Presence Saint Joseph Hospital - Chicago

“On June 4, 2025, from 11:00 am - 1:00 pm, an unannounced on-site investigation 183292 was conducted in response to a complaint originally received in October 2024, concerning extreme temperature fluctuations in the ICU and NICU. The complaint alleged that air handler units were not functioning properly, resulting in extreme temperature fluctuations-ranging from excessively cold to excessively warm conditions. The following facility representatives accompanied this surveyor during the walk-through: “ Director of Facilities (DOF) “ Market COO “ CNO/COO “ Infection Preventionist “ Quality Specialist “ Patient Safety Specialist “ Safety Officer “ President/CEO “ Quality Manager The building was surveyed as existing healthcare under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. The requirements of 42 CFR Subpart 482.41, Physical Environment are NOT MET; Refer to the deficiencies cited under the K-Tags.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 45373 Based on observation, the facility failed to provide a means within the facility’s ventilation cooling system to properly maintain temperature and humidity levels. Failure to maintain the temperature and humidity levels through out the facility could result in increasingly uncompfortable conditions for patients staff and visitors. This deficient practice could affect patients, staff and visitors during the spring and summer seasons of the year. The finding is: On 6/04/2025 from 11 AM through 1PM a complaint investigation was conducted concerning the temperature and humidity levels found through out the facility. The surveyor was accompanied by the faciltiy represeontatives listed in K tag 0000. During the facility walk-through, staff interview and field measurements the surveyor observed spot coolers located within the NICU and ED areas to maintain temperatures and humidity levels. While certain measurements were found to be within range the use of spot coolers within critical care areas does not comply with NFPA 101 section 9.2.1, NFPA 90A 2012 section 2.3.1 ASHRAE/ASHE Standard 170-2008 table 7.1. Spot coolers are not intended to replace a compliant HVAC system.”

“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 1 of 4 patients’ (Pt. #1) grievances reviewed, the hospital failed to ensure that process for resolving grievance was followed in accordance with policy. Findings include: 1. On 1/03/2024, the hospital’s policy titled, “Complaint and Grievance “ (4/2023) was reviewed and included, “ ... Definitions ... C. Grievance - a formal or informal written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by the staff present) by a patient ... Grievance examples include: 1. Concerns of... patient harm are grievances that require immediate investigation and action ... IV. Procedure ... E. Resolution Process: 1 ... Grievances require a written response ... 2. A grievance is considered resolved when the patient/patient representative/complainant is satisfied with the outcome ... 3. When a grievance can be resolved promptly (within 7 days) the organization shall send a written acknowledgement of receipt/resolution of the grievance to the complainant within seven (7) days. The letter must include: a. the issue reviewed, b. actions taken to mitigate the issues, c. results of the actions taken, if applicable, d. name of the contact person who addressed the grievance, e. date investigaiton was completed ...” 2. On 1/03/2024, the clinical record for Pt. #1 was reviewed. On 10/08/2023, Pt. #1 was brought to the hospital’s ED (emergency department) due to back pain. On 10/09/2023 at 2:54 PM, MD #1’s (Resident Physician) notes indicated, “Was notified by nurse (E #4/Registered Nurse) that (Pt. #1) was screaming in pain down at the MRI ... (Pt. #1) reports that the MRI (Technician/E #1) put (Pt. #1) back on the bed like this face down which (Pt. #1) was not comfortable and was in severe pain. ... (Pt. #1) reports that someone came from MRI to transport her and ‘they grabbed her legs’ trying to transition her from the bed which caused her extreme pain.” 3. On 1/03/2024, an event occurrence (ERS/event reporting system) for Pt. #1’s complaint was reviewed. On 10/09/2023 the ERS indicated that Pt. #1 complained of being positioned or handled inappropriately and was in severe pain. 4. On 01/04/2023, the hospital’s timeline of action regarding Pt. #1’s complaint/grievance was reviewed and included: -10/09/2023. At 8:48 AM, MRI was ordered. At 1:02 PM, MRI called the floor, (Pt. #1) was not available for the exam. At 2:05 PM, RN notified (Pt. #1) could not tolerate the exam due to pain, (Pt. #1) was sent back upstairs. Resident notified and the plan to attempt a second MRI same day after additional pain medication. At 3:08 PM, Accompanied by the resident to the MRI department. At 4:10 PM, ERS (event report system) event reported. At 4:42 PM, ERS immediate investigation by Department Director/Patient Safety notified of event. Escalated through chain of command. At 5:15 PM, (Pt. #1) brought back down and the MRI exam was completed. At 5:20 PM, House supervisor spoke it the patient to follow-up as requested by the Radiology Director after the MRI (was completed). -10/10/2023. At 8:00 AM, Radiology Director spoke with (Pt. #1) - escalates through chain of command. At 3:07 PM, Department Director entered concern into Salesforce. At 3:57 PM, Salesforce Specialist called patient and left message. At 5:18 PM, ERS event investigation completed by department director and no deviation from standard of care was identified. -10/11/2023. At 8:15 AM, the Salesforce Specialist called (Pt. #1) a second time - no return calls received. -10/16/2023 through 11/22/2023. On 10/16/2023 - To ensure patient care is provided with optimal experience, the following educational reminders were completed for MRI staff via email and unit huddles: Expectations to ask for assistance when transferring patients onto/off imaging equipment. Expectations to ask the nurse to come to the department to assess the patient using STAR (Stop, Think, Act, Review). From 11/18/2023 through 11/22/2023, MRI staff received an educational PowerPoint and asked to complete a return demonstration regarding the process around safe patient handling. 5. On 1/03/2023, the complaint report for Pt. #1 was reviewed, and the report did not include that resolution/written response was provided to Pt. #1 regarding the following: issue reviewed, actions taken to mitigate the issues, results of the actions taken, if applicable, name of the contact person who addressed the grievance, and date the investigaiton was completed. 6. On 1/03/2024 at approximately 1:47 PM, a telephone interview was conducted with E #3 (Patient Care Specialist). E #3 stated that if the nature of a patient’s complaint was about being handled inappropriately resulting to pain, E #2 stated that the complaint requires an investigaiton and follow-up process of a grievance. E #2 stated that a formal letter will be sent to the patient following the grievance. E #3 confirmed that there was no follow-up letter sent to Pt. #1.”

