The Pavilion

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34824 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 develop policy and/or procedure to transport patients outside of the facility for appointments and/or therapy and to failed to appropriately monitor a patient while outside of the facility. (See A144A) 2. The Hospital failed to have appropriately qualified staff to transport a patient outside of the facility. (See A144B)”

“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: 34824 A. Based on observation, document review and interview, it was determined for 1 of 1 (Pt #1) patients who were transported outside of the facility, the Hospital failed to provide care in a safe setting by failing to develop policy and/or procedure to transport patients outside of the facility for appointments and/or therapy and failing to appropriately monitor a patient while outside of the facility. Findings include: 1. The policy titled, “Patient Observation Level (effective 11/2024)” was reviewed. The policy indicated, “ ... IV Procedure: A. Intervention/Observation a. General Patient Observations/15-minute Rounds - i. All patients are carefully monitored and assess a minimum of every 15 minutes upon arrival to intake. ii. In rare instances, when a patient on precautions must leave the unit, the patient will be accompanied and supervised by staff, who will continue to document 15-minute observations. 2. Pt #1’s record was reviewed throughout the survey. Pt #1 was admitted on the youth psychiatric unit on 7/19/2023 with the diagnoses of ADHD (attention deficit/hyperactivity disorder, a disorder characterized by inattention, difficulty paying attention, keeping on task, or staying organized), PTSD (post-traumatic stress disorder, a condition that can develop after experiencing or witnessing a traumatic event), RAD (reactive attachment disorder, a rare condition affecting children who have experienced severe neglect or abuse early in life leading to an inability to form healthy emotional attachments with caregivers), and DMDD (major depressive disorder, a mental health condition characterized by persistent feelings of sadness, hopelessness, or a lack of interest and pleasure in activities for at least two weeks) and was hospitalized for homicidal ideation. DCFS (Department of Children and Family Services) is the patient’s legal guardian. Pt #1’s 15-minute “Patient Observation Sheet” was found on the following dates to lack documentation of the 15 minutes checks: 3/27/2025 from 10:38 AM to 7:13 PM - logged out for “Appointment.” 4/24/2025 - logged out for “Appointment” at 2:23 PM. Pt #1’s observation log had monitoring at 2:30 PM and then no other monitoring documented for the rest of the day/night. 5/6/2025 from 07:52 AM to 7:18 PM - logged out for “Visitation Pass.” 5/21/2025 from 3:08 PM to 5:29 PM - logged out for Appointment.” 5/30/2025 from 3:18 PM to 4:58 PM- logged out for “Outings.” 5/31/2025 from 3:26 PM to 7:17 PM - logged out for “Outings.” 6/6/2025 from 11:56 AM to 1:45 PM and 2:05 PM to 4:18 PM - logged out for “Appointment.” 6/10/2025 from 3:30 PM to 4:13 PM - logged out for “Appointment.” 6/15/2025 from 3:29 PM to 8:12 PM - logged out for “Outings.” 6/16/2025 from 3:42 PM to 6:31 PM - logged out for “Outings.” 6/27/2025 from 4:24 PM to 7:57 PM - logged out for “Outings.” 6/28/2025 from 1:40 PM to 8:23 PM - logged out for “Appointment.” 6/30/2025 from 2:06 PM to 2:42 PM - logged out for “Outings.” 7/2/2025 from 1:14 PM to 5:49 PM - logged out for “Outings.” 7/6/2025 from 10:15 AM to 12:11 PM - logged out for “Outings.” Pt #1’s monitor log indicated patient was taken outside of the facility 33 times between 2/13/2025 and 7/6/2025. On 15 of the dates, there was no appointment and/or therapy scheduled and no documentation of where the patient was transported to. 2. An interview was conducted on 9/3/2025 at approximately 1:00 PM with Chief Nursing Officer (CNO - E #2) and Director of Risk Management (E #9). E #2 and E #9 was asked for a policy or procedure related to taking patients outside of the facility for appointments, therapy, and/or outings. E #2 and E #9 stated “There is no policy for transfer of a patient outside the facility for appointments, therapy or outings.” E #9 stated, “I realized there was a problem when I returned from medical leave.” 