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Based on review of documentation, interviews, observations, record reviews and review of the facility's complaint log, the facility failed to protect and promote each patient's right's.

Findings include:


A.) The facility failed to ensure proper disposal of patient health information (PHI) that contained information related to payment for service on 10/15/09 for the provision of health care provided by the Hospital.

1.) The Director of Compliance/Privacy Officer was interviewed on 3/7/12 at 10:55 A.M. and 1:30 P.M. and on 3/8/12 at 8:05 A.M. The Director of Compliance/Privacy Officer said that the papers found in Charleston mostly likely came from Central Billing Office, on second floor in Building #1, accounts payable. She said that building #1 was one of three buildings that were going to be demolished. The Privacy Officer said that in July 2011, the billing office was going to move to another location in another town. However, for various reasons, no employee was moved and the door to that office was locked. The papers remained in an empty, locked billing office, unaccounted for, on hospital grounds from July 2011 to approximately January 31, 2012. The Director of Compliance/Privacy Officer said the safekeeping and ultimate disposal of the documents in that room were the responsibility of the VP for Revenue, who was no longer employed by the Hospital.


2.) The Director of Support Services was interviewed in person on 3/8/12 at 1:50 P.M. The Director of Support Services said that during the walk through of the six floors of the building, blue & white stickers were placed on items that needed shredding. He said there was no list to quantify the items and he did not know how the items would be removed for the shredding process.

3.) The VP for Finance was interviewed in person on 3/7/12 at 7:30 AM. The VP for finance said that an individual called the Hospital 2/3/12 to report that he had found a package of papers and reported seeing other similar packages of papers blowing in the wind. The individual reported that the papers had contained the name of the Hospital and patient names. The VP for Finance said that the person was asked to fax the papers to the Hospital, The VP for Finance said that he and the Director of Security immediately went to the site where the papers were found. Their search to find the other packages of papers was unsuccessful, no other papers were found. The VP for Finance said that the papers were forms for collection of payment for services provided at the Hospital. The Hospital was in the process of emptying buildings for demolition where the files were stored.

PHI was found on the ground, outside in Charlestown, several miles from the Hospital's campus, unkown to the Hospital.


B.) The facility failed to inform patients of their right to receive written notice of its decision and actions taken in its resolution of a complaint/grievance.


Review of the Welcome Guide Booklet provided to inform patients of their rights indicated that: a patient advocate is available to meet with any patient who has a conflict, complaint or concern regarding any aspect of the care process. In the event that a problem occurs which interferes with either their right as a patient, or with the quality of care, the patient is encouraged to notify the presidents and the patient advocates office. The Welcome Guide Booklet did not inform patients of their right to expect that the facility would investigate the complaint/grievance, send a written notice which included the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.


Review of the Hospital's Policy Titled Patient Rights indicated that a patient representative is available to meet with any patient who has a conflict, complaint or concern regarding any aspect of the care process. The policy did not indicate that as part of patient rights, a patient would receive a written response as a result of the Hospital's investigation.


The Director of Quality and Safety and the Quality and Safety Coordinator were interviewed in person on 3/7/12 and 3/8/12. Based on review of the Hospital complaint file and interviews, patients were not notified/informed that the Hospital will perform an investigation and provide written notice of the Hospital's investigation results.

Review of the facility's complaint/grievance log from September 2011-March 8, 2012 indicated that 3 of 11 complaints reviewed (Pt #8, Pt #12 and Pt #16), from a total sample of 16 patients reviewed, indicated they had requested a written response from the Hospital regarding the results of the investigation. The patients were not aware that they had the right to receive a written response to their complaint.



i.) Review of a complaint received on 11/4/12 indicated that Pt #8 requested to speak to someone regarding care received during her hospitalization in which she had a cesarean delivery instead of an intended vaginal delivery. The complaint log indicated Pt #8 was advised to discuss her experience with her physician. There was no documentation of an investigation or that the patient's concerns regarding the cesarean section were sufficiently addressed.


ii) Review of a complaint received on 12/1/11 indicated that Pt #16 complained that after having a spinal injection procedure, the patient developed wobbly legs. Review of the Hospital's investigation regarding the complaint indicated that a physician from the pain clinic had a conversation with Pt #16. However, the complaint file did not contain a written response to Pt #16 regarding the complaint.

iii) Review of a complaint received on 2/6/12 indicated that Pt #12 complained about a possible Health Information Portability Act (HIPAA) violation. The complaint indicated that Pt #12 wanted a written response from the Hospital. Pt #12's complaint indicated that on 2/5/12, a resident physician discussed the patient's medication treatment plan for acquired immune deficiency syndrome (AIDS) in front of PT #12's family and friends. Pt #12 had not informed the family, except a sister, of the diagnosis and did not want the diagnosis disclosed to anyone.

