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.
|ADVOCATE ILLINOIS MASONIC MEDICAL CENTER||836 WEST WELLINGTON AVENUE CHICAGO, IL 60657||Nov. 12, 2020|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed for the allegation of abuse. The Hospital failed to ensure the allegation of abuse was reported and investigated to ensure the patient was free from all forms of abuse as required.
1. The Hospital's policy titled, "Resolving Patient/Family Complaints and Grievances (revised 11/4/20) was reviewed and required, "...B. Grievance-a grievance includes any of the following... 2. All verbal complaints regarding the following: a) allegations of abuse or neglect... D. Management of Grievances...b) All grievances will be documented, and an appropriate and timely investigation conducted..."
2. The Hospital's policy titled, "Detection and Reporting of Patient Abuse" (revised 5/15/14) was reviewed and required, "A. Any...site administrator, agent, associate, or medical staff member who has reasonable cause to believe that any patient whom he or she has direct contact has been subject to abuse in the hospital shall promptly report and/or cause a report to be made to Risk Management... B. Risk Management will notify the...site designated Regulatory position and Compliance position as needed, who shall submit the formal report to the (IDPH - Illinois Department of Public Health) Department within 24 hours of obtaining such report...Risk Management Department shall promptly initiate an internal review to ensure the alleged victim's safety..."
3. On 11/10/20, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on [DATE] for a scheduled (2/24/20) tibial talocalcaneal (connection between the talus and the calcaneous) fusion to left lower extremity."
4. On 11/10/20, at approximately 12:10 PM, a telephone interview was conducted with Surgeon (MD #1). MD #1 stated, "I see this patient (Pt. #1) regularly in my office. I do not recall the exact date, but several weeks after his (Pt. #1's) surgery (2/24/20), (Pt. #1) was not very clear but stated that he thought he was probed inappropriately-like having something inserted in his rectum while in the PACU. The patient stated that he did not report this to anyone while in the hospital but had since has filed a report and also filed a police report. I am not sure who he reported this incident to ... (MD #1) stated that in hindsight, (MD #1) should have reported his concern to Risk Management ..."
5. On 11/10/20, at approximately 2:40 PM, an interview was conducted with the Director of Quality (E #2). E #2 stated, "All staff including physicians are expected to report any allegations of abuse ... If a physician becomes aware of an allegation, he or she would follow chain of command and report the allegation ... Staff is educated on identifying abuse and the process of reporting of abuse upon hire and yearly. I have looked thoroughly for a report of abuse for this patient (Pt. #1) and I cannot find any documentation, the physician should have reported this incident."