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MERCY HOSPITAL AND MEDICAL CENTER 2525 S MICHIGAN AVE CHICAGO, IL 60616 Sept. 6, 2018
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed with an ankle x-ray ordered, the Hospital failed to ensure that the process for correcting a radiology report was followed, as required.

1. On 9/5/18 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female, who came to the ED (Emergency Department) on 7/7/18 due to acute left ankle pain and syncope (passing out).

- On 7/7/18 at 2:05 PM, MD #4 (ED Resident Physician) ordered an X-ray of the left ankle. The result of the left ankle X-ray, electronically signed by MD #9 (Radiologist) on 7/7/18 at 3:30 PM, included, " ...Impression: 1. Mild generalized soft tissue swelling ... Correlate for soft tissue injury ankle sprain. 2. No acute fracture or dislocation on left ankle ..."

- The Progress Notes of MD #7 (Podiatrist) and MD #8 (Podiatry Resident Physician) on 7/10/18 included, " ... I have reviewed and examined the patient... Assessment: Acute left ankle fracture ... XR (X-Ray) Non-displaced complete fracture of left malleolus (bone in the ankle). [Original] Read [on 7/7/18] states no fracture."

2. On 9/6/18 at 9:00 AM, the Bylaws of the Medical Staff (dated May 2016) was reviewed and included, "... Each Department shall have written policies to enable to carry out the duties of the Department..."

3. On 9/6/18 at approximately 9:15 AM, the Hospital's policy titled, "Daily Monitoring and Corrections of Radiology Reports" (revision date 1/15), was reviewed and included, "... Reports requiring special attention... correction, changes, or modifications or general questions should be given back to attending radiologist who signed off the report... If the attending radiologist who signed off the report originally is unavailable at the time... the report must be given to the radiology department chairman..."

4. On 9/5/18 at approximately 3:14 PM, an interview was conducted with MD #8 (Podiatry Resident). MD #8 stated, "I reviewed the chart ... we (MD #7 and MD #8) saw (Pt. #1) for left ankle sprain ... I reviewed the X-Ray film (referring to the X-Ray done on 7/7/18 that showed no fracture) ... showed non-displaced fracture of the left fibula ..." MD #8 could not recall talking to the radiologist who interpreted the X-ray.

5. On 9/5/18 at approximately 3:30 PM, a telephone interview was conducted with MD #9 (Radiologist). MD #9 stated, " ... I did not know that there was a discrepancy in the reading until today ... This is the first time I know about it ..." MD #9 stated that they (radiologists) are typically contacted when there's a discrepancy on the interpretation of the X-ray results. MD #9 stated, "I need to look at the film again to make sure ..."

6. On 9/6/18 at approximately 10:30 AM, findings were discussed with E #7 (Director of Quality). E #7 stated, "The chain of command should have been followed."

7. On 9/6/18 at approximately 12:23 PM, a telephone interview was conducted with MD #7 (Podiatrist). MD #7 said, "On the X-ray film (referring to the X-ray done on 7/7/18), there was a non-displaced fracture (a break in the bone that did not move) ... I don't usually talk to the radiologist ... I look at the film myself ... If there was a discrepancy, the radiologist is contacted ... I don't recall talking to the radiologist ..."
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) complaint and grievance records reviewed, the Hospital failed to ensure that the complaint and grievance process was followed, as required.

Findings include:

1. On 9/5/18 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female who came to the ED (Emergency Department) on 7/7/18 due to acute left ankle pain and syncope (passing out).

2. On 9/6/18 at approximately 9:00 AM, the Hospital's policy titled, "Patient Complaint and Grievances" (revision date 7/18), was reviewed and required, "... A grievance includes any of the following... Verbal complaint (including telephone) regarding patients care when the issue cannot be resolved at the time of the complaint by the staff... C. Management of Complaints... 3. All complaints are entered within 24 hours to VOICE (electronic system of logging patient complaint or grievance)... Management of Grievance...b. Grievances are investigated by the leaders of the service for which the concern/issue originated... e. Information pertaining to the investigation and decisions made are in VOICE..."

3. On 9/6/18 at approximately 10:04 AM, an interview was conducted with E #6 (Patient Experience Specialist). E #6 said, "(Pt. #1's) name sounds familiar ... I remember talking to the daughter ... maybe a month ago ... daughter complaining about having difficulty getting her mother's medical records ... the disc ... EKG (electrocardiogram/heart testing) ... I went to the medical records and requested ... called the daughter back and left her a message that she can either pick up the records at my office or the medical records department ... Daughter called back and told me... medical records... were incomplete ... Daughter was upset ... I went back to the medical records (and obtained) the EKG ... I called the daughter back and told her (daughter) that it will be ready by the next day ... Daughter called back and said she (daughter) will obtain the records from me (E #6) at the lobby ... Met daughter at the lobby ... apologized to her and gave (daughter) the records. When asked about documentation, E #6 stated, "I should have documented in VOICE."