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.

ADVENTIST LA GRANGE MEMORIAL HOSPITAL 5101 S WILLOW SPRINGS RD LA GRANGE, IL 60525 March 8, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 2 patients who filed a grievance (Pt. #1), the Hospital failed to acknowledge receipt of the grievance and begin the resolution process per policy.

Findings include:

1. On 3/7/18 at 9:00 AM, the Hospital's policy titled, "Review and Resolution of Grievances" (revised 2/2014), was reviewed. The policy required, "Within (7) days of receipt of any grievance, the reporter shall receive a written acknowledgement of receipt of the grievance."

2. On 3/6/18 at 2:30 PM, a Complaint Request for Pt. #1's Grievance from 2/14/18 was reviewed. Pt. #1 was a [AGE] year old female, who had a transvaginal ultrasound on 2/14/18 at 9:19 AM for irregular menses. The Complaint Request was created on 3/6/18 at 1:09 PM by the Patient Liaison (E #4).

3. On 3/6/18 at 3:00 PM, an email from the Communications Department sent to the Patient Liaison (E #4) on 2/14/18 at 2:27 PM, was reviewed. The email included details of Pt. #1's Complaint submission that was received via the Hospital's website on 2/14/18 at 1:59 PM.

4. On 3/6/18 at 2:50 PM, an interview was conducted with the Patient Liaison (E #4). E #4 stated that once she receives a complaint, she will notify the complainant within 7 days by letter to acknowledge receipt. E #4 stated that she will then assign the complaint to the appropriate department(s) to begin the resolution process. E #4 stated that Pt. #1 should have been notified and the resolution process started by 2/21/18, but the email from the Communication Department was missed. E #4 provided a copy of the Acknowledgement Letter addressed to the complainant and verified that it was sent on 3/6/18.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on document review, observational tour, and interview, it was determined that for 2 of 2 Ultrasound Procedure Rooms (Room #1 and #2) observed, the Hospital failed to ensure that personal privacy was provided, potentially affecting approximately 20 patients seen in these Ultrasound Rooms per day.

Findings include:

1. On 3/7/18 at 10:00 AM, the Hospital's notice of Patient Rights and Responsibilities was reviewed. The notice required, "You [the patient] Have the Right to: ... Expect privacy and dignity in treatment consistent with providing you with good medical and psychiatric care."

2. On 3/6/18 between 11:00 AM and 11:20 AM, a tour of the Ultrasound Department was conducted. There were a total of four rooms used for ultrasounds. Room #1 and Room #2 were designated for vaginal ultrasounds due to probe availability. Each room had its own large wooden door for an entrance from the hallway. There was also a shared sliding door between Room #1 and Room #2 that was open at the time of the tour. The shared door was off its track and unable to be closed, allowing visualization from the adjacent room's entryway.

3. On 3/6/18 at 11:15 AM, an interview was conducted with an Ultrasound Tech (E #2). E #2 stated that the [shared] door is closed during procedures and only left open when moving the probe from room to room. When asked to close the door, E #2 was unable to slide the door more than 2 inches.

4. On 3/6/18 at 11:20 AM, an interview was conducted with the Director of Imaging (E #1). E #1 acknowledged that the [shared] door could not be closed.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review, observational tour, and interview, it was determined that for 2 of 2 Ultrasound Procedure Rooms (Room #1 and #2) observed, the Hospital failed to ensure that the patient care area was free of environmental hazards, potentially affecting approximately 20 patients seen in these Ultrasound Rooms per day.

Findings include:

1. On 3/7/18 at 1:30 PM, an email (dated 12/9/16) from the Regional Associate Vice President, was reviewed. The email required, "Please continue calling ext. 8300 for your Facilities needs (Plant Operations and Maintenance, Biomed, EVS [Environmental Services], Construction, Environmental Safety, etc.)."

2. On 3/7/18 at 1:35 PM, a slide from a Mandatory Annual Training Presentation that was provided to all staff, was reviewed. The training required, "What to do if you see [a] Safety issue: - Call #8300 (Adventist Medical Centers) - Call Facilities or Security to report."

3. On 3/6/18 between 11:00 AM and 11:20 AM, a tour of the Ultrasound Department was conducted. The shared sliding door between Room #1 and Room #2 was off its track and unable to be closed. The following was also observed:

- In Room #1, the wooden frame around the electrical outlet was cracked. Approximately 5 ceiling tiles were broken (leaving the interior ceiling exposed). The paint on the wall by the examination cart was peeling, and the floor had yellow stains throughout.

- In Room #2, two ceiling tiles were broken. An approximately 2 inch strip of paint was peeling off of the entrance door, and the bathroom sink had a yellow stain around the basin.

4. On 3/6/18 at 11:20 AM, an interview was conducted with the Director of Imaging (E #1). E #1 stated, "Maintenance does make rounds and if they find something, they will fix it. We are responsible to report things like the wall needing repair."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 2 of 4 (Pt. #8 and #10) patients in non-violent restraints, the Hospital failed to ensure an order for restraints was obtained within 12 hours of initiation of restraints, per policy.

Findings included:

1. The Hospital's policy titled, "Restraint Management (1/2018)" was reviewed on 3/7/18. The policy required, "Physician order: A verbal/telephone order from a physician must be obtained and entered into the patient's medical record as soon as possible, but not more than 12 hours after the initiation of restraint."

2. The clinical record of Pt. #8 was reviewed on 3/7/18. Pt. #8 was a [AGE] year old male admitted on [DATE] with a diagnosis of acute agitation. Pt. #8 was placed in an enclosure bed restraint on 2/23/18 at 7:18 PM to "prevent unintentional injury or harm." A physician's order for the restraint was entered into the computer on 2/24/18 at 10:15 AM (14 hours and 57 minutes after initiation of restraints).

3. The clinical record of Pt. #10 was reviewed on 3/7/18. Pt. #10 was a [AGE] year old male admitted on [DATE] with a diagnosis of CVA (cerebral vascular accident - stroke). Pt. #10 was placed in bilateral upper extremity wrist restraints on 1/10/18 at 9:29 PM to "prevent unintentional injury or harm." A physician's order was entered into the computer on 1/11/18 at 11:32 AM (14 hours and 3 minutes after initiation of restraints).

4. During an interview on 3/8/18 at 8:45 AM, the Director of Accreditation and Licensure (E#3) stated that the order should have been written within 12 hours.