HospitalInspections.org

Based on observation, document review and interview it was revealed the facility failed to post required signage for reporting unresolved patient safety concerns or complaints. This failure has the potential to negatively impact any patient or visitor wishing to file a safety concern or complaint.

Findings include:

1. An observation was made on 11/09/21 at 11:30 a.m. throughout the facility. The required signage for reporting unresolved patient safety concerns or complaints was not present anywhere in the hospital.

2. W.Va. Code R. §64-12-4.3.7 states, "4.3.7. A hospital shall post signage in every patient room, patient care area or department, and staff rest area information outlining the process for reporting patient safety concerns via the facility's designated internal reporting mechanism and the process for reporting unresolved patient safety concerns or complaints to the West Virginia Office for Health Facility Licensure and Certification. The posting shall include the address and telephone number for the West Virginia Office for Health Facility Licensure and Certification. Signage color and text shall conform to the Office of Safety and Health Administration regulations for safety instruction signs as provided in standard §1910.145. Nothing in the provision precludes any patient, patient representative, or healthcare provider from making a good faith report pertaining to patient safety concerns and/or alleged wrongdoing or waste to any other appropriate authorities as provided §16-39-3."

3. An interview was conducted with the Chief Regulatory Affairs Officer on 11/09/21 at 12:00 p.m. The Chief Regulatory Affairs Officer explained there were no signs, and she/he was unaware of the requirement.