HospitalInspections.org

Based on record reviews and interviews, the facility failed to provide a Notice of Rights to patients admitted to the facility, for ten (Patient #2, 3, 4, 5 ,6, 7, 8, 9, 10, 11) of ten patients.


The findings included:


Review of the facility's policy titled, "Patient/Family Complaints," dated 01/08, showed that patients will be given a patient bill of rights and a policy statement on patient rights to grievances at the time of admission.

Review of sampled patient (SP)#2 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient ' s medical record did not show that the patient was given a notice of patient rights.

Review of SP#3 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient's medical record did not show that the patient was given a notice of patient rights.


Review of SP#4 medical record showed that the patient was admitted as an inpatient to the facility on 03/05/15. The patient's medical record did not show that the patient was given a notice of patient rights.


Review of SP#5 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient's medical record did not show that the patient was given a notice of patient rights.

Review of SP#6 medical record showed that the patient was admitted as an inpatient to the facility on 03/05/15. The patient's medical record did not show that the patient was given a notice of patient rights.

Review of SP#7 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient's medical record did not show that the patient was given a notice of patient rights.

Review of SP#8 medical record showed that the patient was admitted as an inpatient to the facility on 09/15/14. The patient's medical record did not show that the patient was given a notice of patient rights.

Review of SP#9 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient's medical record did not show that the patient was given a notice of patient rights.

Review of SP#10 medical record showed that the patient was admitted as an inpatient to the facility on 03/08/15. The patient ' s medical record did not show that the patient was given a notice of patient rights.

Review of SP#11 medical record showed that the patient was admitted as an inpatient to the facility on 02/25/15. The patient ' s medical record did not show that the patient was given a notice of patient rights.

On 03/10/14 at 2:30PM, the Risk Manager stated that in the past, patients were given a bill of rights. However, patients are not currently given a copy of the bill of rights. She stated that the facility is in the process of printing pamphlets containing patient rights information to be given to patients at the time of admission.

Based on record reviews and interviews, the facility failed to inform the patient of who to contact to file grievances in one ( sampled patient #1) of eighteen sampled patients.


The findings included:


Review of the facility's policy titled," Patient/Family Complaints," dated 01/08, showed that patients will be given a patient bill of rights and a policy statement on patient rights to grievances at the time of admission.

Review of sampled patient (SP)#9 medical record showed that the patient was admitted as an inpatient to the facility on 03/07/15. The patient's medical record did not show that the patient was given a notice of patient rights. On 03/10/15 at 1:35 PM, SP#9 stated that she had a concern with a staff nurse attitude, yesterday (03/09/15). She stated that she left the hospital yesterday and had to return because she was too ill. SP#9 stated that she complained to the nursing supervisor. She stated that before the incident occurred, she did not receive any information on how to file complaints. She stated that she knew who to complain to because she worked in a hospital.

On 03/10/14 at 2:30 PM, the Risk Manager stated that in the past, patients were given a bill of rights. However, patients are not currently given a copy of the bill of rights. She stated that the facility is in the process of printing pamphlets containing patient rights information to be given to patients at the time of admission.

Based on interview and record review, the facility failed to completed background screenings per the policy for 8 sampled employees(A, B, E, F, G, I, J, K); and abuse/sexual misconduct training for 4 sampled employees (A, E, G, O) .


The findings :


Review of the policy with the subject; "Background Screening" dated 12/14, state at 1.a all applicants are screened upon completion of application

Review from a report showed that on 09/16/14, the nursing supervisor approached the Risk Manager regarding a call from SP#1. The report stated that SP#1 stated that while he was a patient in the emergency room (ER) on 09/15/14, he was inappropriately touched by a male member of the ER staff by the name of [Staff A name]. The report showed that SP#1 was called by the Risk Manager and the allegations were confirmed with the patient. On 03/09/15 at 10:14 AM, the Risk Manager stated that there was one incident of sexual misconduct regarding SP#1.


Review of the Staff A, ER tech, personnel file showed that the staff was hired at the facility in 2002. There was no background screen done for Staff A. Review of the Staff A education record showed that the last abuse/sexual misconduct training was completed 02/10.


Review of the Staff B, Registered Nurse (RN), personnel file showed that the staff was hired at the facility in 2012. There was no background screen done for Staff B.

Review of the Staff D, RN, personnel file showed that the staff was hired at the facility in 2011. Review of Staff D education record showed that the last abuse/sexual misconduct training was completed 02/10.


Review of the Staff E, RN, personnel file showed that the staff was hired at the facility in 2005. There was no background screen done for Staff E.

Review of the Staff F, RN, personnel file showed that the staff was hired at the facility in 2004. There was no background screen done for Staff F. .

Review of the Staff G, RN, personnel file showed that the staff was hired at the facility in 2011. There was no background screen done for Staff G.Review of Staff G education record showed that the last abuse/sexual misconduct training was completed in 2013.


Review of the Staff I, ER Tech, personnel file showed that the staff was hired at the facility in 2004. There was no background screen done for Staff I.

Review of the Staff J, RN, personnel file showed that the staff was hired at the facility in 2001. There was no background screen done for Staff J.

Review of the Staff K, Certified Nursing Assistant (CNA), personnel file showed that the staff was hired at the facility in 2005. There was no background screen done for Staff K.


Review of the Staff O, ER tech, personnel file showed that the staff was hired at the facility in 2011. Review of Staff O education record showed that the last abuse/sexual misconduct training was completed 10/11.

On 03/10/15 at 9:39AM, the Human Resources Manager stated that as of 07/01/14, background screens were completed for all newly hired employees. She stated that background screens were not completed for some employees who were hired greater than ten years ago.

On 03/10/15 at 9:39AM, the Human Resources Manager stated that sexual abuse training is completed at general orientation for all new hires. She stated that after general orientation, sexual abuse courses are completed annually by all employees.