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.

ILLINOIS VALLEY COMMUNITY HOSPITAL 925 WEST ST PERU, IL 61354 Aug. 8, 2018
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined in 8 of 8 (Pt's #1, #3, #4 (2 admissions), #5, #6 and #8 (2 admissions)) patient admissions reviewed, the Governing Body failed to ensure Physician orders were authenticated per the Medical Staff's Rules and Regulations. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Rules and Regulations (revised 4/2015) were reviewed on 8/8/18. The Rules and Regulations required "4.4 Orders... f. All orders for treatment shall be recorded... authenticated by the ordering practitioner with his/her valid... signature, date, and time."

2. The clinical record of Pt #1 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #1 was admitted on [DATE] with a diagnosis of an Urinary Tract Infection. A telephone order authored by a nurse on 4/18/18 at 2:00 PM lacked the date and time as to when the Physician authenticated the order.

3. The clinical record of Pt #3 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #3 was admitted on [DATE] with the diagnoses of Pneumonia and Congestive Heart Failure. A Physician's order to continue Norco (pain medication) after discharge lacked a physician's signature, date and time.

4. The clinical record of Pt #4 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #4 was admitted on [DATE] with the diagnosis of an Urinary Tract Infection and readmitted on [DATE] with the diagnoses of Urinary Tract Infection and Bacteremia (blood infection). Two Physician orders signed and dated 4/3/18 lacked the time of the Physician's authentication. Five Physician orders signed and dated 5/5/18 lacked the time of the Physician's authentication.

5. The clinical record of Pt #5 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #5 was admitted on [DATE] for pain management from a Sacral Fracture. A telephone order authored by a nurse on 6/23/18 at 9:40 AM, lacked a date and time of the Physician's authentication. A Physician's order dated 6/23/18 lacked a time the physician authenticated the order. Three pages of written orders for discharge, lacked the date and time the physician authenticated the orders.

6. The clinical record of Pt #6 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #6 was admitted on [DATE] with the diagnoses of Pneumonia and Congestive Heart Failure. Two Physician orders signed and dated 2/20/18 and 2/21/18 lacked the time of the Physician's authentication.

7. The clinical record of Pt #8 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #8 was admitted on [DATE] with a diagnosis of Right Wrist Pain and readmitted on [DATE] with a diagnosis of Pneumonia. Eight Physician orders signed and dated between 5/3/18 to 6/9/18 lacked the time of the Physician's authentication.

8. During an interview on 8/8/18 at approximately 1:30 PM, Vice President/Chief Nursing Officer (E#2) and Director of the Medical Unit (E#3) verbally agreed after reviewing the above mentioned patient records, all orders should be authenticated with a Physician's signature, date and time and Pt #1, #3, #4, #5, #6 and #8's records lacked the required documentation.
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 1 (Pt #5) patient record reviewed with a Consultation Note, the Governing Body failed to ensure the Physician Consultation Note was completed per the Medical Staff's Rules and Regulations. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Rules and Regulations (revised 4/15) were reviewed on 8/8/18. The Rules and Regulations required "Article III Medical Records... 3.18.1 Requirements for Timely Completion of Medical Records... g. A Consultation Note must be completed... within 24 hours of notification of the consult..."

2. The clinical record of Pt #5 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #5 presented to the Emergency Department and was admitted on [DATE] for pain management from a Sacral Fracture. A Consultation by a Physician (MD#3) was conducted on 6/22/18, although the report was dictated on 7/1/18 (9 days after the 24 hour requirement).

