Edward Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 34411 Based on document review and interview, for 1 of 4 (Pt #1) clinical records reviewed for restraints, the hospital failed to ensure that a “Notice Regarding Restricted Rights of Individuals” form was completed when a patient was placed in restraints; administered emergency medications; restricted from telephone communications; and personal belongings removed, in accordance with hospital policy. Findings include: 1. The Hospital’s policy titled, “Guidelines for Care of the Behavioral Health Patient in the Emergency Department” (dated 8/29/2024), was reviewed and required, “ ...Ensure completion State of Illinois Mental Health forms: Restriction of Rights for all patients who must remain the in the ED for evaluation or admission or have been given emergency psychotropic medications ...” 2. The Hospital’s policy titled, “Restriction of Patient Rights for Individuals Receiving Psychiatric Treatment” (date 4/30/2024), was reviewed and required, “ ...Whenever the rights of a patient are restricted, the patient and any guardian, Guardianship and Advocacy Commission (if designated), and/or the patient’s substitute decision maker (if any) must be given the notice and explanation of the restriction ...Completed restriction of rights form is copied and distributed according to the patient’s request. The original form remains in the medical record. A Restriction of Rights is completed for ...restraints/seclusions/therapeutic holds, emergency medications, removal of personal property ...” 3. The clinical record for Pt #1 was reviewed on 3/10/2026. Pt #1 is a minor who presented to the ED (emergency department) on 6/15/2025 at 12:23 PM, for a psychiatric evaluation. - Consent for Care and Services was signed by Pt #1’s parent (Z #2/parent whom Pt #1 resides), on 6/15/2025 at 12:50 PM. - A Public Safety Belongings Checklist (list of patient belongings), dated 6/15/2025 at 12:30 PM, included Pt #1’s belongings that were removed and secured by the public safety office. - ED Initial Assessment note (dated 6/15/2025 at 12:23 PM), documented by the ED Registered Nurse (E # 3/RN), included, “Patient was at a mental health facility [outpatient clinic] and got upset. [Pt #1] punched a wall and was slamming doors [at the outpatient clinic] ...Patient presents [to the ED] tearful and uncooperative. Patient came out of the room and attempted to use the phone, redirected to [Pt #1’s] room where Pt #1 stomped into the room.” ED Quick notes documented by E #3, included: - 6/15/2025 at 2:44 PM: “Patient was told about going inpatient by LSW [licensed social worker -E# 4] and this RN [E # 3] present in the room. Patient asked to speak with [Pt #1’s parent/Z #1]. SW stated that [E #4] would ask [Z #2] if ok to call [Z #1].” - 6/15/2025 at 2:48 PM: “Social Worker [E # 4] told patient that [Pt #1] could not call [Z #1] at this time. [E #4] then asked if patient wanted [restaurant food] to which patient stated, ‘I don’t want that f@** s@** [profanity]’. MD made aware that patient is agitated and is at risk of harming [self]. PRN [as needed medication].” - 6/15/2025 at 3:28 PM: “After administering IM [intramuscular] Haldol [psychotropic medication] patient threw stool across the room at the door and struck the window. Patient got back in bed. Security was at bedside still for IM and helped this RN [E # 3]and other staff to apply four-point restraints. Patient asked how to get restraints off, this RN educated patient that [Pt #1] needs to calm down before we can reassess and take the restraints off ...” - 6/15/2025 at 5:24 PM: “Patient made confidential per parent’s request. Verbal password to be given over the phone per [Z #2] ...” There was no further documentation after the behavioral episode, indicating that Pt #1 was allowed Pt #1 to communicate via telephone. Pt #1 was placed in restraints; administered emergency medication; restricted from telephone usage; and personal belongings were removed. The clinical record lacked the “Notice Regarding Restricted Rights of Individuals” (restriction of rights form). 