3. An interview was conducted with E #2 on 9/3/25 at approximately 2:00 PM. E #2 stated, “(Pt #1) was taken offsite for medical appointments and equine therapy (treatment that utilizes horses to support mental health recovery and personal development) as authorized by DCFS. On other occasions, (Pt #1) was taken on other outings such as to a movie, a trampoline park and walks to the park. We do not have a policy to do that. There is no documentation completed while the patient was outside of the facility. We realize now there are areas of improvement needed for the process.” B. Based on document review and interview it was determined for 1 of 1 (Pt #1) DCFS (Department of Child and Family Services) patient’s transported outside of the facility, the Hospital failed to ensure qualified staff transported a patient outside of the facility. Findings include: 1. The Vehicle logs were reviewed and indicated Mental Health Technician (MHT - E #6), Education Coordinator (E #7). and MHT (E #10) transported Pt #1 outside of the facility. 2. Personnel files were reviewed. E #6 and E #7’s personnel files included “Children and Family Services Licensing - Child Care Facility Driver Eligibility Check Results” which indicated “...approved to transport children...” E #10’s personnel file did not include the Child Care Facility Driver Eligibility Form. 3. An interview was with the Chief Nursing Officer (E #2) conducted on 9/4/2025 at approximately 12:45 PM. E #2 stated, “All drivers who transport youth in DCFS custody must be certified by DCFS. (E #10) did transport (Pt #1) to a movie theater and the trampoline park. (E #10) does not have DCFS certification to drive patient outside the facility and should not have transported this patient as they were not certified to do so with DCFS.””

“Discharge Summary CFR(s): The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization… This Standard is not met as evidenced by: 34824 Based on document review and interview, it was determined for 2 of 5 (Pt #2 and Pt #5) discharged patient records reviewed, the facility failed to ensure a discharge summary was completed. Findings include: 1. The Hospital policy titled “Rules and Regulations of the Medical Staff “ was reviewed. The policy indicated, “... A.8 Documentation... m. Discharge Summaries i. Service Types 1) Inpatient Psychiatric - all patient charts shall contain a discharge summary, which is dictated within thirty (30) days....” 2. Pt #2’s record was reviewed on 9/3/25. Pt #2 was admitted on 4/29/25 with a diagnoses of “Disruptive mood dysregulation disorder, Attention deficit hyperactivity disorder, Posttraumatic stress disorder.” Pt # 2 was discharged on 6/17/25. Pt #2’s record lacked a discharge summary. 3. Pt #5’s record was reviewed on 9/3/25. Pt #2 was admitted on 4/29/25 with a diagnoses of “Mood dysregulation disorder, Suicidal Ideation with plan to overdose on medications.” Pt #5 was discharged on 7/29/25. Pt #5’s record lacked a discharge summary. 4. On 9/3/25 at approximately 2:00 PM, an interview was conducted with CNO. E #2 reviewed the records and verbally agreed that the records lacked discharge summaries.”

“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: 34824 Based on document review and interview for 2 of 10 (Pt #1 and Pt #4) records reviewed,it was determined that the facility failed to ensure documentation of 15-minute observational checks of patients to ensure safety of the patients. Findings include: 1. The policy “Patient Observation (revised 09/2024)” was reviewed. The policy indicated “Nurse/Lead Mental Health Technician (MHT) ...Ensures the patient observations occur a minimum of every 15 minutes, 24 hours per day, seven days a week, for every patient and are documented concurrently on the Observation Flow Record ...MHT (or any employee assigned to Observation) ...Observe each patient, a minimum of every 15 minutes, individualizing according to precaution level and concurrently document observation on the Observation Flow Record.” 2. Pt #1’s record was reviewed. Pt #1 was a 6-year-old patient admitted to the facility on 5/5/25 at 3:16 PM, with a diagnosis of “disruptive mood dysregulation disorder.” A patient progress note from 5/6/2025 at 4:15 PM stated “Pt was in rec (recreational) therapy group when (Pt #1) stood up and flashed (Pt#1’s) genitals to 3 adolescent girls. Pt removed from group... Nurse Manager and Case Manager notified.” Pt #1 was subsequently moved to a single room in the “swing hall” on 5/6/25. The Patient Progress Note for Pt #1, dated 5/8/25, 12:50 PM, stated “Pt reported that (Pt #1) and a peer (referring to Pt #4) were ripping our scrub pants and showing each others private parts’ last night (5/7/25) in peers (referring