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.

HOLY CROSS HOSPITAL 2701 W 68TH STREET CHICAGO, IL 60629 June 3, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and interview, it was determined for 1 of 2 (Pt #1) patient grievances reviewed, the facility failed to ensure investigation of the grievance.

Findings include:

1. The hospital's policy entitled "Patient Complaint/ Grievance Process" (revised 9/1/13) required, "...Definition:... Patient Grievance A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint...All grievances have to be investigated immediately and reported to the Customer Service Center..."

2. The documentation related to the grievance received by the hospital in regards to Pt #1 was reviewed on 6/2/14. The complaint form included the complaint was received on 4/15/14, and the summary included, "Pt's daughter visited pt. on 4-14-14 and there was a gash above pt's left eye. Pt. can't move or talk so family concerned how gash got there. Pt's daughter visited on 4-13-14 and the gash was not there. Investigation/Resolution: Patient's daughter met with [E #4] Acting VP Nursing [on 4/14/14]..." The documentation lacked any investigation of the grievance.

3. On 6/2/14 at approximately 1:30 pm, the surveyor requested from E #6 (current Vice President of Nursing) documentation of the hospital's investigation of Pt #1's grievance. E #6 stated that there was no documentation of an investigation.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, it was determined for 1 of 2 grievances (Pt #1) reviewed, the hospital failed to ensure written responses of the grievance investigation and resolution were provided to the family member.

Findings include:

1. The hospital's policy entitled "Patient Complaint/ Grievance Process" (revised 9/1/13) required, "...Definition:...Patient Grievance A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint...All grievances have to be investigated immediately and reported to the Customer Service Center...In its resolution of the grievance, the hospital is to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion...All patients receive a written response within 7 days..."

2. The documentation related to the grievance received by the hospital in regards to Pt #1 was reviewed on 6/2/14. The complaint form included the complaint was received on 4/15/14, and the summary included, "Pt's daughter visited pt. on 4-14-14 and there was a gash above pt's left eye. Pt. can't move or talk so family concerned how gash got there. Pt's daughter visited on 4-13-14 and the gash was not there. Investigation/Resolution: Patient's daughter met with [E #4] Acting VP Nursing [on 4/14/14], and issue was resolved...Sent for resolution: [E #4] Date sent: 5-15-14 Date resolved: [blank]". The documentation lacked a response letter to Pt #1's daughter/power of attorney.

3. On 6/2/14 at approximately 1:30 pm, the surveyor requested from E #6 (current Vice President of Nursing) documentation of the hospital's written response sent to Pt #1's daughter for this grievance. E #6 stated that no written response was sent to Pt #1's daughter.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient sustaining an alleged injury during hospitalization , the hospital failed to ensure a nurse informed a physician and completed an occurrence report for an injury, preventing analysis of the event and implementing corrective action to reduce similar future adverse occurrences.

Findings include:

1. The hospital's policy entitled "Patient Rights" (approved 2/5/14) required, "...Patient Rights:...To receive care in a safe setting..."

2. The hospital's policy entitled "Quality Reports (Occurrence Reports)" (revised 9/1/13) required, "...Quality reports should be written on any occurrence involving the hospital and occurring anywhere within the hospital grounds which: 1. Adversely affects or threatens to affect the comfort, health or life of a patient..."

3. On 6/2/14 at 9:55 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old female, admitted on [DATE], with diagnoses of unspecified fever, septicemia, stage III pressure ulcers, acute renal failure, dementia, and chronic respiratory failure. Pt. #1's emergency room history and physical on 4/12/14 at 2:41 AM, did not identify an eye injury or swelling. Pt. #1's admission database's wound skin assessment, dated 4/12/14 at 3:00 PM, did not include injury or swelling to Pt. #1's left eye.

4. Pt. #1's 24 hour flow record on 4/14/14 at 10:00 AM, included, "left eye brow wound 2 mm length and 2 mm width with healing scab". Nursing notes dated 4/14/14 at 10:59 PM, include "left eye swollen". Documentation a nurse informed a physician was not found. A physician's progress notes dated 4/15/14 at 11:45 AM, included, "left upper eye lid - small laceration swelling".

5. On 6/2/14 at 11:10 AM, and interview was conducted with the Vice President of Nursing (E #6). E #6 stated the injury was investigated by the Interim Vice President of Nursing (E #4) at the time (4/14/14).

6. On 6/2/14 at 2:15 PM, a phone interview was conducted with the interim acting vice president of nursing (E #4), working on 4/14/14, but no longer employed by the hospital. E #4 stated she met with Pt. #1's daughter and a man in the lobby. Pt. #1's daughter was concerned about Pt. #1's eye and presented a picture of the swelling. E #4 stated she told Pt. #1's daughter she would look into the matter. Pt. #1's daughter thanked E #4 and shook her hand. E #4 believed the issue had been resolved.

7. E #4 was asked by the surveyor what was done to investigate the incident. E #4 stated she spoke with the nurse on duty, who did not know when or how the injury occurred. According to E #4, the discussion with the nurse was not documented. E #4 stated that no other employees providing care for Pt #1 on 4/13/14, such as the night nurse, radiology technician, and respiratory therapist, were interviewed.