Petition for Involuntary Admission” (dated 8/15/2024). - The ED Provider Note (dated 8/15/2024 at 7:28 PM), documented by the ED Attending Physician (MD #1), included, “Patient was brought to the emergency room for psych evaluation [psychiatric evaluation]...Alert, Oriented X3 [person, place, time]. Patient is aggressive and agitated ...” - A Patient Note (dated 8/15/2024 at 7:40 PM), documented by the ED Charge Nurse (E #4), included, “Security and I [E #4] were in Room 9 to have [Pt #1] undress. Patient refusing. Patient took off running out the room and on 2nd attempt broke the ER [emergency room] door and ran off down the street. [Local police department] immediately called.” 3. An Incident Report (dated 8/15/2024), regarding Pt #1, included, “Date & Time Occurred: 8/15/2024 [at] 8:30 PM ...Narrative: On the date and time above, I [Director of Security/E #9] received a call from Supervisor [E # 8], who notified me of a patient who had absconded (eloped) from the ER [emergency room]. A nurse and [E #8] attempted to pursue the patient, but their efforts were unsuccessful. I [E #9], instructed [E #8] to call the MOD [manager on duty], inform them of the situation, and call the police...” 4. The Security Event log (8/2024) was reviewed. The log included Pt #1’s event (dated 8/15/2024), “S/O [security officer/E #8 was called to ER for a patient. The patient broke out the emergency door and ran all the way to [local street] that’s where we stopp[ed] running after [Pt. #1’s}.” Pt #1’s clinical record lacked follow-up documentation from the Security, inquiring about Pt #1’s location following the elopement, as required per policy. 5. On 1/14/2025 at 1:30 PM, an interview was conducted with the President/CEO (E #1). E #1 stated that E #1 was made aware of Pt #1 eloping. E #1 stated that if the staff did inquire or made follow-up attempts to locate Pt #1, the staff should have documented the attempts made inquiring about Pt #1’s whereabouts.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34411 Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights. Findings include: 1. The Hospital failed to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person’s heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered. As a result, Pt #1 was not resuscitated, and subsequently expired. A-132 The IJ began on 4/17/2024, due to the facility’s failure to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person’s heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered and subsequently expired. The IJ was identified on 4/24/2024 at 42 CFR 482.13, Patient Rights. The IJ was announced on 4/24/2024 at 11:20 AM during a meeting with the Chief Executive Officer, Chief Operating Officer, Interim Chief Nurse Officer and Quality Management Director, and was not removed by the survey exit date of 4/24/2024.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt. #1) reviewed for a patient’s death, the Hospital failed to initiate and perform life saving measures for one patient (Pt #1), who had a full code (if a person’s heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status ordered. As a result, Pt #1 was not resuscitated, and subsequently expired. Findings include: 1. “The Hospital’s “Code Blue” Policy (dated 4/2018), was reviewed, and required, “Cardiopulmonary Resuscitation will be done on all patients with an absence of pulse or respiration unless a DNR [do not resuscitate] order is written by the physician ...” 2. The Hospital’s policy titled, “Patient Rights” (dated 10/22), was reviewed, and required, “ ...It is the policy of [Hospital] to have processes in place to ensure each patient’s individual rights ...The hospital has mechanism in place to ensure the following: c) The right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital to comply with these directives ...” 