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.

ADVOCATE LUTHERAN GENERAL HOSPITAL 1775 DEMPSTER ST PARK RIDGE, IL 60068 July 28, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that in 1 of 2 (Pt. #9) clinical records reviewed with restraint usage in the inpatient unit, the Hospital failed to ensure the patient's care plan was modified to include the usage of restraints.

Findings include:

1. On 7/28/17 at approximately 9:30 AM, the clinical record of Pt. #9 was reviewed. Pt. #9 was a [AGE] year old male admitted on [DATE] with a diagnosis of attention-deficit hyperactivity disorder (ADHD). Pt. #9's clinical record indicated that Pt. #9 was in restraint on 3/27/17 from 11:30 PM to 9:15 AM on 3/28/17. However, Pt. #9's care plan failed to include restraint was used.

2. On 7/28/17 at approximately 9:50 AM, the Hospital's policy titled "Utilization of Restraint and Seclusion" (reviewed 6/16) was reviewed and required, "... Documentation of Restraint and Seclusion 1. Regardless of the type of restraint... used... the following will be documented in the patient's medical record... g. Modification of the patient's plan of care..."

3. On 7/28/17 at approximately 10:00 AM, findings were discussed with E #8 (Director of Performance Excellence & Regulatory Affairs). E #8 agreed that restraint use should be included in the patient's care plan. E #8 stated, "I believe it is in our policy."
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed regarding an allegation of abuse, the Hospital failed to ensure the complaint/grievance process was followed as required.

Findings include:

1. On 7/26/17 at approximately 12:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male admitted on [DATE] with a diagnosis of severe persistient asthma. The clinical record of Pt. #1 indicated that Pt. #1's mother verbalized that a Hospital security staff "rubbed his (penis) on me." However, there was no documentation that the allegation of Pt. #1's mother was followed-up by the Hospital.

2. On 7/27/17 at approximately 1:30 PM, the Hospital's policy titled "Resolving Patient/Family Complaints & Grievances" (reviewed 10/16) was reviewed and indicated, "... Definitions... B. Grievance: All verbal complaints (including telephone) regarding the following:... a. allegation of abuse... C. Management of Complaints... 2. If the complaint cannot be resolved... refer the issue to their manager, or to the Patient Relations/Patient Advocacy/Patient Representative Department. D. Management of Grievances...b. All grievances will be documented and an appropriate and timely investigation conducted..."

3. On 7/27/17 at approximately 10:00 AM, the Pediatric Intensive Care Unit (PICU) Manager ( E #1) was interviewed. . E #1 stated that Pt. #1's mother (A #1) made an accusation of inappropriate touching. E#1 stated "I was in the room. I did not see anything inappropriate at that time. It was me and RN (Registered Nurse) and 4 Public Safety Officers(PSOs) in the room when A #1 made the allegation."

4.On 7/27/17 at approximately 11:00 AM, the Social Worker (E #4) was interviewed. E #4 stated that A #1 had told him that a PSO had inappropriately touched her and that she was going to make a report. E#4 stated, "I did not fill out an grievance report because Pt. #1 stated she would do so." E #4 stated that he does not recall if he followed up on the allegation.

5. On 7/27/17 at approximately 11:04 AM, the Chief Nursing Officer (E #5) was interviewed. E #5 stated "leadership (E #1) was in the room when the alleged inappropriate touching occurred." E #5 stated that the PSO was attempting to reach Pt. #1 and Pt. #1's mother was in the middle of the two (PSO and Pt. #1). E #5 stated that if leadership had not been present in the room, an investigation would have been conducted. E #5 stated, "Allegation not found because there was a witness."

6. On 7/27/17 at approximately 11:50 AM, the Performance Excellence and Regulatory Affairs Director (E #8) was interviewed. E #8 stated that regardless of who was present during the alleged incident, a report should have been created and policy followed.