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.

PAVILION FOUNDATION, THE 809 W CHURCH ST CHAMPAIGN, IL March 20, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document/record review,and interview the agency failed to provide a written response to the grievance complaint for 1 of 10 patients (Pt#1).

1. The Hospital Policy titled "Patient Advocate and Grievance Resolution (Reviewed 12/4/2012) was reviewed on 3/20/2014 at 3:00PM. It stated, "IV. Procedure: Response time Frames: within 24 hours after receipt of the complaint...provide the time frame for investigating and written response".

2. The "Patient Advocate Log" from 10/13 to 3/17/14 was reviewed. Pt#1's did not appear on the log.
The "Patient Advocate Log" had only one entry of grievance submitted and completed. from 10/13 to 3/17/14.

3. An interview was conducted on 3/20/14 at 4:30PM with the Patient Advocate. The Patient Advocate (E#5)stated " not all calls to the "Patient Advocate Line" are recorded on the Patient Advocacy Log. I do not have the patient complete a "Grievance Resolution" form nor do I give a written response. I do not document anything in the chart".

4. An interview was conducted with the CEO (#14 ) on 3/20/14 at 4:45PM. E#14 stated all calls are to be reported on the "Patient Advocacy Log",...the patient is to be given a written response".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of Hospital Policy and Procedure, Record Review, and Staff Interviews, it was determined that 2 of 2 (Patient 3, Patient 4) Patient Healthcare Peer Review (HPR) Reports reviewed the Hospital failed to ensure that sexual altercation activity reported to Risk Management was investigated per abuse policy.
Findings include:
1. Hospital policy titled " Pavilion Sexual Aggression and Victimization Prevention and Response/ Notification to Sexual Allegations " (no revised date listed). #5. ... Upon report or discovery of an allegation of sexual behavior ...Charge Nurse and facility leadership: ... Initiate investigation including interviews of the patients involved ...

2. Review of Facility Healthcare Peer Review (HPR) Occurrence Reporting System was completed on 3/20/14 at 3:10 PM. Two HPR reports were found that documented a checkmark on both areas listed " Sexual Allegations " and " Physical Confrontations " . These HPR/Occurrence reports were completed by E#12 (Mental Health Technician). Both HPR reports were signed by both E#4 (Director of Risk Management/Abuse) and E#8 (Nurse Manager).
3. Patient#3 was a [AGE] year male admitted to the facility on [DATE] with diagnosis of increase in Suicidal ideation with a plan and intent.
4. Patient #4 was [AGE] year female with diagnosis of Suicidal Ideation with a plan and intent.
5. Interview with E#4 (Director Risk Management/Abuse) was completed on 3/20 at 10:55 AM. E#4 stated " I remember an altercation between Patient#3 and Patient#4 on 11/10/13 in the hallway. One of the patients struck the other. I reviewed the HPR report, viewed the camera taping of the incident and signed the HPR sheet. I was not aware the " sexual allegation " box was checked. So there was no investigation. "
6. Interview with E#8 on 3/20/14 at 4:45 pm stated " I was not aware of a sexual altercation. I only have knowledge of the physical altercation. To my knowledge, there was no sexual altercation; Just a physical one. "