3. During an interview on 8/8/18 at approximately 1:30 PM, Vice President/Chief Nursing Officer (E#2) verbally agreed after review of Pt #5's record, that the Consultation Note by MD#3 had not been completed within the 24 hour requirement and should have been.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on document review and interview,it was determined for 5 of 5 (MD#1, MD#2, MD#3, MD#4 and MD#5) Physician Credentialing files reviewed, the Governing Body failed to ensure the Medical Staff was accountable for the quality of medical care provided to the patients. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Bylaws (revised 1/1/15) were reviewed on 8/8/18. The Bylaws noted "Section 4. Competency Evaluation... The medical staff will also engage in ongoing competency evaluation to identify professional practice trends that affect quality of care and patient safety... Section 5 Reappointment... 5.1.1 Criteria for Reappointment The MEC (Medical Executive Committee) must also determine that the practitioner provides effective care... regarding ongoing quality...5.2.3 The following information is also collected and verified... e. Timely and accurate completion of medical records: f. Compliance with all applicable bylaws, policies, rules, regulations, and procedures of the hospital and medical staff... Section 6 Clinical Privileges 6.3.3 The basis for privileges... include documented clinical performance and results of the practitioner's performance improvement program activities..."

2. The Physician Credentialing files were reviewed on 8/8/18 at approximately 10:00 AM. The following files lacked documentation of an ongoing competency evaluation related to the quality of care provided, patient safety, and timely and accurate completion of the medical record: MD#1 (recredentialed 7/5/17) ; MD#2 (recredentialed 6/13/18); MD#3 (recredentialed 5/9/18); MD#4 (recredentialed 3/1/17); and MD#5 (recredentialed 7/5/17).

3. The Medical Executive Committee meeting minutes dated February 2018 through July 2018 were reviewed on 8/7/18 at approximately 1:00 PM. The meeting minutes noted "Initial Privileges... Reappointments The files (Physician Credentialing files) were reviewed by the pertinent Division Chairman and the Medical Staff President for... licensure, malpractice insurance, data bank report, peer references, and volume statistics when applicable..." The meeting minutes lacked documentation of an ongoing competency evaluation of quality of care provided, patient safety, or compliance with medical record documentation.

4. During an interview on 8/8/18 at approximately 1:00 PM, Chief Executive Officer (E#1) verbally agreed the MEC did not evaluate MD#1, MD#2, MD#3, MD#4 and MD#5 for the quality of care they provided, patient safety outcomes, nor compliance with medical record documentation and should have. E#1 stated "We don't evaluate individual physician performance like that. I see why we should now." E#1 verbally agreed the Board of Directors grant privileges upon the recommendation of the MEC.

5. See deficiencies cited at A-0449, A-0450, A-0464 and A-0468.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined in 3 of 3 (Pt's #1, #3 and #5) patient records reviewed, the Governing Body failed to ensure documentation was completed per the Medical Staff's Rules and Regulations. This has the potential to affect all patient's who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Rules and Regulations (revised 4/2015) were reviewed on 8/8/18. The Rules and Regulations required "Article III Medical Records 3.1 General requirements The medical record provides data and information to facilitate patient care... supports decision analysis... The medical record should contain information to justify admission or medical treatment, to support the diagnosis, to validate and document the course and results of treatment, and to facilitate continuity of care... 3.8 Progress Notes... record a progress note each day. If a patient is seen more than once per day for a pertinent medical change, then each encounter should be documented in the medical record... 3.12 Final Diagnosis.... document the diagnostic findings and final diagnosis in the patient's medical record... 3.13 Discharge Summaries The content of the medical record should be sufficient to justify the diagnosis, treatment, and outcome... should contain: 1. Reason for hospitalization ; 2. Summary of Hospital course, including significant findings, the procedures performed, and treatment rendered; 3. Condition of the patient at discharge... 3.18.1 Requirements for Timely Completion of Medical Records... e. An Inpatient Progress Note must be recorded and authenticated... at the time of each encounter, and on a daily basis..."

