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PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER 2233 W DIVISION ST CHICAGO, IL 60622 Jan. 11, 2013
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of Hospital documents and staff interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure incorrect clinical record entries were properly amended, all entries were dated, and all entries were legible..

Findings include:

1. Hospital policy entitled, "Amendment to the Medical Record," (revised 11/04) required, "Process: 10. Use of White-out/Obliterations, Under no circumstances is information changed or deleted by the use of liquid white out, erasers, or other means of obliterations."

2. The clinical record of Pt #1 was reviewed on 1/8/13 at approximately 2:00 PM. The clinical record contained physicians' progress notes with inappropriate entry error corrections. Examples include:
1/28/12 at 10:50 AM entered by a Pulmonologist (cross out); 2/1/12 (unknown time) written by a Pulmonologist (write over); and 2/1/12 at 1:00 PM written by a Pulmonologist (cross out).

3. The Hospital's Medical Staff Rules and Regulations (Dated 8/16/12) required, "15. Authentication of Documentation, All entries in the patient medical record are legible, dated, timed ..."

4. The clinical record of Pt #1 was reviewed on 1/8/13 at approximately 2:00 PM. The clinical record contained physicians' progress notes that lacked time of documentation. Examples include: Attending Physician - 1/23/12, 1/29/12, and 1/31/12; Hematology - 1/28/12, 1/29/12, and 1/31/12; Pulmonology - 1/29/12, 1/30/12, 1/30/12, 1/31/12, 2/1/12, and 2/2/12; Renal - 1/29/12, 1/30/12, 1/31/12, and 2/1/12, as well as others throughout Pt #1's stay. The clinical record contained an entry, written by the Renal consultant, (appears to be 1/3/12) that is undated and un-timed.

5. On 1/11/13 at approximately 9:00 AM, the RN Case Manager (E #10) caring for Pt #1 was interviewed. E #10 stated that most of her interactions for Pt #1 were with his daughter regarding the use of Arixtra at home. E #10 stated that she has no recollection of Pt #1 and/or family requesting his medical records during his stay or at discharge. On 1/11/13 between 9:15 and 9:20 AM E #10 was unable to read the physicians' progress notes dated: 1/27/12 by attending physician, 1/28 and 1/29/12 by the Pulmonologist consult.

6. The Director of Medical - Surgical/Telemetry Services was interviewed on 1/11/13 at approximately 10:30 AM. The Director stated that the clinical record documentation was not timed and corrections were inappropriately made.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital documents and staff interview, it was determined that for 1 of 4 (Pt #1) clinical records reviewed of patients' with complaints, the Hospital failed to ensure a written response of the resolution , to the complaint, was forwarded to the patient and/or representative.

Findings include:

1. Hospital policy entitled, "Patient Grievances," (revised July 2007) required, "1.2 Grievance means any complaint that falls in one of the following categories: 1.2.1 Written Complaint. Any written complaint by a patient or a patient's representative (including a...as well as a complaint e-mailed or faxed to hospital administration...). 6. Response to Grievance. 6.2 Written Response Required. The designated hospital representative generally must provide a written response to the patient or representative within 7 business days of acknowledgement. The written response will include a statement of the Hospital decision, hospital contact person...In all cases, the hospital will attempt to resolve grievances as soon as possible."

2. The clinical record of Pt #1 was reviewed on 1/8/13 at approximately 2:00 PM. Pt #1 was a [AGE] year old male that presented to the Hospital's Emergency Department (ED) on 1/27/12 with complaints of Chest Pain With Cough. Pt #1 was triaged as a level 3 (Many Resources) out of 5. On 1/29/12, a physician's order required that Pt #1 receive a PPD skin test (TB test), which was administered on 1/29/12 at 10:50 PM, at which time Pt #1 was transferred to a negative pressure airborne isolation room. Pt #1 was discharged home on 2/13/12 with Home Health and an order for PT/INR.

