HospitalInspections.org

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."

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.