to Pt #4’s) room. Unknown time but roughly 1800-2300 (6:00 PM - 11:00 PM). Pt able to tell story multiple times this AM and is consistent. Peer denies this happening. Staff reports that (staff member) witnessed Pt going into peers room this AM. Pt redirected out and doors were locked once hygiene time was completed.” Pt #1 was discharged on 5/8/2025 at approximately 10:00 PM. Per the Discharge Summary dated 5/8/2025, at 7:38 PM, it was noted “On 5/8/2025, alleged report of patient along with another underage peer ‘touching each other’s private part’ reported to Administration which is being investigated. Guardian was notified, mother decided to pick up patient today, which will be granted as he is not suicidal, not homicidal, not psychotic. In addition, we are not administering any medication at this time as consent has been revoked, further intervention to follow on an outpatient basis.” 3. Pt #4’s record was reviewed. Pt #4 was a 12-year old admitted to the facility on 5/7/2025 with a diagnosis of “disruptive mood dysregulation disorder.” A “Nurse to Nurse Form” (nurse report from outside hospital that transferred Pt #4 to the facility) dated 5/7/25 at 9:30 AM indicated, “Sexually inappropriate ...comments about (family member) licking butt hole ... open DCFS case about sexually inappropriate comments ... no sex victim precautions at this (point).” Pt #4 was admitted to the pediatric unit at 1:36 PM. On 5/7 at 8:45 PM, Pt #4 was moved to the swing unit due to a physical altercation with a peer (not Pt #1). The Patient Progress Note for Pt #4, dated 5/8/2025, 6:57 PM stated “At 17:00 (5:00 PM) Peer (in reference to Pt #1) reported to staff that the previous night between 19:00 - 23:00 (7:00 PM and 11:00 PM) Pts had ripped each other’s pants and showed each other their genitals, kissed each other, and licked each others genitals. AOC (Administrator on Call), Risk Manager, CNO (Chief Nursing Officer) and CEO (Chief Executive Officer) notified at 17:09 - 17:14 (5:09 PM - 5:14 PM). Physician notified at 17:30 (5:30 PM). Guardian notified at 17:52 (5:52 PM). DCFS was also notified of incident. Pt later was on the phone with (family member) and stated ‘I didn’t think a 6 yo (year old) would make this much noise.’” 4. The Observation Flow Records for Pt #1 and Pt #4 for 5/7/2025 were reviewed with Chief Nursing Officer (E #1). The flow sheets lacked documentation of observation at 7:00 PM, 7:15 PM and 7:30 PM for both Pt #1 and Pt #4. 5. An interview was conducted on 6/18/2025 at approximately 11:00 AM, with the Quality Assurance Coordinator (E #6). E #6 stated “during the investigation, staff expressed possible red flags that though there were no previous reported incidents prior to (Pt #1) arriving at the facility.” 6. An interview was conducted on 6/18/2025 at 1:00 PM with E #1. E #1 verbally agreed the checks should have been completed and were not. E #1 stated, “Staff are to document and notify supervisor if the checks are not completed. I cannot find any documentation as to why the checks were not completed and do not see any notification documented.””

“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: 50771 Based on document review and interview, it was determined for 1 of 4 (Pt #6) patients records reviewed, who required the use of restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LIP), authorized to order restraints. Findings include: 1. The Policy titled “POC-46-a Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (revised 08/2024)” was reviewed on 04/14/2025. The policy noted, “ ...3. The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated... 2. The physician’s order for use of restraint or seclusion will be recorded in the medical record...” 2. The Restraint Log for January 1, 2025 to April 14, 2025 was reviewed on 4/14/2025. The log noted Pt #6 was placed in physical restraints on 2/1/2025, 2/14/2025, 2/15/2025, and 2/19//2025. 3. The clinical record of Pt #6 was reviewed on 04/15/2025. Pt #6’s record lacked orders and/or Restraint Packets on the following dates: 2/1/2025, 2/14/2025, 2/15/2025, and 2/19/2025. 4. An interview was conducted on 04/15/2025 at approximately 11:30 AM with the Chief Nursing Officer (E #5). E #5 reviewed Pt #6’s record and verbally agreed, there is no documentation of physical restraints in the record and no order for restraints. E #5 stated, “There should be documentation of the restraints and there should be restraint orders. The only way we knew (Pt#6) was in restraints was from the Restraint Log.””

