Northwestern Medicine Kishwaukee Hospital

“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: 48264 Based on document review and interview, it was determined that for 1 of 4 patients’ (Pt. #1) clinical records reviewed for blood administration, the hospital failed to ensure that the consent to administer blood was completed, as required. Findings include: 1. On 4/19/2025, the hospital’s policy titled ‘Informed Consent’ (effective 3/13/2024) was reviewed and included, “ ...I. Purpose: This policy describes the process for obtaining informed consent ...V. Responsibilities: ...Who May Consent: ...B. Consent for adults who lack decisional capacity, either temporarily or permanently, will be obtained from the following individuals ...1. A decision maker or directive under ...a. Health care agents under a valid Durable Medical Power of Attorney ...Special Consents: A ...this policy should be followed as to who may consent for these treatments/procedures ...1. Blood products ...”. 2. On 4/19/2025, the hospital’s policy titled ‘Blood and Blood Administration (effective 1/06/2025) was reviewed and included, “ ...VII. Procedure: ...B. Obtain informed consent ...”. 3. On 4/18/2025, the clinical record of Pt. #1 was reviewed. On 1/01/2025, Pt. #1 presented to the hospital for right shoulder and right ankle pain post fall, orthopedics consulted and was admitted to the Medical Surgical unit. Pt. #1’s record indicated that Pt #1 had a POA (Power of Attorney), and clinical notes indicated that Pt. #1 was Spanish speaking, requiring interpreter, and intermittently confused. On 1/09/2025 between 12:03 AM and 3:17 AM, one unit of blood was administered to Pt. #1. There was a consent obtained; however, it was in English and no interpreter or POA was utilized to obtain consent. 4. On 4/21/2025 at approximately 12:21 PM, findings were discussed with the Hospitalist (MD #2). MD #2 stated that communication with Pt. #1 required a translator and with Pt. #1 intermittently confused, the consent should have been obtained from the POA.”

“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: 27125 Based on document review and interview, it was determined that for 1 of 2 (Pt. #6) patient records reviewed for violent restraint usage, the hospital failed to get an order as soon as possible after application, per policy. Findings include: 1. The Hospital’s policy titled, “Restraints and Seclusion (12/16/2024)” was reviewed on 4/19/2025 and included, “Obtain provider Violent, Self-destructive Restraint or Seclusion order. For immediate safety of patient or staff, the nurse may initiate a restraint and then notify provider for an order as soon as possible.” 2. The clinical record of Pt. #6 was reviewed on 4/19/2024. Pt. #6 presented to the emergency department on 1/1/2025 with complaint of altered mental status. Pt. #6 was placed in violent (4 way locking - all extremities) restraints on 1/2/2025 at 12:03 AM due to being verbally and physically threatening. The order for the restraints was written on 1/2/2025 at 3:21 AM (3 hours and 18 minutes after application). 3. During an interview on 4/21/2025 at 9:00 AM, the manager of accreditation (E#14) stated that the order should have been written as soon as possible after application of restraints. E#14 stated, “The order was written after the release from restraints.””

“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: 27125 Based on document review and interview, it was determined that for 1 of 2 (Pt. #6) patient records reviewed for violent restraint usage, the hospital failed to ensure the patient was seen face to face with 1 hour of restraint initiation. Findings include: 1. The Hospital’s policy titled, “Restraints and Seclusion (12/16/2024)” was reviewed on 4/19/2025 and included, “Patients need to be seen physically seen by a provider within 1 hour of restraint application.” 2. The clinical record of Pt. #6 was reviewed on 4/19/2025. Pt. #6 presented to the emergency department (ED) on 1/1/2025 with complaint of altered mental status. Pt. #6 was placed in violent (4 way locking - all extremities) restraints on 1/2/2025 at 12:03 AM due to being verbally and physically threatening. The clinical record lacked documentation of a face to face evaluation within 1 hour of restraint application. 3. During an interview on 4/21/2025 at 9:00 AM, the manager of accreditation (E#14) stated that E#14 could not find documentation of the face to face in the clinical records. E#14 stated, “There should have been a face to face because of the usage of violent restraints.””

