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Based on interview and document review, it was determined for 2 of 2 (Pts #8 and #10) Medicare patients, admitted to Observation status, the Hospital failed to ensure patients/patient representatives were notified of the differences in Medicare Part B coverage for Observation versus Inpatient admission status, in advance of furnishing care.

Findings include:

1. An interview was conducted with Director Patient Safety/Quality (E#1) and the Vice President of Patient Care Services/Chief Nursing Officer (E#2) on 1/5/16 at approximately 8:50 AM. Both stated patients are given their patient rights upon admission in an admission packet and the staff are to document this in the patient record. Both stated there is one packet for "Inpatient" admissions and one packet for "Observation" admissions. Both stated the "Observation" admission packet contained a green form that explained the Medicare Part B differences and they were uncertain as to how, or if, there would be documentation of this being given to or discussed with the patient/patient representative.

2. The "Observation" admission packet was reviewed on 1/5/16. The packet contained two green sheets. One stated "ATTN (attention): Unit Secretaries... " and instructed them to give the other green sheet, a patient letter concerning Medicare Part B coverage differences in relation to Observation versus Inpatient status, to the patient to read and contact the Case Manager or physician if they have any questions.

3. An interview was conducted with the Registered Nurse (E#7) on 1/5/16 at approximately 10:15 AM. E#7 stated the CNAs (certified nursing assistants) "do the packet (admission/observation packet)" and the nurse "does the education folder". When asked how the staff would be able to demonstrate Medicare patients admitted to Observation status have received and understood the Medicare Part B information of coverage differences compared to Inpatient coverage, E#7 stated "I don't think we have a place to chart it, every patient gets one."

4. An interview was conducted with the Director Medical/Pediatrics (E#8), the CNA (E#9), the Registered Nurse (E#10) on 1/5/16 at approximately 12:15 PM. When asked how the staff would be able to demonstrate Medicare patients admitted to Observation status have received and understood the Medicare Part B information of coverage differences compared to Inpatient coverage, E#8, E#9, and E#10 each verbally agreed there is no documentation of this. E#10 further stated "It would be a good idea to have a list that we check off that we gave (the information and discussed it with the patient/family)."

5. The complaint/grievance log for November 1, 2015 thru January 5, 2016 was reviewed on 1/5/16. On 11/2/15, the log stated a complaint/grievance was received from Pt #8/patient representative that "Observation status made financial difficulties for family."

6. Pt #8's record for the 10/21/15 Observation stay was reviewed on 1/6/16. Pt #8 was admitted to Observation on 10/21/15 with the diagnoses Hypoxemia and Shortness of Breath. The record lacked any documentation Pt #8, or Pt #8's representative, were given and/or instructed on the Medicare Part B differences in payment for Observation versus Inpatient admissions, medication coverage, the affect on discharge to a Skilled Nursing Facility, and/or the affect on any co-pays.

7. Pt #10's record was reviewed on 1/5/16. Pt#10 was admitted to Observation on 1/4/16 with the diagnosis Chest Pain. The record lacked any documentation Pt #10, Pt #10's representative, were given and/or instructed on the Medicare Part B differences in payment for Observation versus Inpatient admission status, medication coverage, the affect on discharge to a Skilled Nursing Facility, and/or the affect on any co-pays.

8. An interview was conducted with the Director Patient Safety/Quality (E#1) on 1/6/16 at approximately 3:00 PM. E#1 had reviewed the records of Pts #8 and #10 and verbally agreed there was no documentation as to whether or not Pts #8/patient representative or #10/patient representative were notified of the Medicare Part B coverage differences between Observation and Inpatient admission status.

A. Based on document review and interview, it was determined for 4 of 11 (Pts #13, #14, #15, and #16) patients, reviewed for grievance process and resolution, the Board of Trustees failed to ensure its grievance process was clear and followed for all patient grievances.

