The Centers for Medicare and Medicaid cited Hickory Hills Hospital’s governing body for ineffective oversight of the facility and found that the hospital failed to protect and promote patient rights. One patient who was undergoing voluntary treatment of depression signed a “four hour letter” to be released against medical advice. Staff noted she “wants to go back to work before she gets fired.” The patient’s records reflected physician orders to initiate an order of protective custody (OPC) to hold her against her will, and then noted a transfer to another hospital. However, the facility had no record of the legal paperwork required for the OPC. One staff member “informed the surveyor that she checked further into the missing OPC paperwork and said none was filed for Patient #5.” A staff member at the hospital to which Patient #5 was transferred “stated that when Patient #5 arrived to Hosptial B, there was no OPC paperwork provided which indicated that an OPC was in progress.” CMS also found the facility failed to investigate six patient grievances, which contributed to the finding that the hospital failed to protect and promote patient rights.