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HARTGROVE HOSPITAL 5730 W ROOSEVELT ROAD CHICAGO, IL 60644 March 12, 2020
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for 1 of 5 (Pt #1), clinical records reviewed for grievances, the Hospital failed to implement the grievance process for timely referral of patient concerns.

Findings include:

1. The Hospital's policy titled, "Patient Grievance" (revision date 6/25/19), was reviewed on 3/11/2020, and required, "...A patient grievance would also include situations where patients or the patient's representatives call or write to the hospital about concerns...7. The Patient Advocate reviews the grievance, notifies the appropriate Director/Manager of the grievance, and works with the Director/Manager during the investigation process."

2. The clinical record for Pt #1 was reviewed on 3/11/2020. Pt #1's Admission Orders (dated 1/13/2020), indicated that the patient was admitted on [DATE], on the Adult Behavioral Unit, with an admission diagnosis of Unspecified Mood Disorder.

3. On 3/11/2020, the Investigatory Report from the investigation conducted by E #3 regarding Pt. #1 was reviewed. The Investigatory Report included, "Date/Time Retrieved: 3/5/2020 at 1300 [1:00 PM]. Investigation Summary: Mother ...spoke to unit and reported that her son [Pt #1] stated that he was molested in the hospital by another pt. Mother/Patient was unable to provide any information of when this could had taken place. Actions taken: Review the clinical notes and clinical record. Investigation pending..." The Investigation Report lacked documentation indicating that the Patient Advocate was notified of the abuse allegation in order to initiate a formal investigation.

4. On 3/12/2020, the Patient Advocate job description (revised by the Hospital 10/10/07) was reviewed. The job description included, "Position Summary - The Patient Advocate investigates, resolves, documents and reports organization-specific patient and visitor complaints and concerns to leadership and staff."

5. On 3/11/2020 at 1:55 PM, an interview was conducted with the Patient Advocate (E #8). E # 8 stated, "As the Patient Advocate, we retrieve voicemails for complaints and grievances voiced by patients or guardians. We will then get statements from patients, interview roommates, talk to management and then pass this information on to the Risk Management Department. In regards to [Pt #1], Nursing didn't log the patient for an Advocate call. The alleged incident for Pt #1 is not in our Midas [incident reporting] system. None of the three patient advocates obtained the call regarding Pt #1."

6. On 3/11/2020 at 2:45 PM, an interview was conducted with the Risk Manager (E #3). E #3 stated that a call was received from Pt #1's mother on 3/5/2020, with the allegation of someone touching her son (Pt #1). E# 3 stated that as of today, the incident report has not been initiated in the incident reporting system and the Patient Advocates have not been notified of this allegation.

7. On 3/12/2020 at 11:30 AM, an interview was conducted with the Director of Performance Improvement/Risk Management (E #4). E #4 stated that there should have been notification to the Patient Advocate of Pt#1's allegation, so that the Hospital could have moved forward with the investigation.

8. On 3/12/2020 at 3:45 PM, another interview was conducted with E #4. E #4 stated that the Patient Advocate has been notified of the complaint concerning Pt. #1 and they will contact the complainant within 24 hours. E #4 stated that the Patient Advocate will send an official letter with the investigation findings to the complainant within 7 days.

B. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed for incident reporting that Hospital failed to ensure that the process for prompt resolution of patient grievances was implemented by completing an incident report for an abuse allegation.

Findings include:

1. On 3/11/2020, the Hospital's policy titled, "Healthcare Peer Review (HPR) Incident Occurrence Reporting System" (reviewed by the Hospital 12/2019) was reviewed. The policy required, "Procedure: A. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete of direct the completion of a Healthcare Peer Review (HPR) form [incident reporting system]...C. Completing the HPR: a. The HPR is to be completed at the time of the event."

2. The clinical record for Pt #1 was reviewed on 3/11/2020. Pt #1's Admission Orders (dated 1/13/2020), indicated that the patient was admitted on [DATE], on the Adult Behavioral Unit, with an admission diagnosis of Unspecified Mood Disorder.

3. On 3/11/2020, the Investigatory Report from the investigation conducted by E #3 regarding Pt. #1 was reviewed. The Investigatory Report included, "Date/Time Retrieved: 3/5/2020 at 1300 [1:00 PM]. Investigation Summary: Mother ...spoke to unit and reported that her son [Pt #1] stated that he was molested in the hospital by another pt. Mother/Patient was unable to provide any information of when this could had taken place. Actions taken: Review the clinical notes and clinical record. Investigation pending..." The Investigation Report lacked documentation indicating that the allegation was documented in the incident reporting system.

4. On 3/11/2020 at 10:50 AM, an interview was conducted with the Risk Manager (E #3). E# 3 stated, "After a grievance or complaint is received...An incident report should be placed in the Midas. I received a call from a mother of an Adult Psychiatric patient [Pt #1] that was admitted here. The patient [Pt #1] told the mother that someone touched him. We didn't know anything about the incident until we got the call from the mother [on 3/5/20]. There is no incident report in the Midas system [incident reporting] for this allegation [Pt #1's allegation] at this time. I did not document the conversation that I had with the mother."

5. On 3/11/2020 at 1:55 PM, an interview was conducted with the Patient Advocate (E #8). E # 8 stated, "As the Patient Advocate, we retrieve voicemails for complaints and grievances voiced by patients or guardians...In regards to [Pt #1], Nursing didn't log the patient for an Advocate call. The alleged incident for Pt #1 is not in our Midas system..."

6. On 3/11/2020 at 2:45 PM, an interview was conducted with the Risk Manager (E #3). E #3 stated that a call was received from Pt #1's mother on 3/5/2020, with the allegation of someone touching her son (Pt #1). E# 3 stated that as of today, the incident report has not been initiated in the incident reporting system and the Patient Advocates have not been notified of this allegation.