Findings include:

1. The Hospital policy titled "Patient or Family Complaints and Grievances" (Policy #: 100- last reviewed June 2015) was reviewed on 1/5/16. The policy stated on page 3 under "Procedure: E. Grievance Committee and Board of Trustee Oversight:... Board of Trustees is responsible for the effective operation of the grievance process. The grievance process is delegated to a Grievance Committee consisting of the Vice President of Nursing, Assistant Vice President of Nursing... Board of Trustees delegates the responsibility for there grievance process, review and resolution of grievance to the Patient Relations Department and the Grievance Ad Hoc Committee."
2. The Hospital policy titled "Performance Improvement Plan" (last reviewed February 2015) was reviewed on 1/5/16. The plan stated on page 6 under "Grievance Process and Board of Trustee Oversight... The grievance process is delegated to the Patient Relations Advocate who had the authority to coordinate the review and investigation of patient complaints and grievances..." with additional assistance as needed from other staff. The plan further stated a summary of activities would be compiled and reports to the Board of Trustees on an annual basis.

3. The Quality Assurance (QA) Group Minutes, dated November 18, 2014 thru August 13, 2015 were reviewed on 1/7/16.
a. The QA meeting minutes lacked any documentation of communication of any complaints/grievances which had been filed and/or followed up on by the Grievance Committee or the Patient Relations Advocate.
b. The QA meeting minutes further stated the following:
1) On 4/9/15, the QA minutes stated on page 2 under "II. Case Reviews" that a patient (Pt #13) "Alleged abuse by nurse". The minutes further stated on page 3 under "IV. Quality Assurance" that a physician (MD#6) stated complaints related to a patient not receiving a bath (unknown name- Pt #14) and a patient feeling threatened in the Emergency Department that if didn't have an arterial blood gas drawn they would be transferred (unknown name- Pt #15).
2) On 6/11/15, the QA minutes stated on page 1 under "II. Case Reviews. 2... Patient/Family Complaint- Alleged Abuse" (Pt #16).

4. An interview was conducted with the People Services Coordinator (E#6- previous title Patient Relations Advocate) on 1/7/16 at approximately 12:30 PM. E#6 stated there is no Grievance Committee, E#6 does not report to the QA committee, and E#6 reports once a year to the Board of Trustees. E#6 further stated no knowledge of the complaints/grievances (Pts #14, #15, and #16) which were observed in the QA meeting minutes and was uncertain as to who performed the investigation for these.

5. An interview was conducted with the Vice President of Patient Care Services (E#2) between 1/7/16 and 1/8/16. E#2 stated there was no Grievance Committee, all complaints/grievances were to be reported to E#6 for follow-up, E#6 does not report to the QA committee, E#6 reports annually to the Board of Trustees, and the complaints/grievances reported at the QA committee meetings (Pts #14 #15 and #16) were followed up on by members of the QA committee instead of E#6 if a name was known. E#2 stated not being aware the Grievance policy and Performance plan did not match.

B. Based on document review and interview, it was determined for 1 of 7 (Pt #8) patients, whose complaints/grievances were reviewed by the People Services Coordinator, the Board of Trustees failed to ensure all grievances were investigated.

Findings include:

1. The Hospital policy titled "Patient or Family Complaints and Grievances" (Policy#: 100, last reviewed June 2015) was reviewed on 1/5/16. The policy stated on page 1 under definitions "A patient grievance is a written, e-mailed, faxed or verbal complaint (when the verbal complaint... regarding the patient's care... issues related to the hospital's compliance with CMS (Center for Medicare and Medicaid Services) Hospital Conditions of Participation... " On page 2 under C. Grievances, the policy stated the steps to be followed throughout the investigation to sending a letter of resolution.

2. The complaint/grievance log for November 1, 2015 thru January 5, 2016 was reviewed on 1/5/16. On 11/2/15, the log stated a complaint/grievance was received from Pt #8/patient representative that "Observation status made financial difficulties for family."