4. On 3/10/2026 at 12:45 PM, an interview was conducted with the ED RN (E #3). E #3 stated that Pt #1 came in via EMS (emergency medical services) after “acting up” at the psych doctor’s office prior to arrival. E #3 stated that Pt #1 was given Haldol. E #3 stated that after Pt #1 received Haldol, Pt #1 then required 4-point locked restraints. E #3 acknowledged that a Restriction of Rights form was not completed. E #3 stated that that form should be completed whenever the patient’s right has been restricted including when restraints are applied, clothes are removed, and when emergency medication is given. E #3 stated that Z #2 advised not to allow Pt #1 to speak with Z #1. E #3 stated that Pt #1 was not allowed to call (Z #1) due to behavior. E #3 stated that, however, Pt #1 could have used the phone after Pt #1 calmed down. E #3 stated that Pt #1 did not use the phone while still on E #3’s shift (9AM-9PM). E #3 stated that E #3 let Z #2 know when Pt #1 was given Haldol and put in restraints. E #3 stated that E #3 does not recall speaking with Z #1. 5. On 3/10/2026 at approximately 2:50 PM, an interview was conducted with the ED Manager (E #1). E #1 stated that a Restriction of Rights form should be completed when a patient is restrained (chemically or physically). E #1 acknowledged that Pt #1’s clinical record lacked a Restriction of Rights form.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 34411 Based on document review and interview, for 1 of 1 (Pt #1) minor behavioral health patient reviewed, the Hospital failed to ensure patient rights, by not allowing the patient to communicate with a parent (Z #1), as requested by Pt #1. Findings include: 1. The Hospital’s policy titled, “Pediatric Rights and Responsibilities” (dated 6/12/2025), was reviewed, and required, “In addition to the rights of adult patients and the Pediatric Bill of Rights, children and their parents/guardians, have the following rights: Participation of children/parents/guardians in decisions affecting their own medical treatment ...” 2. The clinical record for Pt #1 was reviewed on 3/10/2026. Pt #1 is a minor who presented to the ED (emergency department) on 6/15/2025 at 12:23 PM, for a psychiatric evaluation. - Consent for Care and Services was signed by Pt #1’s parent (Z #2/parent whom Pt #1 resides with), on 6/15/2025 at 12:50 PM. Z #2 was present while Pt #1 was in the ED. - ED Initial Assessment note (dated 6/15/2025 at 12:23 PM), documented by the ED Registered Nurse (E # 3/RN), included, “Patient was at a mental health facility [outpatient clinic] and got upset. [Pt #1] punched a wall and was slamming doors [at the outpatient clinic] ...Patient presents [to the ED] tearful and uncooperative. Patient came out of the room and attempted to use the phone, redirected to [Pt #1’s] room where Pt #1 stomped into the room.” - ED Quick notes documented by E #3, included: - 6/15/2025 at 2:44 PM: “Patient was told about going inpatient by LSW [licensed social worker - E# 4] and this RN [E # 3] present in the room. Patient asked to speak with [Pt #1’s parent/Z #1]. SW stated that [E #4] would ask [other parent/Z #2] if ok to call [Z #1].” - 6/15/2025 at 2:48 PM: “Social Worker [E # 4] told patient that [Pt #1] could not call [Z #1] at this time ...” - 6/15/2025 at 5:24 PM: “Patient made confidential per parent’s [Z #2] request. Verbal password to be given over the phone per [Z #2] ...” There was no further documentation after the behavioral episode, indicating that Pt #1 was allowed Pt #1 to communicate with Z #1 via telephone. 3. On 3/10/2026 at 12:45 PM, an interview was conducted with the ED RN (E #3). E#3 stated that Pt #1 started escalating in the ED when Pt #1 was told that Pt #1 would have to be transferred to inpatient. E #3 stated that Z #2 advised not to allow Pt #1 to speak with Z #1. E #3 stated that Pt #1 was not allowed to call (Z #1) due to behavior. E #3 stated that, however, Pt #1 could have used the phone after Pt #1 calmed down. E #3 stated that Pt #1 did not use the phone while still on E #3’s shift (9AM-9PM). E #3 stated that E #3 does not recall speaking with Z #1. 