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Based on policy review, staff interview, observations and medical record review, the facility failed to ensure Medicare patients or patients' representatives were provided the "Important Message from Medicare" on admission and failed to ensure Medicare patients were provided the message prior to discharge (A0117). The facility failed to ensure outpatients or outpatients' representatives were provided with the address for lodging a grievance with the State agency (A0118). The facility failed to ensure informed consent was witnessed when telephone consent was obtained for a blood transfusion (A0131). The cumulative effect of these systemic practices resulted in the facility's failure to promote patient rights.

Based on medical record review and staff interview, the facility failed to ensure one of one Medicare patients (Patient #5) or his/her representative was provided the "Important Message from Medicare" on admission and failed to ensure one of one Medicare patients (Patient #1) was provided the message prior to discharge. A total of 10 medical records were reviewed and the census was 381.

Findings include:

1) The medical record for Patient #5 was reviewed on 01/27/14. Patient #5 was admitted to the hospital on 01/20/14 with a diagnosis of unwitnessed fall. An admission note dated 01/20/14 revealed the hospital was aware Patient #5's daughter was the patients Power of Attorney (POA). Patient #5's POA was not provided the "Important Message from Medicare" until 01/27/14, after requested during survey.

Staff C was made aware of and confirmed the above finding on 01/28/14 at 9:07 AM.


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2.) The medical record review for Patient #1 was completed on 1/30/14. The review revealed the patient was admitted to the facility from 2/7/13 through 2/25/13. The record did not contain evidence the patient was presented the "Important Message from Medicare" prior to the patient's discharge.

On 1/30/14 at 3:30 PM, Staff A reported the facility was unable to provide evidence the patient was presented with the "Important Message from Medicare" prior to the patient's discharge.

Based on observations, review of the facility's Patient Bill of Rights and Responsibilities form and staff interviews, the facility failed to inform all emergency department (ED) patients and/or their representative of the contact information, specifically the address, for lodging a complaint with the State agency. This affected all ED patients who were not directly admitted to the hospital. The ED average daily census was 300.

Findings include:

1) Tour of the ED on 01/27/14 beginning at 10:51 AM with Staff C and Staff F include the ED lobby, waiting area, triage, registration, and patient rooms. All areas lacked evidence of the address for lodging a grievance with the Ohio Department of Health.

2) Review of the Patient Bill of Rights and Responsibilities contained within the hospital's "consent for medical treatment form" also lacked evidence of the contact address for the Ohio Department of Health to lodge a grievance.

3) Staff B, Director of Nursing Services for the ED, was interviewed on 01/27/14 at 11:00 AM and confirmed the "consent for general treatment" was the only form ED patients received regarding their rights.

4) Staff C was made aware of the above findings during an interview on 01/27/14 at 2:37 PM. Staff C stated the address for the Ohio Department of Health should be in the patient admission folder. Staff C was asked if all patients receive this folder and confirmed that only those patients admitted to the hospital receive the folder of information. Those patients discharged after being seen in the ED would not receive said folder.

Based on medical record review, staff interviews and review of policy, the facility failed to obtain informed consent for general treatment for two (Patients #4 and #5) of 10 patient medical records reviewed for general consent and failed to obtain informed consent for blood transfusion for one (Patient #4) of three patient medical records reviewed for blood transfusions. A total of 10 medical records were reviewed. The census at the time of the survey was 381.

Findings include:

1) The medical record for Patient #4 was reviewed on 01/27/14. Patient #4 was admitted to the hospital on 01/13/14 with a diagnosis of amphetamine overdose. The hospital failed to obtain the "consent for general medical treatment" until 01/20/14, seven days after admission. The medical record revealed evidence of communication with Patient #4's family members on 01/14/14.

An "informed consent for procedure" form dated 01/14/14 for the transfusion of blood products was reviewed on 01/27/14. The form lacked evidence of a witness signature to the telephone consent obtained by the physician who spoke with Patient #4's father via telephone at 6:30 PM.

Staff G confirmed the above findings during an interview on 01/27/14 at 3:45 PM.


2) The medical record for Patient #5 was reviewed on 01/27/14. Patient #5 was admitted to the hospital on 01/20/14 with a diagnosis of unwitnessed fall. The record lacked evidence as of 1/27/14 of a "consent for general medical treatment". An admission note dated 01/20/14 revealed the hospital was aware Patient #5's daughter was the Power of Attorney (POA). Upon request, Staff A provided a "consent for general medical treatment" signed by Patient #5's POA and dated 01/27/14.

Staff C was made aware of and confirmed the above findings regarding Patient #5 during an interview on 01/28/14 at 9:07 AM.


3) Facility policy Consent for Medical Treatment (I-34) was reviewed on 01/27/14 at 4:23 PM. Per said policy, consent should be "obtained from every patient/legal representative upon their first encounter and then annually or at their next encounter, whichever is later." The policy continued "a valid/current consent for medical treatment is necessary whenever a patient is seen by a MHS provider, regardless of the service the patient receives."

The policy further stated "in some cases, spouses or next of kin may give consent for treatment of an adult" who is competent but non-cognitive or is under the influence of alcohol or drugs, as in the case of Patients' #4 and #5. Treatment of said adult "may commence upon consent of the nearest adult relative who can be located in the following order:" adult son or daughter, either parent, adult brother or sister, any other relative.