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Based on medical record review, staff interviews, facility policy reviews and review of emergency department grievance log, the facility failed to inform ED patients of their rights (A117); to inform all ED patients and/or their representative of their right to file a grievance with the Ohio Department of Health with or without first using the facility's grievance procedure and failed to follow facility grievance policy (A118); to establish and inform patients of established time frames for the review of grievances (A122); to provide a written response to ED patients who filed a grievance (A123); to ensure patients had the opportunity to participate in the planning of his/her care (A130); to safeguard privacy for patients treated in the emergency department (A143); and to ensure all patients were protected from abuse or harassment following receipt of an allegation of abuse (A145). The cumulative effect of these systemic practices resulted in risk to health and safety of all patients and/or their representative served by the facility.

Based on medical record review and staff interview, the facility to failed to inform emergency department (ED) patients of their rights for 10 out of 10 (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) medical records reviewed and one of five (Patient 11) ED patients interviewed. The average daily ED census was 60

Findings include:

1) Review of the medical records for Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 on 09/09/13 revealed no evidence that patients or a representative were informed of their rights. Staff A (Vice President of Emergency Department Services) and Staff B (ED director) had been previously asked (11:00 AM on 09/09/13) to provide a copy of this information for each of the 10 medical records being reviewed.

2) Patient 11 was interviewed on 09/09/13 at 1:10 PM and stated he/she had not been informed of their rights or privacy. Patient 11 stated the only information he/she had received thus far was a receipt for his/her copay.

3) On 09/10/13 at 3:20 PM Staff B was informed the documentation indicating patients had been informed of their rights had still not been provided.

On 09/11/13 at 3:30 P.M., Staff B was again notified. No additional information was provided before the survey was completed.

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Based on medical record review, facility policy review and staff interviews, the facility failed to inform all emergency department (ED) patients and/or their representative of their right to file a grievance with the Ohio Department of Health with or without first using the facility's grievance procedure and failed to follow facility grievance policy for one of three ED patient grievances reviewed (Patient 3). The average daily ED census was 60.

Findings include:

1) Review of facility hand out entitled "Patient Rights and Safety" revealed information related to complaints. Per said hand out, patients were informed "you can make a complaint or compliment directly to the hospital" and continued "if your complaint isn't resolved to your satisfaction, you may file a complaint with the state."

2) At approximately 12:50 PM on 09/09/13 Staff A and B returned with the requested complaint/grievance log, including supporting documentation related to the investigation and resolution. Patient 3 was noted to be listed on the log with a grievance recorded on 07/11/13. Type of complaint was identified as "Medication (physician)." Status indicated the grievance was still open.

Staff A and B provided a copy of the grievance, which was entered into the facility's computerized system for reporting grievances (I-Sight), a 07/18/13 resolution letter sent to Patient 3 from Staff B and a 08/02/13 certified letter that appeared to be sent from Patient 3 to the facility recounting his/her grievance. Detailed review of the computerized system record history indicated Staff B had opened the case on 07/11/13. The case was then closed on 07/29/13 by Staff M (service excellence patient liaison). The case was subsequently re-opened on 08/06/13 by Staff M and remained open to this day.

Further review of the 07/18/13 resolution letter indicated an "acknowledgment letter" had been previously sent to Patient 3 and "a thorough investigation has occurred." Staff B wrote "I have reviewed the security tapes and interviewed the nurse" as part of his/her investigation. Staff B also wrote "My department follows a policy that no violent behavior will be tolerated." There was no documented evidence Patient 3 received an acknowledgement letter following his/her 07/11/13 or 08/02/13 grievance. The resolution letter was also not written on facility letterhead.

Staff M (patient liaison) and Staff N (system director) from the department of System Excellence were interviewed on 07/10/13 at approximately 3:55 PM. During the interview Staff M stated he/she "missed" sending out acknowledgement letters to Patient 3 following his/her grievances on 07/11/13 and 08/06/13. Staff N confirmed the facility failed to send Patient 3 an acknowledgement letter and that Patient 3's case remained open and without resolution beyond the 30 day requirement.

