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Based on tour of unit, review of medical records and patient interviews, it was determined that the facility was not effectively notifying all patient/patient's representative of patient's rights as required.

Findings include:

During the unit tour of 7N on 2/14/12 at approximately 11:50 AM, the patient in room 722A was interviewed about Patient's Rights. The patient reported that she was not given a patient rights package.

The patient's medical record MR # 1, was reviewed on 2/14/12 at approximately 10:30AM. It noted that a form titled "Admission Consent, Patient Rights Package and Release against Medical Advice" was located in the record. It was noted that the patient initialed next to the to patient's signature for Consent as well as a second initial for acknowledgement receipt of the booklet, Your Rights as a Hospital Patient. This was discussed with the patient. The patient reported that she thought she was signing for consent as this was not explained to her.

The patient's roommate - RM 722B was interviewed. This patient was spanish speaking and she was interviewed using an interpreter. This patient also reported that she was not given a patient's rights package. This patient's medical record MR # 2 was also reviewed. There was no documentation that this patient was provided with any Patient's Rights information. The acknowledgment form indicating that the patient was informed of her rights was not located in her medical record.

During the tour of the facility's Emergency Department main waiting area on 2/16/12 at
10:00 AM, it was observed that Patient's Rights notices were not posted. This was also observed while touring the Labor & Delivery waiting room on 2/16/12 at 12:30 PM

? The patient in the Mother and Baby unit, on 2/16/12 at 12:45 PM - R 114A, was interviewed regarding her rights. The patient reported that she was to be discharged today. The patient was asked how did the facility informed her of her rights? This patient reported that she was not given a patient rights package and requested this information from the surveyor.

? The nursing staff that was interviewed reported that patients who come to the facility to deliver their babies are registered in the Labor and Delivery Unit. However, the staff was unable to produce the patient rights package. It was unclear if patients were routinely given Patient's Right packages at admission.


While in unit K2 on 2/16/12 at 12:45 PM a sample of inpatient medical records for Medicare beneficiaries was requested to determine whether the records contained a signed and dated IM provided within 2 days of the admission of the patient.
Review of MR # 3 noted that this 66 year old patient was admitted under voluntary admission on 1/24/12. It was noted that an Important Message from Medicare form (IM) was not signed until 2/7/12. There was no documentation why the requirement of 2 days was not followed.

Review of MR # 4 noted that this Medicare patient was admitted on 1/19/12.
The staff that were interviewed on 2/16/12 reported that the facility has discussed discharge planning with this patient. However there was no documentation that a signed IM form was located in the record.

Based on Community Relations & Intergovernmental Affairs Departmental Staff Meeting for the year 2011, Hospital Wide Quality Assurance Minutes (QAPI) for 2011, and Board of Trustee Minutes for January 2011, May 2011, and June 2011 & September 2011, it was determined that the facility was not reviewing and analyzing patients' grievances.

Findings include:
? The staff interviewed was unable to provide written evidence that the governing body delegated the operation of the grievance process in writing to a grievance committee.
? There was no evidence that grievances were discussed in the Governing Bodies' minutes, the hospital's QAPI or the Community Relations Intergovernmental Affairs Departmental staff minutes submitted for review.
? The Facility submitted QA documents for review. It was noted that these documents were for the years 2010 & 2009 but nothing in the year 2011

Based on interview of the staff, the policy and procedure for grievances/complaints is not being implemented effectively.

Findings include:

Review of the facility's policy and procedure for grievances/complaints on 2/17/12 documents that a patient representative is available to assist patients and their families from 9AM-5PM and at all other times the nursing supervisor on duty will initially address all complaints. The Patient Relations staff will conduct follow up. Patient complaints verbal/written, regarding any department/services of the hospital shall be referred to the Patient Representative for initial investigation. When necessary the complaint is referred to other staff/departments.

Based on interview with the DON on 2/16/12 about 4:10 pm when a complaint is received she would talk with the patient/patient's relative and speak with the involved practitioner, however there is no recorded log of the issue, the practitioner or if a referral was made to Patient Relations.

Based on Patients' Grievance files, staff interview and hospital's policy, it was determine that the facility was not providing written responses to patients /patients' representatives on the outcome of their grievances. This finding was noted in all patients' grievances files reviewed.

