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 Aug. 5, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and interview, it was determined for 1 (Pt #1) of 2 grievances reviewed, the hospital failed to ensure the grievance was investigated within the 5 day timeframe per policy.

Findings include:

1. The hospital 's policy entitled "Complaints/Complements-PRIDE Program" (revised 01/2015) was reviewed on 8/4/15 at approximately 1:00 PM and required, "Definitions: ...A grievance constitutes a more significant and complex issue that requires investigation...Patient complaints that are considered grievances also include situations ...with a complaint regarding the patient ' s care or with an allegation of abuse."

2. The complaint from Pt. #1 was reviewed on 8/4/15 at approximately 10:00 AM. The hospital's Clinical Resource Nurse (E #3) received a complaint from Pt #1 on 6/7/15 that included, " ...had some complaints about her stay in PCU ... she felt very "disrespected". The hospital's response and follow up to this complaint was initiated on 6/22/15 (15 days after receipt of complaint).

3. On 8/4/15 at approximately 1:15 PM, an interview was conducted with E #3. E #3 stated she had received an email from E #4 on Monday, 6/8/15 regarding the complaint from Pt #1. E #3 stated that she spoke with E #1 and E #2 about the complaint. E #3 stated Pt #1 had been discharged before E #3 had a chance to talk with her about the complaint. When asked for documentation of any investigation or dates of E #3's communication with E #1 and E #2 prior to 6/22/15, E #3 could not provide dates or produce this documentation.

4. On 8/5/15 at approximately 1:40 PM, an interview was conducted with the Director of Surgical Services (E #7). E #7 stated that this complaint was considered a grievance by the hospital per policy. E #7 stated that E #4 began the investigation when she spoke with E #1 on 6/7/15, but E #3 should have documented her investigation within 5 days of receipt of the complaint.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, for 1 (Pt #1) of 2 grievances reviewed, the hospital failed to send a response to the grievance which communicated the investigation and the outcome of the grievance.
Findings include:

1. The hospital ' s policy entitled " Complaints/Complements-PRIDE Program " (revised 01/2015) was reviewed on 8/4/15 at approximately 1:00 pm and required, " ...A letter detailing the steps taken to investigate the grievance, the results of the grievance process, and the date of completion will be sent within 60 days of receipt of the complaint/grievance ... "

2. The grievance regarding Pt #1 was reviewed on 8/4/15 at approximately 10:30 am and included the grievance was received by the hospital on [DATE].

3. The hospital's response and follow up to the grievance was reviewed on 8/4/15 at approximately 10:30 am. A response letter dated 7/10/15 was sent to Pt #1 from the hospital in regards to her grievance. The letter did not include the outcome or that the complaint was still under investigation. The letter also lacked communication of the steps taken to investigate the complaint.

4. On 8/5/15 at approximately 1:40 pm, an interview was conducted with the Director of Surgical Services (E #7). E #7 stated that this grievance was still under investigation, and Pt #1 should have been informed that the hospital was investigating this grievance.