“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: 34824 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt.#4) clinical records reviewed for suicide risk assessment, reassessments and interventions, the hospital failed to ensure that staff monitored a patient at risk for suicide as required. Findings include: 1. The hospital’s policy titled, “Assessment and Managing Suicide Risk (revised 08/2024)” was reviewed. the policy required, “... Reassessment of Risk: 1. Reassessment of suicidality will occur every 12-hour-shift for any patient on increased observation (i.e. 1:1) or who exhibits a sudden or significant change in mental status. This is documented using the Columbia Reassessment form... 3. Patients who continue, or begin to present at high-risk for suicidality are to continue on, or be evaluated for, heightened observations or precautions, as outline below.... Heightened Observations: All acute patients will be monitored at least every 15 minutes. Patients who are assessed to be at higher risk for suicidality than the rest of the patient population will be placed on suicide precautions and may be placed on a one to one (1:1) observation status as outlined in the Level of Observation policy.... 9. Patients on suicide precautions or heightened observation levels for suicidality self-destructive behaviors may have the following restrictions: ... 1:1 - Toileting and Showering - Staff must be continuously present with patient...” 2. The clinical record for Pt. #4 was reviewed on 11/19/24. Pt #4 was admitted on 9/7/24 with a diagnosis of “1. Bipolar disorder, current episode depressed, severe without psychosis. 2. Posttraumatic stress disorder. 3. Attention deficit hyperactivity disorder and anxiety disorder, by history.” Pt #4 was placed on 1:1 observation on 10/17/24 with an “Indication” of “Major depressive disorder. On 11/13 and 11/14 all suicide risk assessment questions were answered no which indicated no risk. On 11/15/24 a “Daily Nurse Progress Note” indicated for both 7:00 am to 7:00 PM shift and 7:00 PM to 7:00 AM (16th) yes to all suicide risk assessment questions. The clinical record lacked documentation that the provider was notified of the change in risk assessment. The “Psychiatric Progress Note” by the telepsychiatry (MD #1) conducted on 11/16/24 (E #2 reported all evaluations are conducted at 9:30 am every day for Pt #4). The progress note indicated, “... Subjective: ... Patient with limited engagement Reported that ‘I’m still here, no one cares, they can’t find me a place to go.’ ... Continue with one-to-one with high precaution with patient feeling abandoned. Monitoring at all times including while in the bathroom to ensure safety...” A “Patient Progress Note” by E #9 on 11/16/24 at 8:52 PM indicated, “At approximately, 20:52 (8:52 PM) Pt asked the 1:1 staff to go to the bathroom where Pt tied a string on (Pt #4) neck and was on the floor, staff immediately intervened and Pt began having one of (Pt #4’s) psychogenic seizures and wasn’t responding to staff. Staff moved Pt out of (Pt #4’s) room bathroom and took vitals, which were slightly high but o2 (oxygen) was normal. Once Pt began responding to staff, staff told pt (Pt #4) would have to go into a safety suit due to suicidal behaviors....” An order for was placed on 11/16 at 11:00 PM for One-to-one with “no privacy to be observed.” The Psychiatric Progress Note dated 11/17/24 indicated, “... Last evening, it was reported to clinician that patient did find part of (Pt #4’s) clothing, went to the bathroom and tried to strangle self, 1:1 staff intervened promptly. Bathroom supervision continued....” 3. An interview was conducted with E #9 on 11/19/24 at 2:00 PM. E #9 stated, “(Pt #4) was on a one to one. (Pt #4) had been on them for about a month and it had been based on self harming behaviors. The staff had took off the bathroom curtain (acts as a door to the bathroom) when (Pt #4) became a one to one for better visual purpose. (Pt #4) walked into (Pt #4’s) room with the one to one (E #10). From what (E #10) told me after the incident, (Pt #4) had asked to go to the bathroom. At that time we have to be within arms reach of her, so like outside the bathroom door/curtain. We had to visually watch (Pt #4) go to the bathroom at the time. From my understanding the staff member would have been on the outside of the doorway against the wall. The staff was asking (Pt #4) periodically how (Pt #4) was