4. On 3/10/2026 at 2:37 PM, a phone interview was conducted with the Licensed Social Worker (E #4). E #4 stated that E #4 saw Pt #1 while in the emergency department. E #4 stated that Pt #1 came in with aggression and it was determined that Pt #1 needed to be admitted to (affiliated behavioral health hospital). E #4 stated that Pt #1’s parent (Z #2/whom Pt #1 resides with), was present in the Hospital and mentioned that Z #2 is the primary care custodian. E #4 stated that Pt #1 asked if Pt #1 could call (Z #1/parent that lives out of state). E #4 stated that E #4 “ran” Pt #1’s request by Z #2 and Z #2 said “not at this time”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 34411 Based on document review and interview, for 1 of 4 (Pt #1) clinical records reviewed for restraints, the Hospital failed to ensure that when a medication was used as restriction to manage the patient’s behavior, the least restrictive measures and de-escalation attempts were documented, prior to the administration of the chemical restraint. Findings include: 1. The Hospital’s policy titled, “Restraints and Seclusion” (dated 9/4/2024), was reviewed and required, “ ...Chemical Restraint: A medication used to restrain a patient that is not a standard treatment for the patient’s medical or psychotropic condition. Drugs used as restraints are medications used in addition to or replacement of the patient’s regular drug regiment are not considered drug restraints, even if their purpose is to control ongoing behavior ...Restraints are used only after alternative strategies have been attempted or considered and are unsuccessful ...The least restrictive type of restraint is implemented to preserve the patient’s rights, dignity and physical and emotional well-being ...” 2. The clinical record for Pt #1 was reviewed on 3/10/2026. Pt #1 is a minor who presented to the ED (emergency department) on 6/15/2025 at 12:23 PM, for a psychiatric evaluation. - ED Initial Assessment note (dated 6/15/2025 at 12:23 PM), documented by the ED Registered Nurse (E # 3/RN), included, “Patient was at a mental health facility [outpatient clinic] and got upset. [Pt #1] punched a wall and was slamming doors [at the outpatient clinic] ...Patient presents [to the ED] tearful and uncooperative...” ED Quick notes documented by E #3, included: - 6/15/2025 at 2:44 PM: “Patient was told about going inpatient by LSW [E# 4 and this RN [E # 3] present in the room. Patient asked to speak with [Pt #1’s parent/Z #1]. SW stated that [E #4] would ask [other parent/Z #2] if ok to call [Z #1].” - 6/15/2025 at 2:48 PM: “Social Worker [E # 4] told patient that [Pt #1] could not call [Z #1] at this time. [E #4] then asked if patient wanted [restaurant food] to which patient stated, ‘I don’t want that f@** s@** [profanity]’. MD made aware that patient is agitated and is at risk of harming [self]. PRN [as needed medication].” - 6/15/2025 at 3:28 PM: “After administering IM [intramuscular] Haldol [psychotropic medication] patient threw stool across the room at the door and struck the window. Patient got back in bed. Security was at bedside still for IM and helped this RN [E # 3]and other staff to apply four-point restraints. Patient asked how to get restraints off, this RN educated patient that [Pt #1] needs to calm down before we can reassess and take the restraints off. This RN [E #3] then went to the waiting room and updated [Z #2] on event. Parent [Z #2] verbalized understanding and told that they would be kept up to date.” - Physician orders on 6/15/2025, included an order for Haldol 5 mg (milligrams) injection STAT (immediately) at 2:53 PM. - Medication Administration Record (MAR) included Haldol 5 mg injection was given on 6/15/2025 at 2:53 PM. There was no documentation including de-escalation or least restrictive measures attempts prior to the administration of a chemical restraint on nursing flowsheets or narrative nursing notes (from 6/15/2025 at 12:23 PM-6/15/2025 at 9:56 PM) 3. On 3/11/2026 at approximately 1:15 PM, an interview was conducted with the ED Manager (E #1). E #1 reviewed Pt #1’s clinical record and acknowledged that Pt #1’s clinical record lacked documentation of least restrictive measures or de-escalation attempts prior to the administration of the psychotropic medication.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 39802 A. Based on document review, observation, and interview, it was determined that for 2 of 3 (Pts. #1 and #3) patients with infections, the Hospital failed to ensure that isolation precautions were implemented to prevent and control the transmission of infections. Findings include: 1. The Hospital’s policy titled, “Isolation” (revised 4/5/2023), was reviewed and required, “Inpatient departments will initiate isolation based on transmission based precautions recommendations from the Centers for Disease and Control (CDC) see Exhibit A... Contact Isolation: 1. Place patient in a private room with appropriate isolation sign posted