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Based on record reviews, facility policy reviews, and staff interviews the facility failed to protect and promote patient rights. Findings include:

The facility failed to:
-ensure a prompt resolution for patient grievances (See A118.);
-ensure the grievance process specified time frames to review the grievance and the provision of a response (See A122.);
-ensure that a written notice with the required information of the hospital's decision was provided (See A123);
-ensure all patients were able to exercise their patient rights (See A129);
-ensure the patient or representative was invited to participate in her care plan (See A130); and
-ensure the patient or representative was informed of the right to make decisions regarding his or her care (See A131)

Based on record review, and staff and patient interviews, the hospital failed to establish a prompt resolution for patient grievances for 5 (#s 1, 2, 3, 4, and 5) out of 8 grievances reviewed. Findings include:

The Patient Grievance Resolution policy was reviewed on 1/9/13 at 3:00 p.m. "This policy applies to both inpatients and outpatients." A complaint was defined as an issue that staff can not resolve and the issue was raised by the patient or family member. "If the issue raised by the patient or family member can not be resolved at that time and requires some 'follow up' then it is considered a grievance." A grievance is "a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, regarding patient's care... A written complaint is always considered a grievance. For all grievances, a written response must be provided to the patient, family or patient representative."

On 1/9/13 at 3:50 p.m., the Patient Relations Coordinator stated during the interview that not all grievances were sent a letter of resolution within 7 days.

1. Patient #1 sent a letter of complaint to the hospital. The Compliance Concern Form indicated that the letter was received on 11/6/12. Noted on the form was "this is not a HIPPA issue as the sitter is part of our BDH work force." There was no documentation that a written resolution was sent to patient #1.

On 1/7/13 at 1:13 p.m., patient #1 stated in the interview that she never received a letter of resolution.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated that she talked to patient #1 but did not send a letter of resolution. "I did not know I needed to."

2. Patient #2 sent a letter regarding a complaint to the hospital on 10/15/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

3. Patient #3 sent a letter regarding a complaint to the hospital on 1/8/13. Review of the grievance file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

4. Patient #4 sent a letter regarding a complaint on 8/31/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

5. Patient #5 sent a complaint letter to the hospital on 10/11/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent. Further into the interview, the Patient Relations Coordinator stated that the above complaints were not resolved timely according to the hospital policy and procedure.

Based on record review and staff and patient interviews, the hospital failed to provide the required written resolution for patient grievances for 5 (#s 1, 2, 3, 4, and 5) of 8 grievances reviewed. Findings include:


The Patient Grievance Resolution policy was reviewed on 1/9/13 at 3:00 p.m. "This policy applies to both inpatients and outpatients." A complaint was defined as an issue raised by a patient or family member that staff can not resolve. "If the issue raised by the patient or family member can not be resolved at that time and requires some 'follow up' then it is considered a grievance." A grievance is "a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, regarding patient's care... A written complaint is always considered a grievance. For all grievances, a written response must be provided to the patient, family or patient representative."


On 1/9/13 at 3:50 p.m., the Patient Relations Coordinator stated during the interview that not all grievances were sent a letter within 7 days.

1. Patient #1 sent a letter of complaint to the hospital. The Compliance Concern Form indicated the letter was received on 11/6/12. Noted on the form was "this is not a HIPPA issue as the sitter is part of our BDH work force." There was no documentation that a written resolution was sent to patient #1.

On 1/7/13 at 1:13 p.m., patient #1 stated in the interview that she never received a letter of resolution.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated that she talked to patient #1 but did not send a letter of resolution. "I did not know I needed to."

2. Patient #2 sent a letter regarding a complaint to the hospital on 10/15/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

3. Patient #3 sent a letter regarding a complaint to the hospital on 1/8/13. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

4. Patient #4 sent a letter regarding a complaint on 8/31/2012. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution was not sent.

5. Patient #5 sent a complaint letter to the hospital on 10/11/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., the Patient Relations Coordinator stated a letter of resolution were not sent. Further into the interview the Patient Relations Coordinator stated that the above complainants should have received a letter.

Based on record review and staff and patient interviews, the hospital failed to ensure that the notice of the grievance decision included the required result of the grievance process and the date of resolution of the grievance for 5 (#s 1, 2, 3, 4, and 5) of 8 reviewed complaint/grievances. Findings include:

The surveyor began the review of reported grievances on 1/9/13 beginning at 3:00 p.m. During the review, the surveyor noted 8 grievances that were documented in the log as closed. The surveyor requested the completed documentation and communication for review.