doing and then (Pt #4) stopped answering. The staff member went in to check and (Pt #4) was sitting on the floor in between the toilet and the shower. (E #10) had yelled from the doorway to get me. When I came in (Pt #4) had a thin string, like a thread, around (pt #4’s) neck that (Pt #4) might’ve peeled off (Pt #4’s) shirt. (Pt #4) was in scrubs at that time. Once I saw the thread around (Pt #4’s) neck, I removed it and then I had the other staff go grab the vital cart and alert the nurse. We moved (Pt #4) out of the bathroom to a more safe area and ended up calling the code 99 (medical emergency) just to have other nurses come check (Pt #4) out make sure (Pt #4) was doing. 4. An interview was conducted with E #10 on 11/19/24 at 3:00 PM. E #10 stated, “Because of her behavior, (Pt #4) had expressed suicidal ideation, (Pt #4) was on one-to-one. I was (Pt #4’s) one to one that night. (Pt #4) said that (Pt #4) needed to use the bathroom. I was in the doorway but I turned my back so I wasn’t staring at (Pt #4) while on the toilet. I didn’t hear (Pt #4) urinating or anything and (Pt #4) didn’t answer when I called (Pt #4’s) name so, I turned around and (Pt #4) was sitting on the floor between the shower and the toilet. (Pt #4) was just sitting there with her eyes closed and I did not see the string. so I called for the Lead MHT[E#10] and the nurse to come in. I stayed with (Pt #4). The Lead MHT[E#10] came in and we pulled (Pt #4) out of the bathroom. (Pt #4) started coughing and saying (Pt #4) couldn’t breathe. We took her vitals her blood pressure was up but the rest including (Pt #4’s)oxygen was 96 or 98, it was normal.” 5. An interview was conducted with the /E #2 on 11/20/24 at approximately 10:48 AM. E #2 reviewed Pt #4’s record and verbally agreed, Pt #4 was on suicide precautions with 1:1 and the staff were not monitoring the patient while going the bathroom as required. E #2 stated, “(Pt #4’s) plan of care was updated to increase the monitoring. (Pt #4) remains on the one-to-one close observation with the direct visualization while using the restroom. We have not been able to complete the investigation into the event as it was just over the weekend. Each suicide precaution is an order based off of the provider’s impression. Not all interventions are the same. The higher the risk, more interventions/monitoring is put in place. There have been no other incidents.””

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 49555 Based on document review and interview, it was determined for 1 of 1 (Pt #10) clinical records reviewed of a patient with a complaint/ grievance, the Hospital failed to ensure the complaint/ grievance was properly documented, as per policy. Findings include: 1. Hospital policy entitled, “IOP-10 Patient Advocacy and Grievance Resolution” revised on (06/2019) was reviewed on 9/11/24 at approximately 9 AM. This policy states, “A “patient grievance” is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to patient rights and limitations provided by 42 CFR 489 ...The Patient Advocate and Director/ Manager to whom follow-up was assigned will investigate the grievance, including but not limited to: Patient interview; Witness interview; Chart review; and ...The grievance will be logged into the Grievance Log by the Patient Advocate or designee. The Patient Advocate will maintain all completed grievance reports for a period of three years.” 2. The Collateral Contact Note dated 7/26/24 at 9:44 AM stated, “ ...Pt sister reported several concerns ...Pt also stated sister reported she was assaulted by a male on the unit ...CM (Case Management) agreed to call sister back ...to follow up regarding the additional complaints ...CM also provided sister with Patient Advocacy line in order for her to file formal complaint ...” 3. The clinical record of Pt #10 was reviewed on 9/10/24 at approximately 10:00 AM. Pt #10 was admitted on 7-17-24 with a diagnosis of psychosis and hallucinations. Pt #10’s clinical record lacked documentation of any allegation of abuse. Pt #10 was listed on the Physical/Sexual Assault/Adverse Event log. 4. An interview was conducted on 9/10/24 at 3:35 PM with House Supervisor (E #8). E#8 stated, “(Z1) told me that (Pt #10) said that there were people coming in the room and putting fingers in her vagina.” The grievance log was reviewed on 9/10/24 at approximately 9:00 AM and lacked documentation of a compliant or grievance for Pt #10. 