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Based on review of facility postings and admission packet, observation and staff interview, the facility failed to ensure patients were informed of their right to contact the state agency to file a complaint or grievance. This had the potential to affect all patients admitted to the facility. The facility's active census was 159.

Findings include:

Patient rights information was observed posted on signs in the hallway in multiple area of the facility during the survey. The signs posted included the state complaint hotline number, but not the address. On 03/05/13 at 8:00 AM, Staff A acknowledged the signs posted in the facility would not be accessible to immobile patients.

A review of the Patient Rights and Responsibilities packet given to patients on admission by registration was reviewed on 03/05/14. The form states if your concerns cannot be resolved at the hospital level the patient can contact the state complaint line.

The Patient Guide was observed at the bedside of the patient in room 610 B on 03/04/14 at 4:00 PM. The Patient Guide included the patients' Rights and Responsibilities and indicated the patient had a right to lodge a concern with the state, but included the State Quality Improvement Organization address and phone number. The state complaint hotline number and address was not included in this guide. On 03/05/14 at 10:15 AM, Staff A confirmed the state complaint hotline number was not in the Patient Guide.

Based on policy review and interview, the facility failed to report allegations of abuse according to the facility's policy for one discharged patient of 10 medical records reviewed. (Patient #4) This had the potential to affect all of the facility's patients. The facility's active census at the time of the survey was 159 patients.

Findings include:

Staff D, nurse manager, was interviewed on 03/03/14 at 3:54 PM, regarding Patient #4's hospital stay from 01/15/14 until discharge on 01/17/14. Staff D reported speaking with Patient #4 on 01/15/14 upon admission. Staff D stated in this interview that Patient #4 alleged spousal abuse.

Staff D stated the allegation of spousal abuse was not reported to authorities due to Staff D's disbelief of Patient #4. Staff D stated Patient #4's behavior was totally erratic and two code violets were called during the hospital stay in regard to Patient #4's aggressive behavior.

Interview by phone with Patient #4's physician, Staff B, on 03/04/14 at 10:08 AM revealed the patient had a psychiatric history and was going to a counseling center. The physician did recommend a psychiatric consult but the patient refused.

Review of the Patient History Form last updated on 01/15/14 at 7:00 PM by Staff Nurse O revealed Patient #4's social history revealed the patient denied injury/abuse/neglect in household and noted the patient denied feeling unsafe at home.

On 03/03/14 at 4:00 PM, the facility's Child/Adult/Elder Abuse, Neglect or Exploitation policy was reviewed. The policy stated "Any person having reasonable cause to believe that an individual is being abused, neglected or exploited is required to report to the appropriate agency in compliance with Ohio State Laws". The policy stated the Ohio Revised Code requires that health care providers who suspect or identify that a person is abused must document or write that assessment in the medical record.