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.

ST MARGARETS HOSPITAL 600 E 1ST ST SPRING VALLEY, IL 61362 June 29, 2012
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
A. Based on a review of Hospital policy, a review of Hospital Grievance log, a review of Grievance Committee meeting minutes, and staff interview, it was determined in 6 of 6 (Pts #1, #25, #26, #27, #28, #29) grievances reviewed for grievance resolution, the Hospital failed to ensure patients were provided with written notice of resolution findings and date of completion, as per its policy.

Findings include:

1. The Hospital policy titled "Patient Grievances" (issued July 19, 2010) was reviewed. It indicated "... 6. Once the Grievance Committee is satisfied that the patient's complaint has been adequately addressed, it shall notify the patient in accordance with the steps specified in the section "Notification of Investigation Results"...Notification of Investigation Results: A... such notification shall be in writing and shall contain...."

2. The grievance log for January 2012 thru May 2012 and the Grievance Committee meeting minutes for December 2011 thru May 2012 were reviewed. Six of six grievances reviewed on the grievance log and in the Grievance Committee meeting minutes failed to indicate whether the complaints were adequately addressed and/or whether the patient was sent a letter of resolution findings and date of completion.

3. During a staff interview, conducted with the Executive Assistant (the person designated to initiate the grievance investigative process) on 6/27/12 at 9:25 AM, it was verbalized that letters are sent to the complainant to acknowledge receipt of the complaint and to convey that an investigation will be conducted. This is the date placed in the "Completed Date" on the Grievance log. When asked if the patient is sent a resolution letter once the investigation is completed with the findings and date of completion, it was verbalized that they were not.

4. During a staff interview, conducted with the CEO and the VP of Nursing on 6/27/12 at 10:45 AM, it was confirmed that no letter of resolution was sent to patients.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
A. Based on a review of Hospital policy, a review of Hospital Grievance log, a review of Grievance Committee meeting minutes, a review of ER Committee meeting minutes, and staff interview, it was determined in 5 of 6 (Pts #1, #26, #27, #28, #29) grievances reviewed for investigation follow up, the Hospital failed to ensure grievances were addressed in a timely fashion, as per its policy.

Findings include:

1. The Hospital policy titled "Patient Grievances" (issued July 19, 2010) was reviewed. It indicated "A. Initial Review: 2. A representative of the Grievance Committee shall conduct an initial review of the complaint within three days of its receipt... 3. All other complaints shall be assigned to one of two categories: (a) Practitioner Issues, or (b) Hospital Issues..." It further indicated "B. Investigation of Practitioner Issues" would be initiated within 10 days of receipt of the complaint from the Grievance Committee. The Grievance Committee would vote as to whether the case could be closed or whether more information was needed. If more information was needed, it would extend the follow up by 7 more days. The "Hospital Issues" was the same with the exception of the initial investigation would be within 14 days of the receipt of the complaint.

2. The grievance log for January 2012 thru May 2012 and the Grievance Committee meeting minutes for December 2011 thru May 2012 were reviewed. Six of six grievances reviewed on the grievance log and in the Grievance Committee meeting minutes failed to indicate what category the grievance was assigned, failed to indicate follow up within the initial 10 or 14 day timeframe, and failed to indicate whether ongoing 7 days of review was required.

3. The ER Committee meeting minutes for August 2011 thru May 2012 were reviewed. There was no documentation to indicate the grievances referred to the committee (Pts #1, #26, #27, #29) were discussed and/or investigated.

4. The grievance log indicated Pt #1 submitted a grievance on 5/1/12. There was no documentation to indicate category(s) the complaint was assigned. It indicated "Department(s) Involved... Disposition of Complaint: Meeting is to be held with... Date to be determined. Grievance Committee minutes for May 21, 2012 indicated the complaint was sent to the Department Managers of ED and Medical Surgical, the VP of Nursing and the Quality Director to begin followup review. This was outside of the designated timeframes.

5. The grievance log indicated Pt #26 submitted a grievance on 2/23/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved:...; Disposition: ..." The Grievance Committee minutes for March 19, 2012 indicated "Forward to ER Committee for review." This was outside of the designated timeframes. As of 6/29/12 at 8:25 AM, there was no documentation to indicate follow up had been completed.

6. The grievance log indicated Pt #27 submitted a grievance on 4/9/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved:..; Disposition: ..." The Grievance Committee minutes for April 16, 2012 indicated "Forward to ER Committee for review..."
This was outside of the designated timeframes. As of 6/28/12, there was no documentation to indicate follow up had been completed.

7. The grievance log indicated Pt #28 submitted a grievance on 4/9/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved...; Disposition: ..." The Grievance Committee minutes for April 16, 2012 indicated "Records to be reviewed with... Patient called." This was outside of the designated timeframes. As of 6/28/12, there was no documentation to indicate follow up had been completed.

8. The grievance log indicated Pt #29 submitted a grievance on 4/19/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved...; Disposition: ..." The Grievance Committee minutes for May 21, 2012 indicated "To be reviewed at ER Committee..." This was outside of the designated timeframes. As of 6/29/12 at 8:25 AM, there was no documentation to indicate follow up had been completed.

9. During a staff interview, conducted with the Executive Assistant (the person designated to initiate the grievance investigative process) on 6/27/12 at 9:25 AM, it was verbalized that grievances are received, reviewed, and sent to the respective persons and the Quality Director for investigation. When asked how these are then tracked for follow up, it was uncertain as to how this is done.