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ADVENTIST GLENOAKS 701 WINTHROP AVENUE GLENDALE HEIGHTS, IL 60139 Oct. 18, 2019
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 2 (Pt #1) patient grievances, the Hospital failed to ensure that prompt filing of a patient grievance was followed.

Findings include:

1. The Hospital's policy titled, "Safety Event Analysis and Reporting Policy" (revised 7/9/19) was reviewed and included, "Patient Safety Events will be gathered, investigated and evaluated under a comprehensive review process ...PROCEDURE: Required Action Step 1. Notify care provider and immediate supervisor ..."

2. The clinical record of Pt #1 was reviewed on 10/17/19. Pt #1 was admitted on [DATE] with Sepsis (life threatening complication of an infection). A Physician's Progress Note dated 9/19/19 at 10:23 AM, included, "Physical Exam-General: thin frail male, unable to arouse, receiving nebulizer (medication in form of mist used to help treat respiratory diseases) treatment. Skin: warm, dry, no rashes. Skin breakdown to frontal forehead and nasal bridge due to BiPap (Bilevel Positive Airway Pressure-a breathing device used to treat sleep apnea, or lung diseases).

3. On 10/17/19 at approximately 12:50 PM, an interview was conducted with a Registered Nurse (RN-E #1). E #1 stated, "I did take care of this patient (Pt #1) on the day of discharge. I recall that Pt #1 was going to a Skilled Nursing Facility by ambulance. I got a call back later that night by the Nursing Home Nurse saying that Pt #1 was in worse condition than when Pt #1 left. The Nurse said that Pt #1's knee was dislocated and was sent to nursing home with paper towels in the rectum. I recall that Pt #1 had a scab on the bridge of nose, but I do not know when Pt #1 got it. It was skin breakdown because he had a BiPap mask on his face. Pt #1 was very rigid, and his knees were contracted, I did not notice any deformities or injury to knees or lower extremities when I did my assessment. I explained this to the Nursing Home Nurse over the phone and that was it, I did not report this to anyone. I do not have a reason why I did not report it but I should have. Our policy is to report any incident to our supervisor as soon as we become aware."

4. On 10/17/19 at approximately 1:00 PM, an interview was conducted with the Director of Medical Surgical Units (E #2). E #2 stated, "I was not informed of this incident by E #1, I received an email on 9/20/19 from our CNO (Chief Nursing Officer) about this incident that occurred on 9/19/19. The Ambulance Supervisor called to file the report, E #1 should have reported it when he became aware..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, it was determined that for 1 of 2 (Pt #7) patient grievances, the Hospital failed to ensure that the patient was provided with written notice of the Hospital's investigation and results of the grievance process.

Findings include:

1. The Hospital's policy titled, "Review and Resolution of Grievances" (revised 07/2018) was reviewed on 10/17/19 and required, "Definitions:... "Grievance": A formal or informal written complaint... regarding the patient's care, abuse or neglect... Resolution of Grievances:... Within (7) days of receipt of any grievance, the reporter shall receive a written acknowledgement of receipt of the grievance... For all grievances, a Follow-up to the patient and/or their designated representative will include a written response... the author must provide adequate information to address each item stated below... The written report shall contain the following: i. Name of the contact person who addressed the grievance ii. A summary of the steps taken to investigate the grievance iii. The results of the process iv. The date of completion..."

2. The grievance report regarding Pt #7 was reviewed on 10/17/19 at approximately 1:00 PM. Pt #7 was admitted to the Hospital's Medical Surgical Unit (M1) on 7/19/19 with a diagnosis of syncopal episode (episode of dizziness) when standing up from a sitting position. The grievance regarding Pt #7, dated 7/24/19, included, "[Pt #7] had terrible care. There was a urine in unrinal bottom and no one wuld be emptying and there was nothing to wash his hands... [Pt #7] was not bathed, no water... Asked RN (Registered Nurse) for something to bath [Pt #7] and she tossed wipes at patient. States [Pt #7] got up at night because no one was around... no assistance when [Pt #7] did get a shower. Felt things were not in [Pt #7's] reach. No leader rounded... went to nurses' station and they were on their cell phones. Never walked [Pt #7] once and then wheel chair out to care and never walked..."

- The acknowlegement letter, dated 7/24/19, that was sent to Pt #7, completed and signed by the Director of the Medical Surgical Unit (E #2), was reviewed on 10/17/19 at approximately 1:10 PM and included, "I wanted to acknowledge the concerns you expressed... Your experience will be addressed with the staff involved in your care..."

- The grievance report indicated that E #2 called the reporter of E #7's grievance on 7/24/19 and discussed the concerns addressed in the grievance. The grievance report did not include any documentation of the steps taken to investigate the grievance.

- The grievance report included that the grievance status was changed to "resolved" on 7/25/19.

3. An interview was conducted with E #2 on 10/17/19 at approximately 1:45 PM. E #2 stated that this grievance was investigated. E #2 stated that all of the staff involved in Pt #7's care were interviewed and re-educated on the patient care concerns identified in the grievance. E #2 stated that there was no documentation of these interviews or re-education, and no follow-up letter was sent to Pt #7.

4. An interview was conducted with the Regional Director of Accreditation (E #4) on 10/17/19 at approximately 1:50 PM. E #4 stated that there should be documentation of the investigation of a grievance, and a follow-up letter should be sent to the patient regarding the resolution of the grievance.