Findings include:

Patients' grievances files were reviewed on 2/15/12 at approximately 10:00 AM:
1. In the Grievance file for patient in MR # 5 - Contact/Grievance form dated 1/10/11, the Patient Relations Department received grievance from the patient's brother. The allegations was that the patient went to the facility's ED but she did not receive medical treatment because she did not have insurance. In addition, she had a clinic appointment on 1/7/11 but nothing was done. The facility investigated the allegations. It was noted that the outcome of the investigation was related to the patient and the patient's brother on 1/18/11.
The hospital is required to provide the patient/ patient's representative with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. There was no evidence that this requirement was met.


2. In the grievance file for the patient in MR # 6 - Contact/Grievance form dated 4/27/11, it was noted that the patient's spouse filed several complaints to the facility regarding poor care. It was noted that there was an acknowledgement letter to the patient's spouse regarding receipt of "your complaint dated 4/26/11". It was noted that the investigation was completed on 5/13/11. The written response to the patient's representative was not located in the file.

3. In the grievance file for the patient in MR # 7 - Contact/ Grievance form dated 4/19/11, patient's sister filed a grievance regarding the patient's discharge from the facility on 4/18/11. The case was closed on 5/11/11. It was documented that the family member was satisfied. However, there no evidence that the family received a written response detailing the outcome of the investigation.

4. The grievance file for the patient in MR # 8 noted that on 7/1/11 the Patient Relations Department received a grievance from the patient alleging that on 6/27/11 the staff member smacked his face and put his hands around his neck and chocked him. This file indicated that the allegations were investigated and the employee was disciplined. The case was closed on 7/29/11 satisfied- there was no documentation that the patient received a written response.

5. In the grievance file for the patient in MR # 9 - Contact/ Grievance form dated 9/29/11, security was called to the 6th floor unit regarding an irate son. The patient's son found his mother sitting with her feet in a puddle of urine. The Patient Rep wrote "Son came with me to the office and I wrote up his complaint and provided a meal ticket" . There was no documentation that the grievance was investigated or the written response of the outcome of the investigation was sent to the patient's representative.
Similar findings were found for grievance of patients in MR # 10, MR # 11 where no written responses were provided.

In the grievance file for patient in MR # 12, Contact/ Grievance form dated 3/22/11, this patient's grievance was regarding dental care rendered at this facility. It was noted that the case was referred to the Dental Department for investigation. It was documented in the file the patient was informed of the outcome of the investigation but the patient was not satisfied of the outcome. The cased was closed on 4/5/11. It was noted that the patient was not provided with written response of the outcome of the investigation. It was also noted that the patient was not informed of the right to complaint to the State agency.

The Facility's Patient Grievance/Complaints policy was reviewed. It was noted that policy indicated that upon response, the patient or his/her representative will be provided a written explanation of the complaint within 30 days.

The facility is required to provide written responses to grievances. In addition, on average, a time frame of 7 days for the provision of the response would be considered appropriate.

The Administrator interviewed on 2/15/12 at approximately 2:00PM reported that the facility does not routinely provide written responses to patients /patients' representatives who file grievances.

Based on review of medical record and other documents, it was determined that the facility did not consistently informed all patient regarding his or her care.

Findings include:

Review of MR # 13 noted that this patient, 30 year old female, went to the facility's ED on 3/6/11. The chief complaint was vaginal bleeding and abdominal cramping. The patient was admitted for a Dilation and Suction Curettage. The procedure was performed on 3/7/11. It was documented that instead of a suction curettage, the physician had to perform a sharp curettage. During this procedure, the patient's uterine wall was perforated. There was no documentation that the patient was informed of the complication she developed during this procedure.

The consent to the procedure was reviewed. It was noted that the patient signed consent form on 3/7/11 for Dilation and Suction Curettage and related procedure. It was noted that the related procedure was not documented.

This form indicated that the risks involved and the possibility of the complications were explained to patient. However, the actual complications and possible risks were not documented on the form.



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Based on medical record review, staff interviewed and hospital policy,
it was determined that the information entered in the Informed Consent form was incomplete.

Findings include:

During the process of reviewing medical records on 2/15/12 it was observed that MR # 14 had six different "Informed Consent" Forms documented as being obtained verbally over the telephone. The witness on these documents signed their name (illegible) but did not identify themselves. Hospital policy titled "Consents" states the witness on the consent form must be someone who does not have a vested interest in the procedure and this person is to identify him or herself. Due to the witness not identifying themselves it is unknown if this person has or does not have a vested interest in the procedure. The informed consent process was not followed.