3. Pt #8's grievance follow-up documentation was reviewed on 1/6/16. The documentation stated the Director Medical/Pediatrics (E#8) had notified the People Services Coordinator (E#6) of the following: Pt #8 had been hospitalized previously as an Observation patient which affects reimbursement when the patient goes to a nursing home. Pt #8 was discharged from the Hospital to a nursing home and there was going to be a significant financial burden to the family due to Observation status and the family was upset. Pt #8 had been readmitted to the Hospital and requested E#6 to speak with the family "to see how they are doing this time around". The documentation further stated E#6 spoke with the nursing staff at the nursing desk and staff shared with E#6 the difficulties related to Pt #8's last admission and E#6 stated "wanted to stop in to see how this visit was going" and that the patient and patient representative "shared that there were no difficulties at all. Shared that all staff was wonderful." There was no investigation into Pt #8's complaint/grievance related to being in Observation status and the financial difficulties related to this and whether Pt #8 was notified of the Medicare Part B differences in coverage for Observation versus Inpatient status and no letter of resolution.

4. An interview was conducted with E#6 on 1/6/16 at approximately 12:55 PM. E#6 had reviewed Pt #8's grievance and follow-up and stated when E#6 made Administrative rounds, the patient and patient representative didn't voice any concerns "about this stay". When asked if they were asked about their complaint/grievance related to the Observation stay and financial concerns, E#6 stated "No. I just checked to see how this stay was going." When asked if any investigation into whether Pt #8/patient representative were informed of the Medicare Part B differences in relation to financial coverage for Observation, medications, the affect on being discharged to a Skilled Nursing Facility, and/or the possibility of a co-pay, E#6 stated "No, I did not."

Based on document review and interview, it was determined for 1 of 10 (Pt #8) patient, the Hospital failed to ensure a patient/family request for further information related to their care from a physician was addressed.

Findings include:

1. The Hospital form titled "Consent for Treatment, Authorization on for Release of Information and General Conditions for Outpatient Services and/or Admision Form #UM-1001" (last revision: 12/2013) (CARITA) was reviewed on 1/5/16. The form stated "2.3 I have the right to be informed of my diagnosis...; treatment; prognosis... in terms that I understand... 2.15 Patients and families, as appropriate, must ask questions when they do not understand their care, treatment, and service or what they are expected to do..."

2. The Hospital policy titled "Patient's Bill of Rights and Responsibilities (Policy #41- reviewed June 2015) was reviewed on 1/5/16. The policy stated on page 4 under Patient Responsibilities "B... The patient is responsible for asking questions or acknowledging when he/she does not understand the treatment course or care decision..."

3. The complaint/grievance log for November 1, 2015 thru January 5, 2016 was reviewed on 1/5/16. On 12/16/15, the log stated Pt #9 "Patient did not see physician during ER (emergency room) visit even though it was requested to speak to physician about test results."

4. Pt #9's record was reviewed on 1/6/15. Pt #9 presented to the ER on 12/16/15 at 3:49 PM with the chief complaint Blood in Stools/Melena. Pt #9 was evaluated by the Advanced Practice Nurse (APN #1), laboratory testing and computerized topography of pelvis and abdomen were performed, and Pt #9 was discharged home on 12/16/15 at 9:08 PM. The record lacked any documentation of the ER physician (MD#4), providing oversight of the APN on 12/16/15, saw Pt #9.

5. Complaint/grievance follow up documentation was reviewed on 1/6/15. The grievance follow up documentation stated the following: Pt #9 presented to the Urgent Care upon arrival and was sent to the ER due to a possible Gastrointestinal Bleed. Pt #9 was in the ER for 5 hours. The ER nurse (E#12) was not aware of the test results and stated "would have the doctor come in. He never did." Pt #9's family went out and asked one of the nurses "if we could see the doctor" and the nurse stated being unable to find the doctor. It further stated the ER nurse was frustrated as MD#4 had been notified "several times by the nursing staff to please talk to this patient" and "After waiting an extended length of time.... the patient and family left very unhappy." It further stated the grievance was forwarded to the ER contracted service for follow up and the ER Director (MD#5) stated all patients are not seen by the physician (if seen by the Midlevel provider such as the APN) and "Most should be and all that request to see the physician (should be seen by the physician) ."

6. An interview was conducted with the Director Patient Safety/Quality (E#1) on 1/6/16 at approximately 11:35 AM. E#1 reviewed Pt #9's grievance and verbally agreed that if a patient requests to speak to a physician, the physician should speak with the patient and the ER physician did not do this with Pt #9 and should have.