2. The clinical record of Pt #1 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #1 (MDS) dated [DATE] and was admitted on [DATE] for treatment with intravenous antibiotics for an Urinary Tract Infection. Progress Notes dated 4/13/18, 4/14/18, 4/15/18, 4/16/18, and 4/17/18 stated that; Pt #1's primary diagnosis was an Urinary Tract Infection. A Physician's order by the Physician (MD#1) dated 4/18/18 at 3:10 PM noted, "ABG's (Arterial Blood Gases) now."A Progress Note dated 4/18/18 at 9:06 PM authored by MD#1 stated "The patient was seen and examined earlier today... Blood gases (blood test) showed significant acute chronic respiratory acidosis (excess carbon dioxide in the lungs due to poor exhalation).... started on BiPAP (bilevel positive airway pressure/device to assist with breathing).... admitted with Pneumonia." The clinical record lacked documentation of the examination conducted 4/18/18 "earlier today" and an assessment of the change in condition which resulted in the "ABG's now" order. A Progress Note dated 4/19/18 authored by MD#1 stated "The patient was admitted with severe sepsis (blood infection) secondary to community acquired Pneumonia..." The clinical record lacked documentation of an assessment and indicators to support the Pneumonia diagnosis. The Vital Sign Report noted, Pt #1 received continuous oxygen at 3/liters per minute throughout the admission until 4/20/18 at 12:06 AM when the oxygen was increased to 4 liters per minute. The clinical record lacked documentation as to why the oxygen was increased or an order to increase it. The clinical record noted the hemoglobin and hematocrit (blood test for anemia) on 4/18/18 at 8:41 AM was resulted as significantly low although no further tests were ordered to monitor the level prior to discharge on 4/20/18 at 1:50 PM. A Discharge Summery dated 4/20/18 authored by the Physician (MD#2) lacked documentation of a Pneumonia diagnosis, oxygen use, laboratory, and x-ray findings.

3. During an interview on 8/8/18 at approximately 11:00 AM, Vice President/Chief Nursing Officer (E#2 ) and Director of the Medical Unit (E#3) reviewed Pt #1's record. E#2 and E#3 verbally agreed the clinical record lacked a Physician's Progress note for the 4/18/18 initial visit which resulted in the "ABG's now" order; lacked documentation to support a Pneumonia diagnosis; lacked documentation as to why the oxygen was increased to 4 liters; lacked documentation and continued monitoring of the decreasing levels of hemoglobin and hematacrit. Pt #1's Discharge Summary lacked documentation of the Pneumonia diagnosis, oxygen use, laboratory and x-ray findings, and should have.

4. The clinical record of Pt #3 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #3 (MDS) dated [DATE] with a fever, chest pain, and was admitted for observation. The clinical record noted during Pt #3's admission (approximately 16 hours) the white blood cell count increased from 10.3 to 12.5 (blood test/ > 12.0 indicator for infection) although 3 doses of intravenous antibiotics were administered; the hemoglobin decreased from 13.8 to 12.5 (Normal=13.5-17.5); the hematocrit decreased from 40.3 to 38.0 (Normal=Males, 42-54. Females, 38-46); the oxygen level decreased from 93% on room air to 90% on 4 liters of oxygen, and an elevated d-dimer (blood test use to diagnose blood clots). The Short Stay Summary dated 2/28/28 at 9:18 AM authored by the Physician (MD#3) noted only the laboratory values conducted in the Emergency Department on 2/27/18 at 6:32 PM. The Short Stay Summary dated 2/28/28 at 9:18 AM authored by the Physician (MD#3) did not address the most recent laboratory tests conducted on 2/28/18 at 4:47 AM (increased white blood cell count and decrease in hemoglobin and hematocrit levels); noted oxygen level at 93% on room air and lacked documentation of the most recent decrease in oxygen level and oxygen use; lacked documentation of the elevated d-dimer, and stated "I feel the patient is clinically doing quite well and is safe to be transferred back..." Pt #3 was discharged on [DATE] at 11:32 AM.

5. During an interview on 8/8/18 at approximately 11:00 AM, E#2 and E#3 verbally agreed the Short Stay Summary authored by MD#3 lacked an updated assessment based on the elevated d-dimer, the most recent laboratory values, and the change in oxygen requirements prior to discharge and should have.

6. The clinical record of Pt #5 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #5 presented to the Emergency Department and was admitted on [DATE] for pain management from a Sacral Fracture. The clinical record noted during Pt #5's admission the hemoglobin decreased from 12.7 to 10.6 (Normal=13.5-17.5); and the hematocrit from 37.6 to 31.4 (Normal=Males, 42-54. Females, 38-46). The Discharge Summary authored by the Physician (MD#5) on 6/24/18; lacked documentation of an assessment of the decrease in hemoglobin and hematocrit, an Admission Diagnosis, laboratory and x-ray findings.