3) On 09/10/13 at approximately 8:25 AM Staff B was asked if there was a record of the interviews he/she reportedly conducted during the investigation of Patient 3's grievance. Staff B stated he/she would check. Staff B recalled interviewing the nurse (Staff D) and the security guard who was present. Staff B was unable to recall the name of the security guard and stated together they watched the surveillance video on 07/11/13.

Staff B was then interviewed on 09/10/13 at approximately 1:58 PM regarding his/her role in the investigation of Patient 3's grievance. Staff B stated Patient 3 telephoned him/her the morning of 07/11/13. Staff B indicated Patient was abrupt and difficult to talk to on the phone. Patient 3 requested the names and license numbers of ED staff working the night of 07/10/13, which Staff B refused to provide. Staff B stated Patient 3 accused staff of "manhandling" him/her. Patient 3 indicated staff were "rough with me." Staff B stated he/she then viewed the video tape with security. Staff B described Patient 3 as sitting in a chair at the time of the incident, kind of in the hallway. Staff B stated he/she couldn't tell if Staff D took the papers (chart) from Patient 3 but "didn't feel the staff was threatening or acted inappropriately."

At approximately 3:20 PM Staff B brought additional materials related to the investigation of Patient 3's grievance. These included a note written by Staff D immediately following the incident on 07/10/13, a 07/11/13 letter written by Staff B recounting his/her telephone conversation with Patient 3, a 07/13/13 letter written by Staff B recounting his/her interviews with Staff D and security, Patient 3's discharge paperwork and a copy of a "unofficial" police report filed by Patient 3 on 07/11/13.

Per Staff B's 07/13/13 letter recounting the interviews he/she conducted, Patient 3 refused to give the chart back and "began to get louder and louder." Staff D had security stand by then and "finally just grabbed the chart back" from Patient 3. Patient 3 was reportedly becoming "nasty with staff." Security stated the same as Staff D, Staff D "took the chart back and they escorted" Patient 3 out. Most of the incident was "on tape and there was no lying of hands on the patient at any time. Security states no one touched the patient."

On 09/10/13 Staff A provided a copy of the "unofficial" police report filed by Patient 3 on 07/11/13. The alleged offense was "assault." Patient 3 indicated he/she was "grabbed on the arm by the attending nurse and ordered to leave the hospital." No additional information related to a police report was obtained during this investigation. This information had not been evaluated as part of Staff B's investigation.

4) At 11:53 AM on 09/10/13, Staff I (Commander of Protective Services) provided the names of the three security guards ( Staff E, F and O) who were stationed in the ED on 07/10/13. The following interviews were conducted via telephone conferencing in the presence of Staff I.

On 09/10/13 at 11:55 AM by phone, Staff E was interviewed. Staff E indicated the security officers received a call the evening of 07/10/13. The security officers were summoned to ED to standby as a patient was being discharged. Staff E saw Patient 3 writing on a paper. Staff E proceeded to ask Patient 3 what was going on and Patient 3 stated they were treating him/her like a drug seeker and he/she was going to file a complaint. Staff E stated Staff D then walked over and "snatched" the paperwork out of Patient 3's hands and walked away. Staff E acknowledged he/she had not seen any physical contact by Staff D but that Patient 3 looked "shocked."

Staff E stated the nurse, Staff D, "was agitated" because he/she was talking to Patient 3. Staff E stated the nurse's behavior was "inappropriate" and Staff E apologized to Patient 3 because Patient 3 was "upset" and he/she "felt bad" for Patient 3.

Staff E indicated he/she had not been interviewed about this incident, until Staff E was asked to write a report (witness statement) on 08/08/13.

Staff F, who was on duty the evening of 07/10/13, was interviewed on 09/10/13 at 12:10 PM by phone. Staff F indicated when he/she arrived in the ED, Staff F saw Patient 3 writing on some papers. Staff F revealed that Staff D was seen snatching the papers out of Patient 3's hand. Staff F revealed Patient 3 was calm, and Patient 3 had not raised his/her voice. Staff F specified Patient 3 was cooperative and walked out of the ED without assistance of security. Staff F indicated he/she had not been interviewed or asked to write a statement about this incident prior to today.

