The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PALOS COMMUNITY HOSPITAL 12251 SOUTH 80TH AVENUE PALOS HEIGHTS, IL 60463 Dec. 29, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**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) grievance letter received, the hospital failed to ensure the grievance was acknowledged, investigated and a response was provided as required by policy.

Findings include:

1. The complaint logs for 10/1/17-12/27/17 were reviewed on 12/27/17 at approximately 9:20 AM. The logs did not contain any complaints from Pt. #1.

2. The Director of Risk Management (E #3) was interviewed on 11/27/17 at approximately 9:20 AM. E #3 stated there were no complaints received related to Pt. #1, and there have been no grievances received in the last 3 months.

3. The Hospital Policy titled, "Patient Complaint/Grievances (rev. 3/13/17) required, "Definition: Grievance-Written and verbal complaints (that cannot be resolved at the time of the complaint by staff present)...when a complaint cannot be resolved at the time and place of the complaint, it will be considered a grievance, will be reviewed, investigated and responded to in writing within 7 days..."

4. The clinical record for Pt. #1 was reviewed on 9/27/17. Pt. #1 was a [AGE] year old female, who arrived in the Emergency Department (ED) by ambulance on 11/16/17, at 1:22 AM, with complaint of PTSD (posttraumatic stress disorder) and flashbacks. The clinical record indicated Pt. #1 became agitated and was ordered be placed in restraints at 8:50 PM on 11/16/17.

5. An interview with the ED Clinical Nurse Leader was conducted on 12/27/17, at approximately 1:45 PM. The Nurse Leader stated that Public Safety officers, who receive the same restraint and de-escalation training as the ED nurses, apply patient restraints in the ED.

6. On 12/27/17, public safety reports for patient assists for 11/16/17, related to Pt. #1, were requested

7. The Vice President of Nursing (E #4), interviewed on 12/27/17 at approximately 2:40 PM, stated that the hospital Public Safety Department just presented a Patient Assist Report along with and investigation of a written letter of complaint (grievance) related to Pt. #1. According to E #4, she (E #4) and the Director of Risk Management were not aware of the grievance letter from Pt. #1, and only became aware of this grievance letter "today" 12/27/17, at approximately 2:00 PM. E #4 stated the letter had a received date stamp of 11/30/17, and should have been responded to within 7 days. E #4 indicated that the security officer who followed up on the complaint with the police was not sure if there was a response sent to the grievant. E #4 stated, "We have now drafted a response to the letter We know we are late in responding because it was never reported to us."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 2 of 5 (Pt. #1 and #2) records reviewed, the Hospital failed to ensure face-to-face evaluations were conducted on patients within 1 hour of initiating restraints.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 12/27/17. Pt. #1 was a [AGE] year old female who presented in the Emergency Department (ED) on 11/16/17 with anxiety and post-traumatic stress disorder. The clinical record included an order for restraints that were applied on 11/16/17 at 8:52 PM. The restraints were discontinued at 11:25 PM. The record lacked documentation of the face-to-face evaluation of Pt. #1, by the physician, for the restraint use.

2. The clinical record for Pt. #2 was reviewed on 12/28/17. Pt. #2 was a [AGE] year old male who presented in the Emergency department on 11/2/17 with alcohol intoxication. The clinical record included Pt. #2 was restrained at 5:20 PM on 11/2/17 and the restraint order obtained at 5:28 PM. The restraints continued and the order was renewed at 9:42 PM. The record included a face-to-face evaluation of Pt. #2 at 9:45 PM for the renewed restraint order. However, the record lacked documentation of the face-to-face evaluation, by the physician, for the initial restraint application at 5:20 PM on 11/02/17.

3. The Hospital policy titled, "Restraint Policy" (rev. 5/15/17) required, " ...Within one hour of initiating restraint application, a physician is to perform and document a face-to-face assessment of the patient...this evaluation will be a comprehensive physical and behavioral assessment of the patient, including:...evaluation of patients reaction to the restraints...review of system...behavioral assessment...Need to continue or terminate restraints..."

4. The ED Clinical Nurse Leader (E #10) was interviewed on 12/28/17 at approximately 10:00 AM. E #10 stated that a one hour face-to face evaluation and documentation by a physician are expected for all patients ordered and placed in restraints, including renewed restraint orders.