The Patient Grievance Resolution policy was reviewed on 1/9/13 at 3:00 p.m. "This policy applies to both inpatients and outpatients." A complaint was defined as an issue raised by the patient or family member that staff can not resolve. "If the issue raised by the patient or family member can not be resolved at that time and requires some 'follow up' then it is considered a grievance." A grievance is "a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, regarding patient's care... A written complaint is always considered a grievance. For all grievances, a written response must be provided to the patient, family or patient representative."

On 1/9/13 at 3:50 p.m., staff member A, the Patient Relations Coordinator, stated during the interview that not all grievances were sent a letter within 7 days.

1. Patient #1 sent a letter of complaint about care received on the surgical floor and patient rights not being honored. The Compliance Concern Form indicated the letter was received on 11/6/12. Noted on the form was "this is not a HIPPA issue as the sitter is part of our BDH work force." There was no documentation that a written resolution was sent to patient #1.

On 1/7/13 at 1:13 p.m., patient #1 stated in the interview that she never received a letter of resolution.

On 1/10/13 at 8:00 a.m., staff member A stated that she talked to patient #1 but did not send a letter of resolution. "I did not know I needed to."

2. Patient #2 sent a letter regarding a complaint regarding care received by a physician on 10/15/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., staff member A stated a letter of resolution was not sent.

3. Patient #3 sent a letter regarding a complaint regarding care concerns regarding the emergency room on 1/8/13. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., staff member A stated a letter of resolution was not sent.

4. Patient #4 sent a letter of complaint regarding care received by a provider in the emergency room on 8/31/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., staff member A stated a letter of resolution was not sent.

5. Patient #5 sent a complaint letter regarding employees' attitudes and care received in the emergency room on 10/11/12. Review of the grievance/complaint file lacked a letter of resolution from the hospital.

On 1/10/13 at 8:00 a.m., staff member A stated letters of resolution were not sent. Further into the interview, staff member A stated that the above complainants should have received a letter.

Based on record review, and policy review, and staff interviews, the hospital failed to promote patients to exercise their rights for 1(#1) of 19 medical records reviewed. Findings include:

Patient #1 was scheduled on 9/21/12 for an outpatient surgery to remove her gallbladder. Review of the closed record was completed on 1/9/13 at 2:00 p.m. The medical record contained a history and physical signed by the physician on 9/21/12. The history and physical did not note any psychiatric concerns other than a history of depression. The note stated, "The patient is oriented to time, place, person, and situation. The patient affect is normal. The patient is not anxious, denies hopelessness, has normal insight, exhibits normal judgment, is not agitated."

On 1/7/13 at 1:13 p.m., patient #1 stated during an interview that the hospital did not acknowledge her rights or let her exercise her rights. Patient #1 stated that she was required to stay one night in the hospital because of sleep apnea, but she ended up staying two nights. Patient #1 stated that she was assigned a sitter for two days because the hospital staff determined she was suicidal when she was in the recovery room. Further into the interview, patient #1 stated that she repeatedly asked to have the sitter removed and stated that she was not suicidal, "but no one would listen to me. I had no rights."

On 1/9/13 at 1:30 p.m., staff member C, the registration clerk, stated that all outpatients come in and sign forms. The patient rights pamphlet is provided to the patient and the consent for treatment form is an acknowledgment of patient rights.

On 1/9/13 at 3:00 p.m., staff member B, the surgical floor supervisor, stated that when patients were placed on a suicide watch, their patient rights were safe-guarded. Once a patient was assigned a sitter, only the mental health professional can remove the sitter, and usually the mental health professional will visit the same day or the next day. Staff member B stated that patient #1 was not invited to participate in her plan of care. Further into the interview, the surveyor was informed that a code H could be used by any patient.

Review of the Patient Rights and Responsibilities Policy noted that patients have the right to know any hospital rules or policies that apply to their conduct while hospitalized. The hospital staff would assist the patient in exercising her rights. Patients have the right to have their care and treatment decisions based on the patient's identified care, treatment, and service needs. Patients have the right to participate in the development and implementation of their care plan.

Based on record review, and policy review, and staff interviews, the hospital staff failed to invite 1(#1) of 19 patients reveiwed to participate in developing the plan of care. Findings include:

On 1/9/13 at 2:00 p.m., a review of the Patient Rights and Responsibilities Policy noted that patients have the right to know any hospital rules or policies that apply to their conduct while being hospitalized. The hospital staff would assist the patient in exercising her rights. Patients have the right to have their care and treatment decisions based on the patient's identified care, treatment, and service needs. Patients have the right to participate in the development and implementation of their care plan.