C.) The facility failed to protect a patient's right's for personal privacy.

i) The Resident violated Pt #12's rights to personal privacy. Refer to point (iii) above.



D.) The facility failed to ensure that all patients have the right to be free from restraints, both physical and chemical.


i) Review of a complaint received on 11/2/11 indicated that Pt #7 was prescribed Haldol (an antipsychotic medication) which was used as a chemical restraint to control behavior. The Haldol was not his/her usual prescribed medications and was used to an unwanted control behavior.


Review of the physician orders for Pt #7 indicated that on 10/30/12 at 6:06 P.M. Haldol 0.5 mg three times a day was ordered.


Review of the medication administration records (MAR) for Pt #7 indicated that on 10/30/11 at 8:50 P.M. Pt #7 received Haldol. Review of the MAR dated 10/31/11 indicated that at 5:49 A.M. and at 2:23 P.M., Pt #7 was administered Haldol.


ii) Review of a complaint received on 12/5/11 indicated that Pt #10's Family Member requested that the patient not be placed in physical restraints and if there was any change in Pt #10's plan, the family wanted to be notified.


The Hospital's review of Pt #10's care indicated that Pt #10 was placed in physical restraints and his/her family was not notified. Pt #10 was provided 1:1 care in an attempt to keep the Patient safe, however, Patient #10 continued to remain in physical restraints.


E. The facility failed to inform each patient, or his or her representative, about patient's visitation rights.


i.) Review of the Welcome Guide Booklet, page 12, under Visiting, indicated the facility requested that visitors check with the nurse regarding visiting hours on his or her unit. The facility failed to: 1.) inform patients that visitation rights included the right, subject to his or her consent, to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner, another family member, or a friend and his or her right to withdraw or deny such consent at any time and 2.) not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Based on review of documentation and interviews, the Hospital failed to ensure there were processes in place to ensure the confidentially of patient health information [PHI] regarding payment for care provided at the Hospital. The Hospital was never able to definitively determine how the PHI documents ended up in Charlestown, blowing in the wind, several miles from the hospital, because accountability for the proper disposal of the documents were never established.

Findings include:

Please refer to Tag A 115.

There was no accountability process to ensure confidential patient information on the second floor of building #1 was properly disposed of.

Based on review of documentation, interviews, observations, record reviews and review of the facility's complaint log, the facility failed to protect and promote each patient's right's.

Findings include:


A.) The facility failed to ensure proper disposal of patient health information (PHI) that contained information related to payment for service on 10/15/09 for the provision of health care provided by the Hospital.

1.) The Director of Compliance/Privacy Officer was interviewed on 3/7/12 at 10:55 A.M. and 1:30 P.M. and on 3/8/12 at 8:05 A.M. The Director of Compliance/Privacy Officer said that the papers found in Charleston mostly likely came from Central Billing Office, on second floor in Building #1, accounts payable. She said that building #1 was one of three buildings that were going to be demolished. The Privacy Officer said that in July 2011, the billing office was going to move to another location in another town. However, for various reasons, no employee was moved and the door to that office was locked. The papers remained in an empty, locked billing office, unaccounted for, on hospital grounds from July 2011 to approximately January 31, 2012. The Director of Compliance/Privacy Officer said the safekeeping and ultimate disposal of the documents in that room were the responsibility of the VP for Revenue, who was no longer employed by the Hospital.


2.) The Director of Support Services was interviewed in person on 3/8/12 at 1:50 P.M. The Director of Support Services said that during the walk through of the six floors of the building, blue & white stickers were placed on items that needed shredding. He said there was no list to quantify the items and he did not know how the items would be removed for the shredding process.

3.) The VP for Finance was interviewed in person on 3/7/12 at 7:30 AM. The VP for finance said that an individual called the Hospital 2/3/12 to report that he had found a package of papers and reported seeing other similar packages of papers blowing in the wind. The individual reported that the papers had contained the name of the Hospital and patient names. The VP for Finance said that the person was asked to fax the papers to the Hospital, The VP for Finance said that he and the Director of Security immediately went to the site where the papers were found. Their search to find the other packages of papers was unsuccessful, no other papers were found. The VP for Finance said that the papers were forms for collection of payment for services provided at the Hospital. The Hospital was in the process of emptying buildings for demolition where the files were stored.