“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: 27125 Based on document review, video review and interview, it was determined that for a patient (Pt. #13) who presented to the emergency department (ED) on 11/11/2024, the Hospital failed to ensure that the ED’s central log included an individual who presented to the ED seeking treatment, as required. Findings include: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Transfer (2/19/2024)” was reviewed on 4/18/2024 and required, “Emergency Department Log: The Hospital must maintain a central log on each individual who presents for emergency care. The log must indicate whether the individual refused treatment , was refused treatment , was transferred, was admitted to the hospital and treated, was stabilized and transferred, or was discharged.” 2. The video of the alleged presentation of Pt #13 to the ED was reviewed via zoom on 4/22/2025 at 9:50 AM. The video started at 3:09 PM on 11/11/2024, and the following was observed: - 3:10 PM - Woman carrying a child carrier (Pt. #13) entered the ED. Two people were already at the registration desk. The woman placed the carrier on the floor. - 3:12 PM - Woman walked up to the registration desk (carrier moved closer, returned to floor). Woman said something to registrar and registrar pointer towards the window. - 3:12:30 - Woman picked up carrier and walked towards exit. Met a man entering and they exited together. 3. The ED log for 11/11/2024 was reviewed on 4/18/2024. Pt. #13 was not included in the log. 4. The registrar (E#8) on duty the day of the alleged event was interviewed on 4/19/2024 at 10:00 AM. E#8 stated, “There was one person in front of the woman. The person in front of the line registered and asked what the average wait time was. I told the person about 6 hours depending on patient need. We were very busy that day. Next, the woman came up and asked me where the closest immediate care center was. She never told me that anybody needed to be seen or why she was there, so I never started registration. I never saw a baby [only knew there was a baby because was told during the initial investigation done by the hospital].” 5. The medical director of the ED (MD#3) was interviewed on 4/22/2025 at 9:15 AM. MD#3 stated that he was informed that a woman presented to the ED with pediatric patient for evaluation of a respiratory illness. The infant was in a child carrier. The woman asked what the wait time was and asked where else she could go to be seen. MD#3 stated, “The registrar should always ask why the person is presenting and ‘How can I help you.’ The patient is then placed on the log. This did not happen.””