“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: 39802 Based on document review and interview, it was determined that for 2 of 2 violent restraint records (Pts. #9 and #10) reviewed, the Hospital failed to ensure that restraints/seclusion were used in accordance with an order from a physician/licensed practitioner as required. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion Management Policy” (2/10/2023), was reviewed and required, “Orders for violent or self-destructive restraint or seclusion must be entered in the Electronic Health Record by an Authorized Clinician and include: a. The reason for the restraint or seclusions... b. The type of restraint or seclusion...” 2. The clinical record of Pt. #9 was reviewed on 1/4/2024. Pt. #9 was admitted to the intensive care unit for medical clearance on 10/21/2023 with a diagnosis of suicidal ideation. Pt. #9 was placed in 4 point (limb/extremity) locked restraints due to being combative on 10/23/2023 from 10:00 AM to 9:15 PM. Physician orders for violent-restraints, dated 10/23/2023, were reviewed and included that “4 side rails” had been entered electronically as the restraint type, not the actual restraint type used of 4-point locked restraints. 3. The clinical record of Pt. #10 was reviewed on 1/4/2024. Pt. #10 was admitted on 11/18/2023 with a diagnosis of depression and suicidal ideation. Pt. #10 was placed in 4 point (limb/extremity) locked restraints and seclusion due to destroying property and danger to self on 11/19/2023 from 1:00 PM to 9:15 PM. Physician orders for violent-restraints, dated 11/19/2023, were reviewed and lacked the type of restraint to be used and the reason for the restraint. The record also lacked orders for seclusion. 4. An interview was conducted with the Director of Critical Care (E#10) on 1/4/2024, at approximately 9:30 AM. E#10 stated that the restraint order should specify the type of restraint to be used and should include the reason. E#10 verified in the electronic health record that the orders for Pt. #9 and #10 did not contain the correct type of restraints that were used or if seclusion was ordered. E#10 stated that for seclusion, the physician would have to type in a comment to include seclusion in the restraint order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 2 of 2 violent restraint records (Pts. #9 and #10) reviewed, the Hospital failed to ensure that restraints/seclusion were discontinued at the earliest possible time. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion Management Policy” (2/10/2023), was reviewed and required, “Once the unsafe situation ends, the use of restraint or seclusion must be discontinued.” 2. The clinical record of Pt. #9 was reviewed on 1/4/2024. Pt. #9 was admitted to the intensive care unit for medical clearance on 10/21/2023 with a diagnosis of suicidal ideation. Pt. #9 was placed in 4 point (limb/extremity) locked restraints due to being combative on 10/23/2023 from 10:00 AM to 9:15 PM. The restraint flowsheets indicated that between 11:15 AM-2:45 PM ( 3 hours and 30 minutes) Pt. #9 was asleep, and the record lacked documentation of the justification for continuing restraints. 3. The clinical record of Pt. #10 was reviewed on 1/4/2024. Pt. #10 was admitted on 11/18/2023 with a diagnosis of depression and suicidal ideation. Pt. #10 was placed in 4 point (limb/extremity) locked restraints and seclusion due to destroying property and danger to self on 11/19/2023 from 1:00 PM to 9:15 PM. The restraint flowsheets indicated that between 4:00 PM to 7:15 PM (3 hours and 15 minutes), Pt. #10 was asleep, and the record lacked documentation of the justification for continuing restraints and seclusion. 4. An interview was conducted with the Director of Critical Care (E#10) on 1/4/2024, at approximately 9:30 AM. E#10 stated that patients in violent restraints have a one-to-one monitor and the patients behavior and status will be charted every 15 minutes. E#10 stated that patients should be taken out of restraints/seclusion at the earliest time possible.”