7. During an interview on 8/8/18 at approximately 11:00 AM, E#2 and E#3 verbally agreed the Discharge Summary dated 6/24/18; lacked documentation of an assessment of the decrease in hemoglobin and hematocrit, an admission diagnosis, laboratory and x-ray findings, and should have.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on document review and interview, it was determined for 5 of 5 (MD#1, MD#2, MD#3, MD#4 and MD#5) Physician Credentialing files reviewed, the Governing Body failed to ensure that quality of care was provided by the medical staff to all patients. This has the potential to affect all patient's who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Bylaws (revised 1/1/15) were reviewed on 8/8/18. The Bylaws noted "Section 4. Competency Evaluation... The medical staff will also engage in ongoing competency evaluation to identify professional practice trends that affect quality of care and patient safety... Section 5 Reappointment... 5.1.1 Criteria for Reappointment The MEC (Medical Executive Committee) must also determine that the practitioner provides effective care... regarding ongoing quality...5.2.3 The following information is also collected and verified... e. Timely and accurate completion of medical records: f. Compliance with all applicable bylaws, policies, rules, regulations, and procedures of the hospital and medical staff... Section 6 Clinical Privileges 6.3.3 The basis for privileges... include documented clinical performance and results of the practitioner's performance improvement program activities..." The Bylaws noted Physician privileges may be granted by the Board of Directors upon recommendations of the Medical Executive Committee.

2. The Physician Credentialing files were reviewed on 8/8/18 at approximately 10:00 AM. The following files lacked documentation of an ongoing competency evaluation related to the quality of care provided, patient safety, and timely and accurate completion of the medical record: MD#1 (recredentialed 7/5/17) ; MD#2 (recredentialed 6/13/18); MD#3 (recredentialed 5/9/18); MD#4 (recredentialed 3/1/17); and MD#5 (recredentialed 7/5/17).

3. The Medical Executive Committee (MEC) meeting minutes dated February 2018 through July 2018 were reviewed on 8/7/18 at approximately 1:00 PM. The meeting minutes noted "Initial Privileges... Reappointments The files (Physician Credentialing files) were reviewed by the pertinent Division Chairman and the Medical Staff President for... licensure, malpractice insurance, data bank report, peer references, and volume statistics when applicable..." The meeting minutes lacked documentation of an ongoing competency evaluation of quality of care provided, patient safety or compliance with medical record documentation.

4. The Board of Directors meeting minutes dated February 2018 through July 2018 were reviewed on 8/7/18 at approximately 1:30 PM. The meeting minutes noted the Medical Executive Meeting Minutes were reported and the physicians recommended by the MEC for initial or reappointments were approved by the Board of Director.

5. During an interview on 8/8/18 at approximately 1:00 PM, Chief Executive Officer (E# 1) verbally agreed the MEC did not evaluate MD#1, MD#2, MD#3, MD#4 and MD#5 for the quality of care they provided, patient safety outcomes, nor compliance with medical record documentation and should have. E#1 stated "We don't evaluate individual physician performance like that. I see why we should now." E#1 verbally agreed the Board of Directors grant privileges upon the recommendation of the MEC.

6. See deficiency cited at A-0347.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, it was determined for 10 of 10 (CO#1, CO#2, CO#3, CO#4, CO#5, CO#6, CO#7, CO#8, CO#9 and CO#10) complaints related to patient care, listed on the complaint log, the Hospital failed ensure the Complaint/Grievance policy was followed. This has the potential to affect all patients served by the Hospital with an average daily census of 25 patients.

Findings include:

1. The policy titled "Complaints/Grievances" (last reviewed 1/18) was reviewed on 8/8/18. The policy defined a complaint as "an issue that can be resolved promptly by staff, a billing issue (with no care issues), a lost and found issue." The policy defined a grievances as "a complaint that cannot be resolved at the time of the complaint... required investigation... involves quality of care issues, an allegation of patient harm, abuse or neglect or failure of the hospital to comply with regulatory requirements." The policy stated a Patient Representative would obtain further information from complainant within 2 days and conduct an investigation. The policy required all complaint and grievances to be entered into the Patient Relation database and the resolution to be determined by the Grievance Committee.