“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: 27125 A. Based on document review, video review, and interview, it was determined that for 1 of 21 (Pt #13) ED (emergency department) records reviewed for individuals presenting to the ED at Hospital A, Hospital A failed to ensure an appropriate medical screening exam was performed to determine if an emergency medical condition existed. Finding include: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Transfer (2/19/2024)” was reviewed on 4/18/2024 and required, “When an individual presents to hospital premises for emergency care, the individual must receive a medical screening examination to determine if an emergency condition exists.” 2. The ED log at Hospital A for 11/11/2024 was reviewed on 4/18/2024. Pt. #13 was not included in the log. 3. The video of the alleged presentation of Pt #13 to the ED at Hospital A was reviewed via zoom on 4/22/2025 at 9:50 AM. The video started at 3:09 PM on 11/11/2024, the following was observed: - 3:10 PM -Woman carrying a child carrier (Pt. #13) entered the ED. Two people were already at the registration desk. The woman placed the carrier on the floor. - 3:12 PM - Woman walked up to the registration desk (carrier moved closer, returned to floor). Woman said something to registrar and registrar pointer towards the window. - 3:12:30 - Woman picked up carrier and walked towards exit. Met a man entering and they exited together. 4. The provider note from the ICC (immediate care center), dated 11/11/2024, included, “On 11/11/2024: ICC staff informed me a parent that had concerns with a child in the front waiting room. I was advised by staff up front that the child was under 6 months old, per their policy they could not check in at this clinic. Parents had concerns with the child’s breathing after an emesis [vomiting] episode, father stated he suctioned baby and patted back. Father stated they went to [Hospital A] initially but was told there was a 6 hour wait. Father stated that the breathing was a concern to him and wanted the baby to be seen. ICC staff offered ambulance transport to [Hospital B]. I checked the child with permission of the parents to see if further immediate intervention was indicated. I briefly saw the patient (child) who was in the car seat. The child did not appear in acute distress at this time (did not appear cyanotic [blue], limp, unresponsive, no stridor [whistling sound] noted), normal color noted, crying, alert, movement noted. I did note some expiratory course sounds in the lungs when listened too. I recommended ED follow up (needing an immediate higher level of care due to concerns of age and complaint presented) to parents. I offered an ambulance transport back to [Hospital A]. Parents were very upset with them [Hospital A], and we discussed [Hospital B] transport. Parents then left.” 5. The clinical record of Pt. #13 from Hospital B (receiving hospital) was reviewed on 4/21/2025. Pt. #13 presented to the ED on 11/11/2024 at 4:48 PM with complaint of respiratory distress. Vital signs upon arrival were temperature 100.4 degrees (normal 97.9 - 100.2) heart rate of 213 (normal range100 -190), respirations 60 (normal range 30 - 60), Oxygen saturation 79 % (normal range 95 - 100%). The ED provider note, dated 11/11/2025 at 5:49 PM included, “Presenting with difficulty breathing after episode of choking on formula at home today around noon. Dad fed baby, laid [Pt. #13] in bassinet, later heard a funny noise, noted to be vomiting formula and choking. Sat baby up, briefly gave a few compressions of CPR [cardiopulmonary resuscitation]. Appeared to be breathing throughout but choking. Breathing was different from baseline after the event. They went to [Hospital A] ED, wait time 6 hours, not seen, went to ICC [immediate care center] where they were told they do not see infants less than 6months. Could not get baby to settle in car, mom held [Pt. #13] while driving. Coughing on and off for around 1 week. No fevers. No vomiting. ...” The physical exam included: “General: Is irritable, in acute distress. ... Nose: Congestion present. ... Pulmonary: Tachypnea [fast], respiratory distress, nasal flaring, and retractions [chest wall sinks in with each breath] present.” Medical decision making included, “Presenting with hypoxic [low oxygen level] respiratory failure in the setting of choking on vomit/spit up at home 4-5 hours prior, found to have aspiration pneumonia [lung infection from inhaling something into lung]. Upon arrival, noted to be cyanotic with oxygen saturation 75 %. Hypoxia resolved with noninvasive ventilation, however noted to be tachypneic, grunting and head bobbling and hypoxic once again to 88%, therefore transitioned to HFNC [high flow nasal cannula]. CXR [chest x-ray] with right infiltrate with healing left clavicle fracture. ... appropriate for PICU [pediatric intensive care] admission.” Pt. #13 was admitted to PICU on 11/11/2024 at 8:47 PM at Hospital B. 6. The director of operations of emergency services (E#9) was interviewed on 4/21/2025 at 8:20 AM. E#9 stated, “We received an event tracking form from [Hospital B]. After review of the concern, we took this event to increase our awareness to potential EMTALA concerns. We conducted a refresher EMTALA training to all ED staff, we have an arrival nurse [started in January from 11AM - 11PM but is now 24 hours] that the patient presents to first, and instructed to inform patients that wait times vary and never give an estimate time.” E#9 stated that there have been no other incidents identified related to EMTALA. 7. The medical director of the ED (MD#3) was interviewed on 4/22/2025 at 9:15 AM. MD#3 stated that he was informed that a woman presented to the ED with pediatric patient for evaluation of a respiratory illness. The infant was in a child carrier. The woman asked what the wait time was and asked where else she could go to be seen. MD#3 stated, “Nobody clinical ever saw the child to evaluate the situation. The child should have gone through triage.” MD#3 stated that all patients presenting have the right to be seen and have a medical screening exam completed. 8. The risk manager (E#13) was interviewed on 4/22/2025 at 9:30 AM. E#13 stated, “We need to make sure every patient is triaged to proceed to the required medical screening exam.””