Based on document review and interview, it was determined for 3 of 10 (Pts #8, #4, and #5) patients, the Hospital failed to ensure patients were assessed for the presence of and/or change in a patient's Advance Directive.

Findings include:

1. The Hospital policy titled "Advance Directives" (Policy #81; revised May 2015) was reviewed on 1/5/16. The policy stated on page 1 under "II. Procedure:... providing patients with information and counseling about Advance Directives upon admission... B. Inpatients 1. Patient Registration Personnel. a. As part of the regular registration or admitting process, an intial inquiry will be made and documented...
b. This patient is also given a packet on admission of information regarding Advance Directives... 3. Nursing Departments. a. During the admission process, and R.N. (Registered Nurse) or L.P.N. (Licensed Practical Nurse) shall inquire of ... This information is documented on the patient record..."

2. The Hospital form titled "Consent for Treatment, Authorization for Release of Information and General Conditions for Outpatient Services and/or Admisison Form #UM-1001" (CARITA) was reviewed on 1/5/16. The CARITA stated under "11. I understand that .... must provide information to me on Advance Directives..." and then lists "I have received the Statement of Illinois Law on Advance Directives... I have an "Advance Directive" document... I provided a copy of my "Advance Directive"..." Each statement is followed by a "Yes" box and a "No" box which is to be filled in by the Hospital staff. Under #12, The CARITA lists "I understand that I am being treated" and has a line for Emergency Room, Urgent Care, Inpatient, and Outpatient (Observation... ) which is to be initialed by the patient/patient representative.

3. Pt #8's admission record for 11/1/15 was reviewed on 1/5/16 with the Clinical Information Specialist (E#3). Pt #8 was admitted to the Hospital with the diagnosis of Acute Chronic Diastolic Congestive Heart Failure. Registration documentation lacked any inquiry as to Pt #8's current Advance Directive status.
The CARITA form Advance Directive area was blank. The nursing admission assessment stated "Advanced Directives Information Want life to be prolonged regardless of condition or changes for recover."

An interview was conducted with E#3 during Pt #8's record review. E#3 reviewed Pt #8's record and "captured a screen print" of one of the areas of the patient's electronic record where staff can check on Advance Directive status. Pt #8's "screen shot" stated "Patient has a Living Will only" and was dated 1/24/12. E#3 further went into another area of the electronic record and was able to view and print Pt #8's Advance Directives. On 3/24/15, Pt #8 had executed a "Practitioner Orders For Life-Sustaining Treatment (POLST) Form" and on 6/2/15, Pt #8 had executed a"Durable Power of Attorney for Healthcare Decisions" (DPOAHC). When asked how the staff would know the first area had not been updated to accurately reflect Pt #8's current Advance Directive status and/or when it was updated, E#3 stated "They wouldn't know unless they happened to go into the other screen." E#3 verbally agreed Pt #8's record lacked an inquiry as to the current Advance Directive status upon registration and/or admission to the Emergency Department and that the electronic record had not been updated to reflect the changes in Pt #8's Advance Directives.


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4. Pt#4's record was reviewed on 1/5/16 at approximately 3:00 PM. Pt #4 was admitted to the Hospital on 12/26/15 with Diagnosis of Shortness of Breath secondary to Pneumonia. The record included a CARITA, dated 12/25/15. The section of the form that included "...#11. I understand that ... (the hospital) must provide information to the patient on Advanced Directives" was blank and not signed by the pt. The form lacked the information regarding the pt. receiving Statement of Illinois Law on Advance Directives, if the pt. has an Advance Directive document and if the pt. provided a copy of the Advanced Directive. The pt. profile/ pt. detail form included pt. does not have an Advanced Directive with the effective date of 7/15/11. The profile/detail lacked updated Advance Directive information after 7/15/11.