Based on documents reviewed and staff interviews, it was determined that the facility did not ensure that patient's safety requirements were met.

Findings include:

It was noted that the facility's record indicated that on 2/5/11 a mother was able to walk off the pediatric unit with a 15 month infant. It was noted that the facility's Infant/Child Abduction Response was revised on 2/23/11. The record also showed that on 3/9/11 at 0845 a 15 year old patient walked off the unit.

It was noted that although the facility had two encounters with patients that were able to walk off the unit undetected, the facility did not have an infant/child abduction drill until 12/30/11 over eight months later.

Review of Chronological Summary of Events regarding Code Pink on December 30, 2011 noted that the volunteer was able to walk off the Pediatric Unit undetected. After the Infant/Child Abduction Respond Drill on 12/30/11, the facility took corrective action. However, the facility did not test the plan of correction for its effectiveness.

The Director of security was interviewed on 2/15/12 and reported that the Code Pink Drill is done annual. The record indicated that there was a drill in 12/09 and 12/30/11 but there was none done in 12/10.

While on the unit on 2/16/11 at 12:45 PM, the RN that was interviewed reported that the children in the unit have an alarm band and if a patient walked past the red line in front of the nursing station an alarm will sound. This staff reported that the age of the patients in the unit ranged from months- 20 years. This staff also stated that the older patients often do not want the alarm and they are not given one.

The protocol and plan to address this group of patients were not provided

Based on tour and staff interview, it was determined that the facility failed to provide a safe environment where care and treatment are provided.

Findings include:

1. A tour was conducted in the In-patient Psychiatric Unit (2K) on 2/16/12 at approximately 12:00PM. Surveyor was accompanied during tour by the Unit Director.
It was observed that the exterior walls and walls inside the shower in the bathrooms of rooms 254, 252, 253, 250, 248 and 249 were deplorably chipped. The chips were large and hung on the walls. The shower curtains were ripped and hanging from the shower rod. Upon interviewing the staff on the unit the surveyor was informed that complaints and multiple work requests has been provided to the Engineering Department without success.

2. A tour was conducted in the In-patient Pediatric Unit (1N) on 2/16/12 at approximately
2:00PM . Surveyor was accompanied during tour by the Director of Nursing. The unit's
"Playroom" was observed to have many toys of all dimensions. A toddler was present with a staff nurse. The toddler was playing with a car toy (approx. 2 inches) on the floor.
The staff nurse was asked how does the toys get cleaned and sanitized. She answered that she did not know the housekeeping employee does that. There was no evidence of a cleaning log or protocol to clean the different surface area and tiny toys available to children.
A similar issue was found in the Pediatric Emergency Department. The Medical Director of the unit was present. Surveyor observed a sick child with mother in the waiting area playing with hardcover books from a child library bookcase. Medical Director could not answer the surveyor regarding the sanitation of this book case and prevention of infection by the use of these books.

Based on hospital's policy, it was determined that the facility does not have a hospital wide policy and procedure for investigating of allegations of abuse and neglect of all patients.

Findings include:

Review of hospital's policy submitted for review on 2/15/12 noted that the facility has a policy of investigating allegations of abuse and neglect in the Psychiatric Unit. However, it does not address other population.

There is a facility Patient/Visitor Incident Reporting policy. However, this policy is not a written procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations.

The medical staff did not provide patients with care that met the prevailing standards of practice.

Findings include:

Review of MR # 15 on 2/15/12 noted that nursing documentation on 6/6/11 at 7:40pm indicated that "I was informed by the daughter that patient has shortness of breath. 02 sat 88% RA, placed on 02, 02 sat increased to 92-94%. B/P 125/90, HR 109, RR 20 and the physician was informed and reevaluated the patient." Physician's orders noted at 9:00pm for 02 to Ventimask 40%, change IVF to SL flush Q shift, portable chest x-ray and, Atrixtra 7.5 MG SQ, first dose at 9:50PM. There was also a physician's note at 10:00pm regarding the examination/evaluation of the patient. However, both notes are more than 1 hour and two hours respectively for a patient with shortness of breath/respiratory distress. The facility staff failed to assessed in a timely manner a patient with shortness of breath/respiratory distress.