Staff O was interviewed by phone on 09/11/13 at 1:50 PM. Staff O revealed Patient 3 was sitting in a chair and Staff D was standing over Patient 3. Staff O indicated Staff D grabbed the papers out of Patient 3's hand and asked security to escort Patient 3 out. Staff O indicated he/she had not been interviewed about this incident or asked to write a statement prior to today.

5) Review of facility policy "Patient Grievance", a grievance was defined as any one of the following:

A complaint expressed in written form
A claim of harm, injury, abuse or neglect
A complaint that is not resolved to the satisfaction of the patient/guest
An attachment to a patient's survey requesting follow up

The same policy indicated the procedure included sending a "complaint" or "grievance" acknowledgment letter to the patient. Resolution was expected "as soon as possible but not to exceed 30 days" following a "thorough investigation" by the manager or director. The grievance resolution letter was to be "written on letterhead and includes the date and name of hospital contact person and signature of the author." The grievance resolution letter was also to include "steps taken on behalf of patient/guest to investigate the grievance" and "the hospital is to provide adequate information to address each item stated in the original grievance."

6) Staff A and Staff B were made aware of the above finding on 09/11/13 at approximately 3:19 PM. At that time staff neither denied or confirmed the finding.

Based on review of facility patient rights hand out and staff interviews, the facility failed to establish and inform patients of established time frames for the review of grievances (all patients). The average daily ED census was 60.

Findings include:

1) Review of facility hand out entitled "Patient Rights and Safety" revealed information related to complaints. Per said hand out, patients were informed "you can make a complaint or compliment directly to the hospital" and continued "if your complaint isn't resolved to your satisfaction, you may file a complaint with the state." None of the information provided to patients informed them of when the facility would review the grievance and when they would respond to the grievance.

2) Staff A and Staff B were made aware of the above finding on 09/11/13 at approximately 3:19 PM. At that time staff neither denied or confirmed the finding.

Based on grievance log review, staff interviews and review of facility policy, the facility failed to provide a written response to one of three ED patients (Patient 3) reviewed who filed a grievance. The average daily ED census was 60.

Findings include:

1) At approximately 12:50 PM on 09/09/13 Staff A and B returned with the requested complaint/grievance log, including supporting documentation related to the investigation and resolution. Patient 3 was noted to be listed on the log with a grievance recorded on 07/11/13. Type of complaint was identified as "Medication (physician)." Status indicated the grievance was still open.

Staff A and B provided a copy of the grievance, which was entered into the facility's computerized system for reporting grievances (I-Sight), a 07/18/13 resolution letter sent to Patient 3 from Staff B and a 08/02/13 certified letter that appeared to be sent from Patient 3 to the facility recounting his/her grievance. Detailed review of the computerized system record history indicated Staff B had opened the case on 07/11/13. The case was then closed on 07/29/13 by Staff M (service excellence patient liaison). The case was subsequently re-opened on 08/06/13 by Staff M and remained open to this day.

2) Staff N (director, department of service excellence) was interviewed on 09/10/13 at approximately 3:55 PM. Upon receipt of Patient 3's letter dated 08/02/13, Staff N stated the 07/11/13 case was re-opened and assigned to the facility's Risk Management team. The Service Excellence team became aware of the second grievance at that time. Staff N confirmed Patient 3's case remained open and without resolution beyond the 30 day requirement.

3) Staff A and Staff B were made aware of the above finding on 09/11/13 at approximately 3:19 PM. At that time staff neither denied or confirmed the finding.

Based on medical record review and staff interviews, the facility failed to ensure patients had the opportunity to participate in the planning of his/her care. This affected one of 10 ED patient medical records reviewed (Patient 3). The average daily ED census was 60.

Findings include:

1) At approximately 2:46 PM on 09/09/13 Staff B was interviewed regarding the management of pain in the ED. Staff B indicated there should be an assessment of patient's pain pre and post treatment. Staff B indicted the assessment would be different based on the type of medication administered, oral or intravenous. Staff B further stated complaints of acute or chronic pain should both include a pre and post assessment of the patient. Staff B was asked what would warrant additional testing in a patient complaining of pain and indicated this was physician's judgement but that new or worsening pain would warrant more testing. Staff B was then asked if the attending physician should call the patient's primary care physician (PCP) to consult and stated that if a physician sends a patient to the ED you would expect this to happen. Staff B stated there is no record of this contact though.

