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MT SINAI HOSPITAL MEDICAL CENTER 15TH STREET AT CALIFORNIA CHICAGO, IL 60608 June 9, 2015
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed that contained documentation of a patient complaint, the Hospital failed to ensure the complaint was investigated through to resolution.

Findings include:

1. Hospital policy entitled, "Rights and Responsibilities of Patients," (reviewed/updated: June 2014) required, "Patient Rights: Complaints and Grievances: The patient and his or her family have the right to have complaints reviewed by the Hospital."

2. Hospital policy entitled, "Patient Complaints/Grievance Process," (reviewed /updated June 2014) required, "Definitions: B. Grievance: A grievance includes any of the following: 1. All verbal complaints (including telephone) regarding the patient's care that cannot be reasonably addressed immediately... Procedure: E. Management of Grievances: 1. Grievance Investigation: a. All grievances will be documented and an appropriate timely investigation conducted...2. Timeline for completion: a. The Hospital will work to resolve each grievance as soon as possible. b. For the majority of grievances, resolution will be reached within seven days (7) days ..."

3. The clinical record of Pt #1 was reviewed on 6/5/15. Pt#1 was a [AGE] year old male (MDS) dated [DATE] with depression and schizoaffective disorder. Pt #1 was voluntary admitted on [DATE] 12:50 AM.





4. On 6/5/15 at approximately 11:42 AM the Director of Psychiatry, (E #1), was interviewed. E #1 stated that the patient (Pt #1) had multiple accusations towards staff and dissatisfactions of the service provided at this Hospital. E #1 stated Pt #1 would complain about the staff in general but not any particular staff. E #1 stated Pt #1's mother verified that it was the patient's baseline behavior to continuously accuse people, it was a manifestation of his illness. E #1 stated "I was not on the unit when the patient was making the complaints, the Patient Care Coordinator handled the situation." E #1 stated "when a complaint is not verified we don't document any other place then the patients chart."

5. On 6/5/15 at approximately 12:14 PM, the Patient Care Coordinator (E #2) was interviewed via telephone. E #2 stated Pt #1 made multiple telephone calls to the patient advocate system that would then forward them to me. Pt #1 had multiple complaints of staff. Staff that were present and staff that didn't exist. E #2 stated Pt #1 had a difficult time understanding how not to be hostile. "As long as I said yes, he was ok.." E #2 stated "I have reviewed the chart and would observe Pt #1 at the same time continuously call me to voice complains. E #2 failed to provide documentation of the investigation that was conducted regarding the allegations made about the unit's staff.

6. Pt #1's clinical record contained nursing documentation dated 6/1/15 at 11:41 PM that included, "Pt is agitated and upset towards specific staff...Advised that physical harm will not be tolerated..."

7. On 6/9/15 at approximately 12:0 0 PM the Registered Nurse making the note from 6/1/15, (E#6), was interviewed via telephone. E #6 stated to recall Pt #1. E #6 stated Pt #1 was passing by the medication window and I heard him making verbal threats so I called him and asked him what was going on. E #6 stated Pt #1 was complaining of a staff member (E#7).

8. The complaint log reviewed on 6/5/15 failed to include an investigate of Pt #1's accusations as required.

9. E #2 stated during an interview on 6/5/15 at approximately 12:14 PM that he did not document any of the patient's complaints regarding care.