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Based on review of the patient admission/registration packet, four patient interviews, and staff interview the hospital failed to ensure each patient was informed of whom to contact in order to file a grievance.The hospital census at the time of the survey was 45 patients.

Findings Included:

Review of the patient admission/registration packet was completed on 01/14/13 at 11:00 AM and lacked documentation that the patients received, as a part of their patient rights, the State of Ohio's phone number and address for lodging a grievance. Review of the patient admission/registration packet also lacked documentation that the patients received, as a part of their patient rights, information that they may lodge a grievance with the State of Ohio directly, regardless of whether they first used the hospital's grievance process.
An interview was completed with Patient #8 on 01/14/13 at 11:30 AM in the intensive care unit. Patient #8 and his/her family were present and stated that although they did receive a folder from the hospital on admission, they were not aware that the state had a hotline number or an address for filing complaints.

An interview was completed with Patient #5 on 01/14/13 at 1:35 PM in the acute care unit. Patient #5 stated that he/she was not aware that the state had a hotline number or an address for filing complaints.

An interview was completed with Patient #3 on 01/14/13 at 1:45 PM in the acute care unit. Patient #3 stated that he/she was not aware that the state had a hotline number or an address for filing complaints.

An interview was completed with Patient #6 on 01/14/13 at 1:50 PM in the acute care unit. Patient #6 stated that he/she was not aware that the state had a hotline number or an address for filing complaints.

This finding was confirmed with Staff A and Staff C on 01/15/13 at 9:00 AM. Staff A and Staff C stated the healthcare facility complaint hotline number was displayed on a sign at the points of patient entry into the hospital (labor and delivery, patient registration and patient registration in the emergency department), however, patients transported by emergency squad are not able to see these signs.

Based on medical record review, staff interview, and policy review; the facility failed to ensure consent was obtained for all patients. This affected two of four discharged medical records reviewed (Patients 2 and 9).

Findings included:

The closed medical record for Patient 2 was reviewed on 01/14/13. The patient came into the emergency room and was placed in observation status on 12/21/12. On 12/24/12, the patient was admitted to the facility as an inpatient. The patient was discharged to a nursing facility on 12/26/12. The medical record noted the patient was unable to sign consents and that consent would be obtained when family came to the facility. The medical record contained a copy of the patient's durable power of attorney, but lacked documentation the power of attorney was contacted to obtain either verbal or written consent. The medical record lacked documentation of any consent for treatment as of 01/14/13. This was verified on 01/14/13 at 4:20 PM by Staff A.

The Obtaining Consent for Treatment and Acknowledgement of Notice of Privacy Practices policy was reviewed on 01/15/13. The policy stated that if a patient was admitted and/or treated without proper consent that the facility was responsible for following up and obtaining proper consent prior to the patient's discharge. If the legally authorized representative was not present, then every effort must be made to obtain written or verbal consent prior to treatment.


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The closed medical record review for Patient 9 was completed 01/15/13 at 1:15 PM. Patient 9 was admitted to the hospital on 12/09/12 fever, shortness of breath, and pneumonia. The patient was diagnosed with AML (acute myeloid leukemia, a cancer in the bone marrow) on 12/11/12 and expired on 12/16/12. The medical record lacked documentation that the patient and/or the patient's representative consented to treatment. The medical record also lacked documentation that the patient and/or the patient's representative were made aware of his/her Medicare rights. This finding was confirmed with Staff A on 01/15/13 at 1:20 PM.