3. The clinical record of Pt #1 was reviewed on 4/22/2024. Pt #1 presented to the ED (emergency department) for Altered Mental Status on 4/13/2024. Pt #1 was on ED hold and then transferred to the Intensive Care Unit (ICU) on 4/15/2024 at 4:29 PM. Pt #1 expired in the Hospital on 4/17/2024 at 6:41 AM. Pt #1’s clinical record included the following: - An ED Provider note, (dated 4/13/2024), documented by the ED Physician (MD #5), included, “ ...nursing home patient ... [Pt #1] is a DNR [Do Not Resuscitate] ...has a history of advanced dementia [Pt #1] cannot give a history ...” MD #5’s note indicated that Pt #1 was a DNR, however, there was no supporting documentation or paperwork on file. -Pt #1’s Nursing Admission Assessment (dated 4/14/2024), that included the Medical/Legal section, documented by the ED RN (E #15), was left blank. There was no Existing Advance Directive; Advance Directive provided; or Power of Attorney documented on this assessment. - ED nursing notes documented by the ED RN (E #8), included: - 4/15/2024 at 11:16 AM: “E #8 spoke with Pt #1’s guardian.” - 4/15/2024 at 4:06 PM), included, “This pt is a Full Code.” - 4/15/2024 at 4:28 PM: “Spoke with [Z #1] the Guardian and [Z #1] is working with us to set up a DNR. Paperwork being faxed to [MD #1] now.” - A “Letter of Instruction: Office of the Cook County Public Guardian Adult Guardianship” form (dated 4/15/2024) indicating that Pt #1 had a State Guardian (Z #1). - A Physician progress note, documented by the covering ICU Physician (MD #1), dated 4/15/2024 at 3:15 PM, included, “Transferred from ER to ICU ...Per ER notes patient is DNR. However, no DNR papers in chart ...No family. Called State Guardianship Office ...Spoke with [State Guardian/Z #1]. Surrogate paperwork is being completed. Until all paperwork completed [Pt #1] will be Full Code ...” - Pt #1’s Physician orders included an order (initiated on 4/15/2024 at 4:07 PM), for “Resuscitation Status” as Full Code. - 4/17/2024 at 7:27 AM, nurse’s note, documented by E #5: “Patient HR [heart rate] decreased to 30 BPM [beats per minute/low heart rate]. Kussmaul breathing [abnormal respirations] ...Unable to get a pulse or O2 [oxygen] saturation. Patient went asystole [pulseless] at 0622[AM]. House MD paged. Patient pronounced at 0641[AM].” No resuscitative measures were initiated on Pt #1 who was a Full Code. - A Physician progress note (dated 4/17/2024 at 6:47 AM) documented by the House Physician (MD #2) included: “I [MD #2] was called by the pt’s nurse [E #5] to evaluate the pt for a death announcement. On exam the pt [Pt #1]was unresponsive to verbal and tactile stimuli. The patient had no spontaneous respirations. The pt had no palpable pulses. The pt had no heart sounds. The pt’s pupils were fixed and dilated. The pt was pronounced dead at 6:41 AM on 4-17-24.” -The clinical record did not include a DNR order or a POLST (Practitioner Order for Life-Sustaining Treatment) form. 4. On 4/22/2024 at 10:23 AM, an interview was conducted with the House Physician (MD #2). MD #2 stated that the House Physician is called to all “Code Blues” and also called to pronounce a patient’s death. MD #2 stated that MD #2 was called (on 4/17/2024), to pronounce Pt #1’s death. MD #2 stated that when MD #2 arrived at the ICU where Pt #1 was, Pt #1 had no signs of life, and MD #2 then pronounced Pt #1’s time of death. MD #2 stated that the RN on the unit is the one that confirms the patient’s DNR/Code Status prior to calling the Code. 5. On 4/22/2024 at 10:35 AM, an interview was conducted with the Social Worker (E #3). E #3 stated that Pt #1’s Public Guardian (Z #1) told E #3 that Z #1 came into the hospital and met with Pt #1’s RN to fill out the DNR form. E #3 stated that Z #1 left the DNR forms with the nurse to have them filled out. E #3 stated that Z #1 wanted the DNR form faxed back to Z #1’s office once the form was completed. E #3 stated that there was going to be a meeting at the Public Guardian’s office to discuss the patient’s DNR status and get approval. E #3 stated that Pt #1’s DNR papers were not faxed back to the office, since Pt #1 had already expired. E #3 stated that 2 physicians are required to sign the POLST form. E #3 stated that Pt #1 would have still been considered a Full Code until the required paperwork was in the chart. 