Staff B was then asked why Patient 3's PCP had not been contacted when the medical record indicated he/she informed the attending, Staff H, that their PCP had instructed him/her to come to the ED. Staff B was unable to say. Staff B was also made aware of and confirmed that there was no reassessment of Patient 3's reported 9/10 lower back pain before he/she was discharged.

2) Staff H (attending emergency medicine physician) and Staff K (chair, department of emergency services) were interviewed via telephone on 09/10/13 at approximately 9:32 AM. Staff H was asked if he/she had the opportunity to review Patient 3's medical record and stated yes. Staff H also confirmed he/she had cared for Patient 3 on the evening of 07/10/13. Staff H was then asked if he/she recalled completing/filling out the "T" sheet on Patient 3. Staff H stated yes as he/she recalled one was completed. Staff H was asked if a physical assessment of Patient 3 was completed and responded yes.

After multiple requests for the complete medical record of Patient 3, including "T" sheets, consent, discharge form and notice of privacy, Staff B admitted during the same interview on 09/10/13 that the "T" sheets for Patient 3 were missing and medical records was attempting to locate them. Staff K stated he/she was not aware the sheets were missing until now but missing "T" sheets has been an issue.

Staff H was then asked to describe what he/she recalled about Patient 3 and the evening of 07/10/13. Staff H proceeded to say he/she recalled the patient's initial history and that Patient 3 reported having chronic pain for 15 years. Staff H stated Patient 3 requested a Percocet refill. Patient 3 reportedly described his/her pain as old, not new, with no changes. Staff H then spoke to Patient 3 about ways to manage his/her chronic pain and reviewed the Ohio ACEP (American College of Emergency Physicians) chronic pain policy with the patient. Staff H stated Patient 3 was "initially in agreement with the plan but not happy about it."

Staff H stated when it was time to discharge Patient 3, Staff D notified him/her that the patient was refusing to leave. Staff H went back to talk with Patient 3 and Patient 3 requested an MRI (magnetic resonance imaging test) and a Percocet prescription. Staff H informed Patient 3 a MRI was not warranted. Staff H stated he/she returned two additional times to speak with Patient 3 and Patient 3 continued to refuse to leave the ED. Staff H then asked for security to be called. Staff H stated Patient 3 was not aware that security had been called. Staff H also did not witness security escort Patient 3 out of the ED, he/she was in the physician's room at the time. No violent behavior was witnessed. Staff H again stated there was "no emergent condition warranting further testing."

Staff H and K were asked when they first became aware of Patient 3's grievance and indicated it was "sometime around 08/06/13." Staff K stated he/she re-educated staff about pain management and agreed to provide the material for review.

Review of said education indicated all "faculty" received an e-mail correspondence from Staff K on 08/14/13. It in the e-mail, Staff K referenced the said guide and stated if "there is any question please give the patient the benefit of the doubt." Staff K continued "If patient rate their pain a 10 and you disagree please consider comfort measures, non-narcotic drugs and other efforts to make them pain free. Also please clearly document your attempts to contact their providers and offer solutions."

Based on observation, patient interview and staff interview, the facility to failed to safeguard privacy for patients treated in the emergency department (ED). This had the potential to affect 21 patients. The average daily census was 60.

Findings include:

1) On 09/09/13 from 11:00 AM to 11:20 AM., a tour was conducted of the ED. Two large screens in the hallway with patient information were visible when walking from the entrance of the ED to the beds within the ED. The screens revealed patients' full name, the location (bed)of patients, age, acuity level and time stamp. Staff B indicated the time stamp provided information about the patient's status in the ED process, i.e. seen by the physician, discharged or admitted to the hospital.

On 09/09/13 at 11:20 AM, Staff B was notified of privacy concerns with the screens.

2) Patient 11 was interviewed on 09/09/13 at 1:10 PM., as he/she was being treated in ED. Patient 11 indicated he/she had not given authorization for disclosure of his/her personal information.