5. On 9/11/24 at approximately 12:00 PM, an interview was conducted with the Director of Performance Improvement and Risk Management (E#3) and it was stated the allegation did not appear on the grievance log because the allegations were found to be unsubstantiated and no contact was made with Pt #10’s family. E# 3 verbally agreed there was no complaint listed on the complaint and grievance log for pt #10. 6. An interview was conducted with Patient Advocate (E#13) on 9/11/24 at 9:00 AM regarding the investigation process of complaints and grievances. E #13 stated, “I attempted to interview Pt #10 but was unable to due to mental state, however, I do not have any documentation of that attempt. I also do not have documentation of witness interviews, staff interviews, or chart review.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 49555 Based on document review and interview, it was determined that for 28 of 28 patients, the Hospital failed to ensure the patient’s right to privacy was maintained. This failure resulted in a visitor being granted access onto a locked inpatient psychiatric unit and violated Illinois Administrative code Part 250 Hospital Licensing Requirements, Section 250.2270. Findings include: 1. An email dated 7/30/24 written by Case Manager (E #9) stated, “ ...She (Z1) was taken to the unit for a visit by House Supervisor (E #8).” 2. An email dated 8/5/24 written by RN Manager (E #10) stated, “(Z1) refused to leave without seeing her sister who didn’t want to visit or was to psychotic to leave the unit. A decision was made by the House Supervisor(s) to bring Z1 to the unit to see Pt #10. (Z1)’s complaint was that HIPAA was broken by allowing her to visit the unit and that she was put into a dangerous situation.” 3. On 9/10/24 at approximately 3:35 PM, an interview was conducted with the House Supervisor (E #8). E #8 stated, “(Z1) was insisting to go to the floor where (Pt #10) was to see her and make sure she was ok, so I took (Z1) to the floor where (Pt #10) was.” 4. Illinois Administrative Code Subchapter b: Hospitals and Ambulatory Care Facilities part 250 hospital licensing requirements section 250.2270 Admission, Transfer and Discharge Procedures was reviewed on 9/12/24. Section 250.2270 states, “All admissions to and discharges from psychiatric hospitals and the psychiatric department or service of a general hospital shall be in accordance with the Mental Health and Developmental Disabilities Code (Ill. Rev. Stat. 1983, ch. 91½, pars. 1-100 et seq.), effective January l, 1979, as hereafter amended - Public Act 80-1414.” 5. On 9/12/24 at approximately 10:30 AM, an interview was conducted with Chief Nursing Officer (E #2). E #2 stated, “(Z1) was taken to the 3rd floor inpatient unit to see (Pt #10). The House Supervisor made that decision because they did not feel (Pt #10) was safe to leave the 3rd floor for the visit. It was reported that (Z1) refused to leave the facility until they saw (Pt #10) was ok.” E #2 verbally agreed it was a HIPAA violation to allow visitors on the inpatient unit. 6. The visitor granted access onto the locked inpatient psychiatric unit had to traverse over half of the unit to reach Pt. #10’s room, thus passing other patients and potentially other patients protected information.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 49555 Based on document review and interview, it was determined that for 1 of 10 (Pt #1), clinical records reviewed for discharge planning, the Hospital failed to complete a discharge summary with all necessary medical information pertaining to the patient’s course of treatment to notify the appropriate specialists and practitioners responsible for the patient’s follow-up care. Findings include: 1. On 04/17/2024 the policy titled “Assessment Timeframes for Chart Completion” (revised 03/2024) was reviewed. The policy states, “Discharge Summary ...Attending Psychiatrist ...Within 30 days of discharge.” 2. The clinical record for Pt #1 was reviewed on 4/16/2024. Pt #1 was admitted to the Hospital on 2/11/2024 with the diagnosis of bipolar disorder and Schizophrenia. Pt #1 was discharged from the Hospital on 2/28/2024. Pt #1’s clinical record was reviewed, and it was noted Pt #1’s chart lacked a completed discharge summary. 3. During an interview on 4/16/2024 at approximately 3:30PM, E #1 (Facility Risk Manager) reviewed Pt #1’s record and verbally agreed that the record lacked a completed discharge summary.”