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.
|WEST SUBURBAN MEDICAL CENTER||3 ERIE COURT OAK PARK, IL 60302||Feb. 21, 2020|
|VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES||Tag No: A0122|
|Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) grievances reviewed, the Hospital failed to provide Pt. #1 a response letter, to ensure that the grievance process was followed.
1. On 2/19/2020 at approximately 12:00 PM, the Hospital's policy titled, "Complaints/Grievances" (reviewed by the Hospital on 3/2019) was reviewed and included, "... Definition... Grievance means an oral or written Complaint that is not immediately resolved at the time of the Complaint... A grievance may be made by the patient or the patient's representative regarding, but not limited to... abuse... V. Procedure... C. Patient Grievance... 2. The manager/director will complete the investigation... If the resolution of the grievance is to take longer than seven days, Administration will send an acknowledgement to the patient informing him/her that the Hospital is still working to resolve the grievance and that the the Hospital will follow-up with a written response... No more than seven days shall elapse before a response is sent to the patient... D. Complaint/Grievances Post-Discharge. Patient grievances may also include situations where a patient or patient representative calls or writes to the Hospital expressing concerns related to care... The process of registering these grievances once the patient has been discharge is identical to the inpatient grievance process..."
2. On 2/19/2020 at approximately 12:30 PM, the Hospital's email to E #7 (Director of Risk, Insurance and Claims) from the CEO's (Chief Executive Officer) Secretary dated 2/4/2020 was reviewed and included, "We received a voicemail message from (Detective from Oak Park Police Department Officer) yesterday afternoon. He's following up on a complaint they received from a woman claiming she was mistreated while she was a patient here in July, 2019..."
3. On 2/19/2020 at approximately 12:45 PM, the Complaint/Grievance log from 6/2019-2/2020 was reviewed. The log did not include a grievance related to Pt. #1's allegation of sexual assault by a hospital's staff.
4. On 2/19/2020 at approximately 12:30 PM, an interview was conducted with E #7. E #7 stated that the Hospital knew of Pt. #1's allegation of sexual assault on 2/4/2020. However, E #7 stated that a letter in response to the Pt. #1's grievance has not been sent. E #7 stated that a response letter should have been sent to Pt. #1 within 10 days from the date the grievance was received by the Hospital.
|VIOLATION: PATIENT RIGHTS: INFORMED CONSENT||Tag No: A0131|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #5) clinical records reviewed in 4 North (Telemetry/Medical Surgical Unit), the Hospital failed to obtain a consent for Hospital treatment, to ensure Pt. #5 was accorded the opportunity, to make an informed decision regarding her treatment.
1. On 2/18/2020 at approximately 11:00 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was admitted on [DATE] with a diagnosis of nausea and vomiting. Pt #5's clinical record lacked the consent for Hospital treatment.
2. On 2/19/2020 at approximately 10:00 AM, the Hospital's policy and procedure titled, "Informed Consent" (revised 5/16) was reviewed and included, "This policy describes the process for providing documented evidence of intent and informed consent signed by the patient... for treatment... Any health care relationship, treatment or refusal... to the patient requires documented evidence of an informed consent form executed by the patient..."
3. On 2/19/2020 at approximately 10:15 AM, a blank copy of the Hospitals consent for Hospital treatment document titled, "Conditions of Treatment Agreement" (undated) was reviewed and included, "...This is to certify that I, the patient... have read the above agreement... understand its contents, and accept its terms..."
4. On 2/18/2020 at approximately 11:00 AM, the findings were discussed with E #2 (Director of Progressive Care Unit, ICU and Medical Surgical Unit). E #2 stated that Pt. #5's clinical record did not include a consent for Hospital treatment. E #2 stated, "It should have been completed by Registration and placed in the patient's chart."
5. On 2/21/2020 at approximately 9:00 AM, E #8 (Director of Quality Management) stated that Pt. #5's consent for Hospital treatment could not be found.