3) Staff A and Staff B were made aware of the above finding on 09/11/13 at approximately 3:19 PM. At that time staff neither denied or confirmed the finding.

This substantiates the allegation contained in Substantial Allegation OH00071350.

Based on review of facility policies, grievance log review and staff interviews, the facility failed to ensure all patients were protected from abuse or harassment following receipt of an allegation of abuse by one patient (Patient 3). The average daily ED census was 60.

Findings include:

1) Staff B was then interviewed on 09/10/13 at approximately 1:58 PM regarding his/her role in the investigation of Patient 3's 07/11/13 grievance. Staff B stated Patient 3 telephoned him/her the morning of 07/11/13. Staff B indicated Patient 3 was abrupt and difficult to talk to on the phone. Patient 3 requested the names and license numbers of ED staff working the night of 07/10/13, which Staff B refused to provide. Staff B stated Patient 3 accused staff of "manhandling" him/her. Patient 3 indicated staff were "rough with me." Staff B stated he/she then viewed the video tape with security. Staff B described Patient 3 as sitting in a chair at the time of the incident, kind of in the hallway. Staff B stated he/she couldn't tell if Staff D took the papers (chart) from Patient 3 but "didn't feel the staff was threatening or acted inappropriately."

At approximately 3:20 PM Staff B brought additional materials related to the investigation of Patient 3's grievance. These included a note written by Staff D immediately following the incident on 07/10/13, a 07/11/13 letter written by Staff B recounting his/her telephone conversation with Patient 3, a 07/13/13 letter written by Staff B recounting his/her interviews with Staff D and security, Patient 3's discharge paperwork and a copy of a "unofficial" police report filed by Patient 3 on 07/11/13.

Per Staff B's 07/13/13 letter recounting the interviews he/she conducted, Patient 3 refused to give the chart back and "began to get louder and louder." Staff D had security stand by then and "finally just grabbed the chart back" from Patient 3. Patient 3 was reportedly becoming "nasty with staff." Security stated the same as Staff D, Staff D "took the chart back and they escorted" Patient 3 out. Most of the incident was "on tape and thereno one placed hands on the patient at any time. Security states no one touched the patient."

On 09/10/13 Staff A provided a copy of the "unofficial" police report filed by Patient 3 on 07/11/13. Staff A had just printed it out. The alleged offense was "assault." Patient 3 indicated he/she was "grabbed on the arm by the attending nurse and ordered to leave the hospital." No additional information related to the police report was obtained during this investigation. This information had not been evaluated as part of Staff B's investigation.

2) At 11:53 AM on 09/10/13, Staff I (Commander of Protective Services) provided the names of the three security guards ( Staff E, F and O) who were stationed in the ED on 07/10/13. The following interviews were conducted via telephone conferencing in the presence of Staff I.

On 09/10/13 at 11:55 AM by phone, Staff E was interviewed. Staff E indicated the security officers received a call the evening of 07/10/13. The security officers were summoned to ED to standby as a patient was being discharged. Staff E saw Patient 3 writing on a paper. Staff E proceeded to ask Patient 3 what was going on and Patient 3 stated they were treating him/her like a drug seeker and he/she was going to file a complaint. Staff E stated Staff D then walked over and "snatched" the paperwork out of Patient 3's hands and walked away. Staff E acknowledged he/she had not seen any physical contact by Staff D but that Patient 3 looked "shocked."

Staff E stated the nurse, Staff D, "was agitated" because he/she was talking to Patient 3. Staff E stated the nurse's behavior was "inappropriate" and Staff E apologized to Patient 3 because the nurse was "upset" and he/she "felt bad" for Patient 3.

Staff E indicated he/she had not been interviewed about this incident, until Staff E was asked to write a report (witness statement) on 08/08/13. In this statement Staff E recounted the "patient was not happy with the care" he/she received. Patient 3 reported "staff were very rude." Staff E continued, recounting that he/she observed Staff D "come over and snatch the papers out of the patients hands."