3. On 1/10/13 at approximately 9:30 AM the Hospital presented a patient complaint filed in behalf of Pt #1, from Pt #1's daughter. The complaint and follow up included: ISSUE: My Father is currently hospitalized in Room 839 at St. Mary's Hospital. Today will be the 8th day of his hospital stay. We have encountered several errors and issues with his care and testing. We will be writing letters to JCAHO, IDPR, and the Health Bureau, this is by far the worst hospital and you should not even be in business due to poor patient care and unacceptable errors. We are currently looking into transferring out to a hospital that actually offers good clinical practice.
Reason For Referral: Conclusion/Recommendation:
2-2-12, I left a message for Ms. (complainant) regarding her concerns. I notified (retired Director of Quality Improvement) of this. I visited the patient who told me that his daughter may take time to call back because she is a pharmacist and cannot make personnel calls during work hours. (Pt #1) told me that he is concerned about his isolation status. He does not think he has TB. I explained to (Pt #1) that such concerns should be brought to the attention of his physician. I asked him to convey to his daughter that I stopped by and that I am very interested in speaking with her.

2-3-12: I left another message for (Complainant) asking for a meeting. I explained that even though I worked until 5:00 PM I would be willing to accommodate her schedule. I asked (Pt #1) if he knew what her concerns were he told me that it was related to his isolation status.

2-6-12: I visited the patient. I asked him if I should expect to hear from his daughter. He told me that he did not know.

2-8-12: I visited the patient. He is looking forward to going home.

2-10-12: (Pt #1) told me that he would be discharged within the next 48 hours. He was discharged on [DATE].

Pt #1's grievance conclusion failed to include that written notification had been sent to the pt and/or representative of the lack of findings or lack there of in regards of Pt #1's daughters failure to respond to the Hospital's inquires.

4. The Coordinator of Guest Relations was interviewed on 1/10/13 at approximately 9:30 AM. The Coordinator stated that he did not send a written response to Pt #1's daughter acknowledging the complaint and/or resolution.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital documents, and staff interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure patients were placed in isolation precautions in a timely manner. Thus potentially placing all patients and staff in the ED on 1/27/12 as well as all staff on the 8th floor at risk for infection.

Findings include:

1. Hospital policy entitled, "Tuberculosis Control Plan," (revised date 11/09) required, "4. Early Identification: 4. Early Identification: 4.3 High-risk groups include but are not limited to: 4.3.3 Foreign born persons from countries with a high incidence of TB. 4.4 If TB is suspected or confirmed the patient will be transferred as soon as possible to an airborne isolation room. Until then symptomatic patients should wear a mask if possible and instructed on proper respiratory hygiene. 5. Airborne Isolation: 5.1. Indicators for airborne isolation and placement in an airborne infection isolation (AII) room include: 5.1.1 Any person with suspected or confirmed TB. 5.1.2. Exposure to someone with TB."

2. The clinical record of Pt #1 was reviewed on 1/8/13 at approximately 2:00 PM. Pt #1 was a [AGE] year old male that presented to the Hospital's Emergency Department (ED) on 1/27/12 with complaints of Chest Pain With Cough. Pt #1 was triaged as a level 3 (Many Resources) out of 5. At 12:35 PM on 1/26/12, documentation included that Pt #1, " Claims to have exposure to someone with TB exposure. MD aware " . Pt #1 was admitted to room 800 West (non airborne room). On 1/29/12, a physician's order required that Pt #1 receive a PPD skin test (TB test), which was administered on 1/29/12 at 10:50 PM, at which time Pt #1 was transferred to room 800 west (a negative pressure airborne isolation room). Pt #1 was discharged home on 2/13/12 with Home Health and an order for PT/INR.

3. The ED physician caring for Pt #1 on 1/26/12 was interviewed on 1/9/13 at approximately 2:00 PM. E #4 stated that he does not remember the conversation with the nurse that is indicated in the note that indicated Pt #1 had a possible TB exposure. E #4 stated that when he performed his physical exam he covered all aspects for possible active TB (cough, nights sweats, and weight loss). However the physical examination does not indicate if the patient had a recent exposure or latent TB. The physician stated if any doubt he would have placed Pt #1 in isolation and ordered appropriate sputum and a PPD test.

4. reviewed. The log included Pt #1 as being in isolation from 1/29/12 until 2/2/12. The log did not indicate that Pt #1 was in isolation from 1/26 until 1/29/12 (ED admit).

5. On 1:15 PM the Infection Control Nurse (E #5) was interviewed. E #5 stated that Pt #1 was not placed into isolation and followed by her from the ED because Pt #1 was not isolated by the ED and TB testing was not ordered. On 1/29/12 when the testing was ordered, Pt #1 was then followed by the IC department.