PRINTED: 08/12/2008, DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES (0938-0351 STATEMENTOF OEFCIENCIES | 0K1) PROVOERSUPPLIERCLUA [MULTIPLE CONSTRUCTION foo) oxrE survey [AND PLAN OF CORRECTION {DENTPIGATION NUMBER, Ipewnes courtsteD or c 144008 eee 08/05/2008 WANE OF PROVIGER OR SUPPLIER ‘STREET ADORESS, CITY, STATE, IP CODE {8311 WEST ROOSEVELT ROAD RIVEREDGE HOSPITAL FOREST PARK, IL 60130 ae ‘GUNBUARY STATENENT OF OEFIGENGIES > "PROVIDERS PLAN OF CORRECTION m9, FeGrx | EACH ORPGENGY MUST BE PRECEDED BY FULL nro GACHCORRECTNE ACTION SHOULD 8c | couTON TAS | REGULATORY OR SC IDENTIFYING INFORMATION) Tas, | CHOSSREFERENGED To THE aPrroPReare | “ame DEFCENCT ‘A 131) 482.13(b)(2) PATIENT RIGHTS: INFORMED Att CONSENT The patient or his or her representative (as | allowed under State law) has the ight to make | informed decisions regarding his or her care. ‘The patients rights include being informed of his cor her health status; being involved in care ' | planning and treatment; and being able to request oF 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. ‘Surveyor: 15168 ‘A. Based on Hospital policy review, clinical record review, and staff interview, it was determined for 1 of 2 closed clinical records reviewed, (Pt. #2) that the Hospital falled to ensure adherence to Hospital policy governing ‘consent for psychotropic medication. | Findings include: 41, Hospital potcy #R-123 (311) entitled, "Patient Education and informed Consent For ' Psychotropic Medication," requires, "Ensures that patient... sign the Patient Notification/Consent for Peychotropic Medications form prior to \UIBORATORY DRECTORS OR PROVIOERISUPPLIER REPRESENTATIVES SIGNATURE ‘Any deficiency statement ending with an astesk (7) danotes a deficiency wich the inaliton may be excused Wimh comecting proving fp Gelgrmined that ‘ther safeguards provide sufclent protection tothe patients. (See instructions.) Except for nursing homes, the ienge stated above:se dscosable 90 days {ollowing the date of survey whether o nt plan of correction is provided. For nursing homes, the above ndings plan of conection are discloesble 14 tye folowing the date these documents are made avaliable tothe facliy. If deficiencies are ed, an approved plan of conection le equi to continued ‘rogram parcpation,DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 08/12/2008 FORM APPROVED OMB NO. 0938-0391, STATEMENT OF DEFICIENCIES oxi) PROVIDERVSUPPLERCLA JAND PLAN OF CORRECTION IDENTIFICATION NUMBER: 144009 x) MULTIPLE CONSTRUCTION 1A auwows 2. wna. (x3 DATE suRVEY ‘COMPLETED 'WAME OF PROVIDER OR SUPPLIER RIVEREDGE HOSPITAL | STREEY ADDRESS, CITY, STATE, 2P CODE 48311 WEST ROOSEVELT ROAD FOREST PARK, IL 60130 "SUMMARY STATEMENT OF DEFICIENCIES H DEFICIENCY MUST BE PRECEOED BY FULL P20) ad [REGULATORY OR LSC IDENTIFYING INFORMIATION) Fron aS ‘PROVIDER'S PLAN OF CORRECTION 2, ‘A131 | Continued From page 1 | medication dispensing 2. The clinical record of Pt. #2 was reviewed on 6/08. This was a 27-year-old female, admitted {8/2107 with a diagnosis of Schizoaffective Disorder. The record included documentation that the patient recelved 10 doses of Clozapine (an antipsychotic) between the dates of 8/7/07 through &/9/07. The Patient Consen/Notfication For Psychotropic Medications lacked documentation of Pt. #2's signature 3. The above finding was conveyed to the CEO | during an interview on 8/6/08 at approximately 4:00 PM. -482,13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING i ‘The patient has the right to receive care in a safe setting. A146 ‘This STANDARD is not met as evidenced by: Surveyor: 07105 ‘A. Based on clinical record review, a review of incident reports and staff interview, it was determined for 1 of 2 closed records reviewed, (Pt. #2) that the Hospital failed to ensure increased monitoring and provide adequate | assistance for patients to help prevent injuries. | Findings include: 4. The clinical record of Pt #2 was reviewed on 816/08. This was a 27-year-old female, admitted Anas L FORM GMS 2567(02 6) Previoo Verona Obele ‘Eve DUTY Foy O=ZTED Weontinuation sheet Page 2 ofDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 08/12/2008 FORM APPROVED OMB NO. 0938-0391 [STATEMENT OF DEFIGENCES | t) PROVIDER/SUPPLIERICLA [AND PLAN OF CORRECTION |DENTIFRAATION NUMBER. 144009 [e2) MULTIPLE CONSTRUCTION lA sunowe Je wc. oo) DaTE suave (COMPLETED c 08/05/2008 [NAME OF PROVIDER OR SUPPUER RIVEREDGE HOSPITAL FOREST PARK, IL. ‘STREET ADDRESS, CITY, STATE, Z CODE. {8511 WEST ROOSEVELT ROAD 200 PREFIX Tas. |< MinARTSiaTorenT oF sence | eaSibeGencr wus ne enecebeD oy ru. Seager en actocTe vs neon) r "PROVIDER'S PLAN OF CORRECTION. =. PRERX (GACH CORRECTIVE ACTION SHOULD BE_. COMAETON TAG | CROSS-REFERENCED TO THE APPROPRIATE are DECENCY) Ata A286) Continued From page 2 ! 8/2107 with a diagnosis of Schizoaffective Disorder. The record included documentation in the progress notes dated, 8/10/07 at 5:15 AM., that about 1:35 AM., Pt. #2 was provided assistance to sit up on the edge of the bed, and | assistance to stand up. "Pt. reported that she was tired, but needed to go tothe restroom. Staff | encouraged Pt. to take her time, but to go to the restroom if she needed to go..... Pt. began walking toward the restroom and was holding conto the wall. Pt" s legs appeared to become weak and gave out. Pt fel tothe floor... Code Blue was called .." The record further included documentation on the Discharge Summary dated 8/10/07, that " The patient was taken to Loyola | Hospital's Emergency Room, where efforts were made to revive her, but at 2:35 a.m., the patient expired twas felt thatthe patient had a pulmonary embolism and possible heart fallure ." ‘The record lacked documentation to evidence that Hospital staf provided Pt. #2 assistance | _ambulating to the bathroom, to help prevent falling in light of the evidence that the patient was ‘experiencing some weakness and required assistance to eit up on the edge of the bed, and to stand up. (15168) 2. ‘The above findings were conveyed to the CEO ‘during an interview on 8/6/08 at approximately 4:00 P.M, -482.21(c)(2) QAP! TRACKING. | Performance improvement activities must track _ Medical errors and adverse patient events. Atas A286 FORD CaS-286702-90) Prova Verne Oboe Bea UST FactyW-NZTEO Weontinuaton sheet Page 3 0f6