Review of the closed record was completed on 1/9/13 at 2:00 p.m. Prior to her surgery, on 8/8/12, an office visit assessment under psychiatric, "The patient is oriented to time, place, person, and situation. The patient affect is normal. The patient is not anxious, denies hopelessness, has normal insight, exhibits normal judgment, is not agitated." On 9/21/12 patient #1 had surgery to remove her gallbladder. During the medical record review, the history and physical lacked documentation of psychiatric concerns. The medical record lacked documentation that patient #1 or her daughter were invited to participate in the development of the care plan.

On 1/7/13 at 1:13 p.m., patient #1 stated during an interview that the hospital did not acknowledge her rights or let her exercise her rights regarding her care at the hospital in September 2012. Patient #1 stated that she was required to stay one night in the hospital because of sleep apnea, but she ended up staying two nights. Patient #1 stated that she was assigned a sitter for two days because the hospital staff determined she was suicidal when she was in the recovery room. She repeatedly asked to have the sitter removed because she was not suicidal, "but no one would listen to me. I had no rights." When the surveyor asked if she was invited to participate in her plan of care she stated "No. I would have liked to."

On 1/7/13 at 3:14 p.m., the daughter of patient #1 stated during the interview that she was not invited to participate in her mother's plan of care. The daughter further stated that the hospital staff did not go over any patient rights with her.

On 1/9/13 at 3:00 p.m., staff member B stated she was not sure if patient #1 was invited to participate in her plan of care. The medical chart lacked documentation of patient #1 being invited participation in her care plan.

Based on record review, policy review, and staff interview, the hospital staff failed to inform the patient or patient's representative of the right to make informed decisions regarding health care needs for 1 (#1) of 19 medical records reviewed. Findings include:

On 1/9/13 at 2:00 p.m., a review of the Patient Rights and Responsibilities Policy noted that patients have the right to know any hospital rules or policies that apply to their conduct while being hospitalilzed. The hospital staff would assist the patient in exercising her rights. Patients have the right to have their care and treatment decisions based on the patient's identified care, treatment, and service needs.

Patient #1 was scheduled on 9/21/12 for an outpatient surgery to remove her gallbladder.

On 1/7/13 at 1:13 p.m., patient #1 stated during an interview, that the hospital did not acknowledge her rights or let her exercise her rights while hospitalized. Patient #1 stated that she was assigned a sitter for two days because the hospital staff determined she was suicidal when she was in the recovery room. Further into the interview, patient #1 stated that she repeatedly asked to have the sitter removed and that she was not suicidal, "but no one would listen to me. I had no rights." When the surveyor asked if she was invited to participate in her plan of care she stated "No. I would have like to. I wanted a staff member to listen to me regarding my care needs." Patient #1 stated that she was informed that she would not be discharged until the mental health worker met with her. Patient #1 stated she did not have a say regarding her health care while hospitalized.

On 1/7/13 at 3:14 p.m., the daughter of patient #1 stated during an interview that the hospital staff did not go over any patient rights with her. She was not asked to have any input regarding her mother's care.

On 1/9/13 at 1:00 p.m., staff member B stated that usually the nurse would review the plan of care with a patient and ask if they understood the care being provided, and if there were questions. Staff member B stated she was not aware if patient #1 or the daughter were asked to participate in any decision making because patient #1 was on a suicide watch.

Based on record review, the hospital failed to maintain medical records for patients. Findings include:

During record review, concerns with the medical records were noted. These concerns included the facility not:
-ensuring that all entries in the medical record were timed, dated, and/or signed, (See A450)
-ensuring that all physician orders in the medical record were timed, dated, and/or signed, (See A454)
-ensuring that all consents were timed, dated, and/or signed, (See A466)

Based on record review, policy review, and staff interview the hospital staff failed to ensure medical record entries were completed, dated, timed, and signed for 7 (#s 1, 9, 11, 12, 14, 15, and 18 ) of 18 medical records reviewed. Findings include:

On 1/9/13 at 4:00 p.m., the policy for Medical Record Guideline for Physicians was reviewed and noted on the policy, "all entries must be timed, dated and authenticated."