Staff F, who was on duty the evening of 07/10/13, was interviewed on 09/10/13 at 12:10 PM by phone. Staff F indicated when he/she arrived in the ED, Staff F saw Patient 3 writing on some papers. Staff F revealed that Staff D was seen snatching the papers out of Patient 3's hand. Staff F revealed Patient 3 was calm, and Patient 3 had not raised his/her voice. Staff F specified Patient 3 was cooperative and walked out of the ED without assistance of security. Staff F indicated he/she had not been interviewed or asked to write a statement about this incident prior to today.

Staff O was interviewed by phone on 09/11/13 at 1:50 PM. Staff O revealed Patient 3 was sitting in a chair and Staff D was standing over the Patient 3. Staff O indicated Staff D grabbed the papers out of Patient 3's hand and asked security to escort Patient 3 out. Staff O indicated he/she had not been interviewed about this incident or asked to write a statement prior to today.

3) Staff N (director, department of service excellence) was interviewed on 09/10/13 at approximately 3:55 PM. Staff N confirmed he/she was familiar with Patient 3's grievances and further stated that if abuse or harassment was corroborated, as Patient 3 was alleging, the staff member in question would be suspended until the investigation was completed.

4) Staff Q (Vice President of Employee Relations) was interviewed on 09/11/13 at approximately 1:40 PM. At that time he/she provided a policy entitled "Workplace Violence" for review. Staff Q was asked to explain what would happen if a patient alleged abuse by a staff member. Staff Q stated to ensure the facility protects patients the staff member would not be allowed to work until an investigation was completed. Staff Q stated the staff member would not necessarily be suspended, particularly if the staff member was not scheduled to work anyway.

Staff Q was unable to locate where in the policy this is stated, as none of the three policies provided stated staff would be placed on leave (Abuse, Known or Suspected; Workplace Violence; and Disciplinary Process and Rules of Conduct) . Staff Q stated it does happen but confirmed it was not clearly stated in any of the policies.

Staff A was also present during the interview and interjected the facility did an investigation and there was no evidence the nurse touched the patient. Staff A stated the nurse didn't work after the alleged incident either, he/she wasn't scheduled. Staff A was then asked what the facility did to protect patients after they received the second letter from Patient 3, alleging abuse. Staff A again stated they had already investigated and found no wrong doing.

5) Review of facility policies was conducted on 09/11/13. Workplace Violence indicated "any act of violence or aggression, including verbal and non verbal threats, will not be tolerated and will result in progressive discipline, up to and including termination from employment."

Violence/Aggression was defined as "any intentional conduct, whether verbal or physical, which causes injury or is sufficiently severe, offensive, or intimidating" and Violent Act was defined as "behavior including, but not limited to, any disruptive, harassing, intimidating, coercing or belligerent behavior."

The policy continued indicating the facility would "promptly and thoroughly investigate any complaint or report of a violation of this policy. During pendency of the investigation, to the extent possible, measures will be taken to prevent any further contact or interaction between the person who believes he/she has been subject to violence or aggression and the alleged violator of this policy."

Disciplinary Process and Rules of Conduct, under the heading suspension, indicated "in situations where a serious incident occurs, an immediate suspension pending an investigation may be utilized so that documentation and circumstances can be reviewed prior to a final decision." The policy did not speak specifically to patient allegations of abuse/harassment by staff. It also did not speak to how other patients would be protected.

Abuse, Known or Suspected was also reviewed. The policy was found not to be applicable to patient allegations of abuse/harassment by staff. The policy was directed toward staff in cases of suspected domestic violence, sexual assault, etc observed in patients presenting to the facility.

6) Review of the Staff D's time detail revealed he/she worked the following days surrounding the initial allegation of abuse on 07/11/13 and the second allegation received on 08/06/13:

07/19/13 - 07/22/13
07/24/13
07/27/13
08/12/13-08/13/13
08/16/13
08/19/13
08/23/13
08/26/13-08/27/13
08/29/13

Staff D continued to work during the course of this investigation and was observed providing direct patient care in the ED on 09/09/13 at approximately 1:25 PM.

7) Staff A and Staff B were made aware of the above findings on 09/11/13 at approximately 3:19 PM. At that time staff neither denied or confirmed the finding.