2. The Complaint log dated February 2018 through August 2018 was reviewed on 8/7/18 at approximately 11:30 AM. The Complaint log lacked documentation the following patient complaints related to patient care were reviewed or investigated by a Patient Representative and followed the Grievance resolution process per policy:
CO#1/Pt #3, 2/28/18- discharged too soon
CO#2, 3/5/18- Communication with staff/Rude/Insensitive staff member
CO#3, 4/1/18- Perceived lack of care
CO#4, 4/12/18- Perceived lack of care
CO#5/Pt #1, 4/15/18- discharged too soon
CO#6, 5/10/18- Perceived lack of care
CO#7, 5/26/18- Perceived misdiagnosis
CO#8/Pt #5, 6/24/18- discharged too soon
CO#9, 7/16/18- Perceived lack of care
CO#10, 7/27/18- Perceived lack of care

3. The Grievance log dated February 2018 through August 2018 was reviewed on 8/7/18 at approximately 11:30 AM. The Grievance log lacked documentation the following complaints were reviewed, investigated or followed the Grievance resolution process per policy: CO#1, CO#2, CO#3, CO#4, CO#5, CO#6, CO#7, CO#8, CO#9, and CO#10.

4. The Grievance Committee Meeting Minutes dated February 2018, March 2018 and June 2018 were reviewed on 8/8/18 at approximately 11:00 AM. The meeting minutes lacked documentation the complaint log was reviewed to ensure that patient complaints were accurately identified as grievances, investigated by the Patient Representative and resolved via the Grievance Committee per policy.

5. During an interview on 8/8/18 at approximately 11:30 AM, Vice President/Chief Nursing Officer (E#2) and Director of the Medical Unit (E#3) stated all complaints were reviewed by 1 of the 2 Patient Representatives who determine if each complaint met the definition of a grievance. E#2 verbally agreed there was no oversight by the Grievance Committee to ensure the Patient Representative investigated all complaints of patient care and followed the grievance policy. E#2 stated CO#1, CO#2, CO#3, CO#4, CO#5, CO#6, CO#7, CO#8, CO#9 and CO#10 met the definition of a grievance although were not investigated or resolved per the Grievance policy and should have been.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined in 3 of 3 (Pt #1, #3, and #5) patient records reviewed, the Governing Body failed to ensure Discharge Summaries were completed per the Medical Staff's Rules and Regulations. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 25 patients.

Findings include:

1. The Medical Staff Rules and Regulations (revised 4/15) were reviewed on 8/8/18. The Rules and Regulations required "3.13 Discharge Summaries The content of the medical record should be sufficient to justify the diagnosis, treatment, and outcome... should contain: 1. Reason for hospitalization ; 2. Summary of Hospital course, including significant findings, the procedures performed, and treatment rendered."

2. The clinical record of Pt #1 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #1 was admitted on [DATE] with a diagnosis of an Urinary Tract Infection. A Progress Note dated 4/19/18 authored by Physician
(MD#1) stated "... admitted with severe sepsis (blood infection) secondary to community acquired Pneumonia..." The record noted Pt #3 was administered continuous oxygen and had multiple laboratory and x-ray tests conducted throughout the admission. A Discharge Summery dated 4/20/18 authored by a Physician (MD#2) lacked documentation of a Pneumonia diagnosis, oxygen use, laboratory and x-ray findings.

3. The clinical record of Pt #3 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #3 was admitted for observation on 2/27/18 for the diagnoses Pneumonia and Congestive Heart Failure. The Short Stay Summary (History and Physical/Discharge Summary) dated 2/28/28 at 9:18 AM, authored by a Physician (MD#3) noted the laboratory values conducted in the Emergency Department on 2/27/18 at 6:32 PM, but lacked the most recent laboratory tests conducted on 2/28/18 at 4:47 AM, and lacked documentation of the most recent decrease in oxygen level and required use of oxygen.