6. On 4/22/2024 at 11:25 AM, an interview was conducted with the ICU RN (E #4/RN who admitted Pt #1). E #4 stated that when the ED was going to transfer Pt #1 to the ICU, E #4 noticed that there was no Code status in the system for Pt #1. E #4 stated that the ED nurse then put the order in as Full Code (on 4/15/2024), prior to Pt #1 transferring from the ED. E #4 stated that if a patient does not have a DNR order, then the patient is treated as a Full Code. E #4 stated that for the 2 days that E #4 took care of Pt #1, Pt #1 was a Full Code. 7. On 4/22/2024 at 1:15 PM, a phone interview was conducted with the ICU Physician (MD#1/covering Pt #1). MD #1 stated that Pt #1’s Code Status was uncertain. MD #1 stated that MD #1 spoke with Pt #1’s Guardian (Z #1) to clarify the Code Status. MD #1 stated that Z #1 faxed over the DNR paperwork, and MD #1 signed the papers. MD #1 stated that the DNR papers require 2 physicians to sign it. MD #1 stated that in the meantime, before the DNR form is completed, the patient would still be considered a Full Code. 8. On 4/22/2024 at 1:30 PM, a phone interview was conducted with the ED RN (E #8). E #8 stated that while Pt #1 was boarded in the ED, there was no Code Status for Pt #1. E #8 called Pt #1’s Guardian (Z #1). E #8 stated that Pt #1 was not a DNR at that time, but that Z #1 and the nursing home were trying to initiate the DNR since Pt #1’s condition was declining. E #8 stated that Z #1 told E #8 that Pt #1 was still a Full Code until the DNR process was completed. E #8 stated that when report was given to the ICU RN (E #4) on 4/15/2024 on day shift. E#8 reported that Pt #1 was still a Full Code. 9. On 4/23/2024 at 8:47 AM, a phone interview was conducted with the ICU RN (E #5/cared for Pt #1 when Pt #1 expired). E #5 stated that Pt #1’s monitors were alarming, and it was noted that the patient’s heart rate was dropping. E #5 stated that E #5 went into Pt #1’s room and noticed the patient was with heavy breathing. E #5 stated that Pt #1’s pulse was then checked and at that time, there was no pulse and within a minute, the patient expired. E #5 stated that Pt #1 was not Coded (resuscitated) since E #5 was told in report that Pt #1 was a DNR. E #5 stated that the House Doctor (MD#2) was then called to pronounce Pt #1’s death. E #5 stated that when MD #2 came up and reviewed Pt #1’s chart, it was identified that Pt #1 was actually still a Full Code and not DNR. E #5 stated that it was a misunderstanding about Pt #1’s Code status. E #5 stated that the usual process for patients with DNR status, is that the “RED” (POLST form) would be located on the front of the patient’s chart and nurses would look to verify their Code status. E #5 stated that after the incident, E #5 let the Nursing Supervisor (E #10), the Attending MD (MD #1), and the Chief Nurse Executive (E #2), know on 4/17/2024. E #5 stated that there had been no further communication from Administration regarding the incident. 10. On 4/23/2024 at 10:25 AM, an interview was conducted with the Interim ICU Manager (E #12). E #12 stated that E #12 made the nursing staff aware every day that Pt #1 was here, that the patient was a Full Code and not a DNR until we got the paperwork. E #12 stated that E #12 advised the nurses that we still must treat Pt #1 as a Full Code until those papers get faxed over. E #12 stated that the morning that Pt #1 expired, E #12 was told by the Nursing Supervisor (E #10) that Pt #1 expired. E #12 stated that E #12 asked if the pt was “Coded”. E #10 told E #12 “no” since Pt #1 was a DNR. E #12 stated that a Code should have been done on Pt #1. 11. On 4/23/2024 at 9:50 AM, an interview was conducted with the Chief Nursing Executive (E #2). E #2 stated that E #2 was aware of Pt #1’s incident. E #2 stated that there had been no incident report completed and no follow-up actions implemented (as of 4/23/2024).”