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.

ELMHURST MEMORIAL HOSPITAL 155 EAST BRUSH HILL ROAD ELMHURST, IL 60126 March 13, 2020
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 clinical records reviewed for grievances, the Hospital failed to implement the grievance process as required.

Findings include:

1. The Hospital's policy titled, "Complaints and Grievances" (revised 10/2018), included, "Grievance: A concern communicated by the patient...2. It refers to alleged abuse or neglect, or violation of patient's rights...Grievance Process...6. Grievances that endanger the patient such as neglect or abuse...are reported to Risk Management for immediate investigation...10. Patient Experience Manager provides a written response to the patient or patient representative within 7 days..."

2. The clinical record for Pt #1 was reviewed on 3/11/2020, and indicated that Pt #1 was admitted on [DATE] through 6/7/2019, with an admission diagnosis of pain in left shoulder.

3. The Hospital's Complaint and Grievance Log dated 5/29/19 - 1/31/2020, was reviewed on 3/11/2020. Pt #1 was listed and handled as a complaint.

-The "Complaint Follow-Up" documentation dated 7/10/19, from the Manager of Patient Experience (E #3) was reviewed on 3/10/2020, and included, "Issue ...stated that his (Pt #1) Civil Rights were violated by the security staff ...he was physically assaulted in his bed ...E #3 called patient (Pt #1) and talked about his experiences here in the hospital. He stated that our public safety officers assaulted him and took his possessions form him ...E #3 spoke to the Director of Patient Care (E #14) and E #3 was informed that the patient's complaints were unfounded ..."

4. An interview was conducted with the Manager of Patient Experiences (E #3) on 3/11/2020 at approximately 9:45 AM. E #3 stated that she became aware of this situation sometime around July 2019 when the patient (Pt #1) called their complaint hot-line, and the Complaint process was followed. I spoke with this patient (Pt #1) on 7/10/2019 by phone, regarding his experience at the hospital and his perception. Based on what he (Pt #1) told me, I spoke with the CNO (E #13) and Director of Patient Care (E #14) and was told that they had extensive conversations with this patient about this situation and since the local Police Department was involved and Public Safety department was also involved and did their own investigation and interviews, the patient's complaints were unfounded and E #3 continued to treat as a complaint and did not feel that further investigation was required.

5. An interview was conducted with the Chief Nursing Officer (E #13) on 3/12/2020 at approximately 7:40 AM. E #13 stated, "This case was treated as a complaint, so the Manager of Patient Experience followed the Complaint process. We felt that since the patient (Pt #1) had several encounters with our Public Safety Department and the Local Police department and based on their reports it was treated as a complaint and not a grievance."