1. Patient #1's closed out-patient surgical medical record contained the following:
-The anesthesia consult form lacked a time;
-The preoperative case record lacked a time:
-The operative report lacked a signature of the physician;
-The general surgery preoperative orders lacked a date;
-The physician's orders lacked a time on 9/20/12 and 9/21/12; and
-The discharge medication list lacked a date and time for the nurse's and patient's signatures.

2. Patient #9's closed out-patient surgery medical record lacked a time on a physician's order dated 11/2/12.

3. Patient #11's closed out-patient medical record lacked the a time on a physician's order dated 9/23/12.

4. Patient #12's closed out-patient medical record lacked the following:
- A physician signature on the operative report;
-The date and time was missing by the physician on the general surgery preoperative orders; and
- The time was missing from physician orders dated 12/21/12 and 12/27/12.

5. Patient #15's open out-patient surgery medical record on 1/10/13 lacked the following:
-The communication form did not have the signature of the patient, or patient representative, or the date and time;
-The informed consent lacked a time and date;
-The consent for blood form lacked the time and date;
-The sterilization consent form lacked the time and date;
-The informed consent for anesthesia had no time or date; and
-The informed consent for the out-patient surgery did not have a time or date.

6. Patient #18's closed out-patient medical record lacked a physician signature on the discharge summary dated 9/15/12.

7. Patient #14's open out-patient surgery on 1/10/13 lacked a time on the physician order in the medical record .

On 1/10/13 at 8:30 a.m. staff member D, stated that all entries in the medical records must be timed, signed, and dated.

Based on record review, policy review, and staff interview, the hospital failed to ensure physician's orders were completed with a date, time, and signature for 6 (#s 1, 9, 11, 12, 14, and 18 ) of 18 medical records reviewed. Findings include:

On 1/9/13 at 4:00 p.m., the policy for Medical Record Guidelines for Physicians was reviewed and noted on the policy, "all entries must be timed, dated and authenticated."

1. Patient #1's closed out-patient surgery medical record contained the following:
-The general surgery preoperative orders lacked a date;
-The physician's orders lacked a time on 9/20/12 and 9/21/12; and
-The discharge medication list lacked the date and time for the nurse's and/or patient's signatures.

2. Patient #9's closed out-patient surgery medical record lacked a time on a physician's order dated 11/2/12.

3. Patient #11's closed out-patient medical record lacked the a time on a physician's order dated 9/23/12.

4. Patient #12's closed out-patient medical record lacked the following:
-The date and time was missing by the physician on the general surgery preoperative orders; and
- The time was missing from physician orders dated 12/21/12 and 12/27/12.

5. Patient #18's closed out-patient medical record lacked a physician signature on the discharge summary dated 9/15/12.

6. Patient #14's open out-patient surgery on 1/10/13 lacked a time on the physician order in the medical record .

On 1/10/13, staff member D, the accreditation coordinator, stated that all entries in the medical records must be timed, signed, and dated.

Based on record review, policy review, and staff interview, the hospital failed to ensure consent forms were completed, dated, timed, and signed for 1 (#15 ) out of 15 medical records reviewed. Findings include:

On 1/9/13 at 4:00 p.m., the policy for Medical Record Guideline for Physicians was reviewed and noted on the policy, "all entries must be timed, dated and authenticated."

1. Patient #15's open out-patient surgery medical record on 1/10/13 lacked the following:
-The communication form did not have a signature of the patient, or patient representative, the date and time;
-The informed consent lacked a time and date;
-The consent for blood form lacked a time and date;
-The sterilization consent form lacked a time and date;
-The informed consent for anesthesia had no time or date; and
-The informed consent for the out-patient surgery did not have a time or date.

On 1/10/13, staff member D, the accreditation coordinator, stated that all entries in the medical records should be timed, signed, and dated.

Based on record review, policy review, and staff interview, the hospital failed to ensure out-patient surgical consent forms were complete, dated, timed, and signed for 1 (#15 ) out of 15 medical records reviewed. Findings include:

On 1/9/13 at 4:00 p.m., the policy for Medical Record Guideline for Physicians was reviewed and noted on the policy, "all entries must be timed, dated and authenticated."

1. Patient #15's open out-patient surgery medical record on 1/10/13 lacked the following:
-The communication form did not have a signature of the patient, or patient representative, the date and time;
-The informed consent lacked a time and date;
-The consent for blood form lacked a time and date;
-The sterilization consent form lacked a time and date;
-The informed consent for anesthesia had no time or date; and
-The informed consent for the out-patient surgery did not have a time or date.

On 1/10/13, staff member D, the accreditation coordinator, stated that all entries in the medical records must be timed, signed, and dated.