4. The clinical record of Pt #5 was reviewed throughout the survey on 8/7/18 and 8/8/18. Pt #5 was admitted on [DATE] for pain management from a Sacral Fracture. The record noted daily laboratory test were performed and x-rays were conducted. The Discharge Summary authored by a Physician (MD#5) dated 6/24/18 lacked documentation of an assessment of an admission diagnosis, laboratory and x-ray findings.

5. During an interview on 8/8/18 at approximately 1:30 PM, Vice President/Chief Nursing Officer (E#2) reviewed the patient records of Pt's #1, #3, and #5's Discharge Summary and E #2 verbally agreed that, it did not include the required elements and should have.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on document review and interview, it was determined for 10 of 10 (CO#1, CO#2, CO#3, CO#4, CO#5, CO#6, CO#7, CO#8, CO#9, and CO#10) complaints of patient care issues or premature discharges noted on the Complaint log, the Governing Body failed to ensure Complaints and Grievances were reviewed, resolved by the Grievance Committee, and implemented into the quality program per policy. This has the potential to affect all patients served by the Hospital with an average daily census of 25 patients.

Findings include:

1. The policy titled "Complaints/Grievances" (last reviewed 1/18) was reviewed on 8/8/18. The policy defined a grievances as "a complaint that cannot be resolved at the time of the complaint... required investigation... involves quality of care issues, an allegation of patient harm, abuse or neglect. or failure of the hospital to comply with regulatory requirements." The policy stated a Patient Representative would obtain further information from complainant within 2 days and conduct an investigation. The policy required all complaint and grievances to be entered into the Patient Relation database and incorporated in to the Hospital's Quality Assessment and Performance Improvement Program. The policy noted "The Hospital Board of Directors approves the complaint and grievance resolution process and delegates ultimate decision-making authority to the Grievance Committee."

2. The Complaint log dated February 2018 through August 2018 was reviewed on 8/7/18 at approximately 11:30 AM. The Complaint log lacked documentation that the following patient complaints; related to quality of care or premature discharge were reviewed or investigated by a Patient Representative and followed the Grievance resolution process per policy:

CO#1/Pt #3, 2/28/18- discharged too soon
CO#2, 3/5/18- Communication with staff/Rude/Insensitive staff member
CO#3, 4/1/18- Perceived lack of care
CO#4, 4/12/18- Perceived lack of care
CO#5/Pt #1, 4/15/18- discharged too soon
CO#6, 5/10/18- Perceived lack of care
CO#7, 5/26/18- Perceived misdiagnosis
CO#8/Pt #5, 6/24/18- discharged too soon
CO#9, 7/16/18- Perceived lack of care
CO#10, 7/27/18- Perceived lack of care

3. The Grievance log dated February 2018 through August 2018 was reviewed on 8/7/18 at approximately 11:30 AM. The Grievance log lacked documentation the following complaints were reviewed, investigated, or followed the Grievance resolution process per policy: CO#1, CO#2, CO#3, CO#4, CO#5, CO#6, CO#7, CO#8, CO#9, and CO#10.

4. The Grievance Committee Meeting Minutes dated February 2018, March 2018, and June 2018 were reviewed on 8/8/18 at approximately 11:00 AM. The meeting minutes lacked documentation the complaint log was reviewed to ensure patient complaints were accurately identified as grievances and followed the grievance resolution process.

5. The Quality Assurance and Performance Improvement Meeting Minutes dated April 2018 and July 2018 were reviewed on 8/8/18 at approximately 11:00 AM. The meeting minutes noted the Grievance Committee Meeting Minutes were reviewed; although the meeting minutes lacked documentation that the Complaint and/or Grievance logs were reviewed to ensure that complaints of quality of care or premature discharge were appropriately resolved per policy.

6. During an interview on 8/8/18 at approximately 11:30 AM, Vice President/Chief Nursing Officer (E#2) and Director of the Medical Unit (E#3) stated all complaints were reviewed by 1 of the 2 Patient Representatives who determine if the complaints met the definition of a grievance. E#2 verbally agreed there was no oversight by the Grievance Committee or the Quality Assurance and Performance Improvement Committee to ensure complaints of quality of care or premature discharge were resolved per the Grievance policy.