outside room. 2. a. Gown and gloves when entering the patient’s room or treatment area... Exhibit A Isolation Guidelines: ...Infection/Condition: Extended-spectrum beta-lactamase (ESBL) [and] Multi-drug resistant organism (MDRO) [and] (VRE); Precautions Required: Contact... [for] Infection- current or within the past year...” 2. The clinical record of Pt. #1 was reviewed on 3/4/2024. Pt. #1 was presented to the Hospital on 10/16/2023 with a chief complaint of diarrhea. A body fluid culture, collected on 11/2/2023 and resulted on 11/5/2023, was positive for VRE [vancomycin-resistant enterococcus]. A contact isolation order was placed on 11/5/2023. The clinical record included nursing education notes regarding isolation starting on 11/9/2023 (4 days after the order was placed). In addition, the nursing flowsheet lacked documentation indicating that precautions were implemented and in place. 3. The clinical record of Pt. #3 was reviewed on 3/5/2024. Pt. #3 was admitted on 3/2/2024 with a diagnosis of MDRO e. [escherichia] coli UTI [urinary tract infection]. The History and Physical, dated 3/2/2024 at 8:56 AM, included “[Pt. #3] presenting to the ED [emergency department] for UTI requiring admission for IV [intravenous] antibiotics... Differential diagnosis includes ESBL UTI... Previous records reviewed. Urine culture obtained February 24, 2024 was positive for ESBL...” The record lacked orders and implementation of contact precautions as required for ESBL infections. 4. During a tour of the Medical-Oncology Unit on 3/4/2024, at approximately 9:50 AM. Pt. #3’s room was observed and lacked signage posted to indicate Pt. #3 was on contact precautions. Staff entering the room did not don gloves and gown. 5. An interview was conducted with the Manager of Infectious Disease (E#20) on 3/6/2024, at approximately 10:52 AM. E#20 stated if a patient has a current infection or infection within the past year with a MDRO, the patient will be placed on contact precautions. E#20 stated that Pt. #3 should have been on contact precautions. E#20 stated that if the cultures were done at the Hospital, it would normally flag the record to order the precautions. E#20 stated that in Pt. #3’s case, the results were from the another hospital and should have been ordered by the nurse or physician when doing the admission screening and assessments. 6. An interview was conducted with the Nurse Educator (E#21) on 3/6/2024, at approximately 12:35 PM. E#21 stated that when an order is placed for isolation, the nurse should acknowledge the order and document that education was provided regarding the isolation precautions and MDROs. B. Based on document review, observation, and interview, it was determined that for 3 of 4 staff (E#6-#8) observed providing patient care, the Hospital failed to ensure that hand hygiene was performed to prevent and control the transmission of infections. Findings include: 1. The Hospital’s policy titled, “Standard Precautions” (revised 11/3/2021), was reviewed and required, “Perform hand hygiene in the following situations: ... before donning gloves and after removing gloves...” 2. During a tour of Medical Oncology Unit on 3/4/2024 the following was observed: - At approximately 9:40 AM. Registered Nurse/RN (E#6) was observed administering IV [intravenous] antibiotics to Pt. #2. E#6 moved the garbage bin closer to the bedside and then changed gloves without performing hand hygiene. E#6 proceeded to connect the IV lines to the pump. - At approximately 9:50 AM, RN (E#7) was observed administering antibiotics to Pt. #3 through the patients newly placed PICC [peripherally inserted central catheter]. E#7 connected the IV tubing to Pt. #3’s PICC port and then changed gloves without performing hand hygiene. - At approximately 10:21 AM, RN (E#8) was observed administering a medication IV push to Pt. #5. E#8 wiped the IV port with alcohol and went to throw away the pad in the garbage. E#8 used the left gloved hand to lift the garbage lid. E#8 then went back to administer the medication through the patient’s peripheral IV line without changing gloves and performing hand hygiene. After administering the medication, E#8 changed gloves without performing hand hygiene. 3. An interview was conducted with Registered Nurse (E#6) on 3/4/2024, at approximately 11:10 AM. E#6 stated that hand hygiene should be done before putting on gloves and after removing them.”