5. Pt.#5's record was reviewed on 1/5/16 at approximately 2:15 PM. Pt #5 was admitted on 12/25/15 with the Diagnoses of Pancreatitis and Atrial Fibrillation. The record included a CARITA, dated 12/25/15. The section of the form that included ...#11. I understand that ...hospital must provide information to the pt. on Advanced Directives was blank and not signed by the pt. The form lacked the information regarding the pt. receiving Statement of Illinois Law on Advance Directives, if the pt. has an Advance Directive document and if the pt. provided a copy of the Advanced Directive. The pt. profile report included pt does not have an Advanced Directive with last documented date of 7/14/12. The profile report lacked updated Advance Directive information after 7/14/12.

6. An interview was conducted with E#1 and the Vice President of Patient Care Services (E#2) on 1/7/16 at approximately 3:30 PM. E#1 had reviewed the records of Pts #4 and #5 and verbally agreed the records did not follow the Hospital's policy for assessing the presence and/or change in an Advanced Directives and whether or not information was given to the patient or family.

Based on document review and interview, it was determined for 2 of 3 (Pts #5 and #7) patients, the Hospital failed to ensure orders for restraints were obtained and authenticated in accordance with Hospital policy.

Findings include:

1. The policy titled "Restraints/Adaptive and/or Protective Actions" (revised 11/15), was reviewed on 1/5/16 at approximately 2:00 PM. The policy required "...III. Restraint Definitions and Guidelines: A. Physical restraint for Acute Medical/ Surgical Patient: 1...
Telephone orders for restraints can be used in an emergency for initial application and are to be authenticated within 24 hours. CPOE (computerized physician order entry)... is entered into the record within 24 hours of restraint."

2. Pt #5's record was reviewed on 1/5/16 at approximately 2:15 PM. Pt #5 was admitted on 12/25/15 with the Diagnoses of Pancreatitis and Atrial Fibrillation. The nursing notes dated 1/1/16 included the restraints using limb holder for left and right arm was initiated at 10:15 AM and discontinued on 1/3/16 at 1545 (3:45 PM). The record lacked an order by the physician or licensed practitioner for the restraints.

3. Pt #7's record was reviewed on 1/6/16 at approximately 10:30 AM with the Diagnoses of Urinary Tract Infection and Altered Mental Status. The nursing notes dated 12/5/15 to 12/6/15 included the pt. was in Limb holder restraints for left and right arm. The record included an order for restraints for the patient for 24 hours submitted by the LPN (Licensed Practical Nurse) dated 12/5/15 at 2053 (8:53 PM). The telephone order was electronically signed by the MD (Medical Doctor) on 12/7/15 at 1637 (4:37 PM), 40 hours after the initial order.

4. It was confirmed during an interview with the Director of Patient Safety/Quality (E#1) on 1/6/16 at approximately 2:30 PM, that any patient with restraints requires a physician's order and it should be authenticated by the physician within 24 hours of the initial order.

Based on document review and interview, it was determined for 2 of 4 (MD#2, MD#3) physicians, reviewed for training/review of the Hospital policy/procedure for restraints/seclusion, the Hospital failed to ensure all physicians, who could potentially or have ordered the use of restraints, were trained on the Hospital's restraint/seclusion policy/procedure.

Findings include:

1. MD#2's credential file was reviewed on 1/6/16 at approximately 1:00 PM with the Credentialing Coordinator (E#11). The file lacked documentation of MD #2 receiving annual training on the Hospital's restraint/seclusion policy/procedure. The last training was dated 10/2013. MD#2 ordered restraints for Pts #5 and #7.

2. MD#3's credential file was reviewed on 1/6/16 at approximately 1:00 PM with E#11. The file lacked documentation of MD#3 receiving training on the Hospital's restraint/seclusion policy/procedure.

3. An interview was conducted with the Director Patient Safety/Quality (E#1) on 1/6/16 at approximately 1:30 PM. E#1 stated physicians should be receiving restraint/seclusion education with annual education. E#1 stated both MD#2 and MD#3 do order the use of restraints and that both were not present at the "Mandatory Practitioners' Education" meeting on September 23, 2015 in which restraint/seclusion was discussed and handouts given. E#1 stated both physicians were sent emails to review this information; however, "I don't have anything that says they have reviewed it."