PHI was found on the ground, outside in Charlestown, several miles from the Hospital's campus, unkown to the Hospital.


B.) The facility failed to inform patients of their right to receive written notice of its decision and actions taken in its resolution of a complaint/grievance.


Review of the Welcome Guide Booklet provided to inform patients of their rights indicated that: a patient advocate is available to meet with any patient who has a conflict, complaint or concern regarding any aspect of the care process. In the event that a problem occurs which interferes with either their right as a patient, or with the quality of care, the patient is encouraged to notify the presidents and the patient advocates office. The Welcome Guide Booklet did not inform patients of their right to expect that the facility would investigate the complaint/grievance, send a written notice which included the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.


Review of the Hospital's Policy Titled Patient Rights indicated that a patient representative is available to meet with any patient who has a conflict, complaint or concern regarding any aspect of the care process. The policy did not indicate that as part of patient rights, a patient would receive a written response as a result of the Hospital's investigation.


The Director of Quality and Safety and the Quality and Safety Coordinator were interviewed in person on 3/7/12 and 3/8/12. Based on review of the Hospital complaint file and interviews, patients were not notified/informed that the Hospital will perform an investigation and provide written notice of the Hospital's investigation results.

Review of the facility's complaint/grievance log from September 2011-March 8, 2012 indicated that 3 of 11 complaints reviewed (Pt #8, Pt #12 and Pt #16), from a total sample of 16 patients reviewed, indicated they had requested a written response from the Hospital regarding the results of the investigation. The patients were not aware that they had the right to receive a written response to their complaint.



i.) Review of a complaint received on 11/4/12 indicated that Pt #8 requested to speak to someone regarding care received during her hospitalization in which she had a cesarean delivery instead of an intended vaginal delivery. The complaint log indicated Pt #8 was advised to discuss her experience with her physician. There was no documentation of an investigation or that the patient's concerns regarding the cesarean section were sufficiently addressed.


ii) Review of a complaint received on 12/1/11 indicated that Pt #16 complained that after having a spinal injection procedure, the patient developed wobbly legs. Review of the Hospital's investigation regarding the complaint indicated that a physician from the pain clinic had a conversation with Pt #16. However, the complaint file did not contain a written response to Pt #16 regarding the complaint.

iii) Review of a complaint received on 2/6/12 indicated that Pt #12 complained about a possible Health Information Portability Act (HIPAA) violation. The complaint indicated that Pt #12 wanted a written response from the Hospital. Pt #12's complaint indicated that on 2/5/12, a resident physician discussed the patient's medication treatment plan for acquired immune deficiency syndrome (AIDS) in front of PT #12's family and friends. Pt #12 had not informed the family, except a sister, of the diagnosis and did not want the diagnosis disclosed to anyone.

C.) The facility failed to protect a patient's right's for personal privacy.

i) The Resident violated Pt #12's rights to personal privacy. Refer to point (iii) above.



D.) The facility failed to ensure that all patients have the right to be free from restraints, both physical and chemical.


i) Review of a complaint received on 11/2/11 indicated that Pt #7 was prescribed Haldol (an antipsychotic medication) which was used as a chemical restraint to control behavior. The Haldol was not his/her usual prescribed medications and was used to an unwanted control behavior.


Review of the physician orders for Pt #7 indicated that on 10/30/12 at 6:06 P.M. Haldol 0.5 mg three times a day was ordered.


Review of the medication administration records (MAR) for Pt #7 indicated that on 10/30/11 at 8:50 P.M. Pt #7 received Haldol. Review of the MAR dated 10/31/11 indicated that at 5:49 A.M. and at 2:23 P.M., Pt #7 was administered Haldol.


ii) Review of a complaint received on 12/5/11 indicated that Pt #10's Family Member requested that the patient not be placed in physical restraints and if there was any change in Pt #10's plan, the family wanted to be notified.


The Hospital's review of Pt #10's care indicated that Pt #10 was placed in physical restraints and his/her family was not notified. Pt #10 was provided 1:1 care in an attempt to keep the Patient safe, however, Patient #10 continued to remain in physical restraints.


E. The facility failed to inform each patient, or his or her representative, about patient's visitation rights.


i.) Review of the Welcome Guide Booklet, page 12, under Visiting, indicated the facility requested that visitors check with the nurse regarding visiting hours on his or her unit. The facility failed to: 1.) inform patients that visitation rights included the right, subject to his or her consent, to receive visitors whom he or she designates, including, but not limited to,