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Based on closed record reviews and interview, the hospital failed to provide documentation that the hospital informed each patient, or when appropriate, the patient's representative of the patient rights in advance to furnishing patient care for 4 of 19 closed patient charts (Patient 15, 16, 17, and 18), and failed to provide documentation that each patient was informed of whom to contact to file a grievance for 14 of 19 closed patient records (Closed Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) and 3 of 3 Inpatient records reviewed (Inpatient 1, 2, and 3)


The findings are:


On 7/26/2018 from 9:00 a.m.. to 1:30 p.m., review of the closed chart for Patient 1 revealed the patient was admitted on 7/13/2018 at 5:09 p.m. with a Terminal Ileus, and the hospital failed to provide evidence that the notice of patient rights was given to the patient and/or family prior to the provision of care, and failed to provide evidence that the hospital gave the patient its grievance procedure(s) including how to submit a written grievance hospital.

On 7/26/2018 from 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 2 revealed the patient was admitted on 7/14/2018 at 2:34 p.m. with an Abdominal Wall Abscess. The hospital failed to demonstrate that the hospital's notice of the patient rights, or the hospital's grievance procedure(s) were given the patient and/or family prior to the provision of care.

On 7/26/2018 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 3 revealed the patient was admitted on 7/15/2018 at 5:57 a.m. with Acute Cystitis. The hospital failed to demonstrate that the hospital's notice of patient rights, or the hospital grievance procedure(s) were given to the patient prior to the provision of care.

On 7/26/2018 from 9 a.m. to 1:30 p.m., review of the closed chart for Patient 4 revealed the patient was admitted on 7/7/2018 with Abdominal Pain and General Weakness. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9 a.m. to 1:30 p.m., review of the closed record for Patient 5 revealed the patient was admitted on 7/15/2018 at 1:40 a.m. with a Motor Vehicle Accident. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9 a.m. to 1:30 p.m., review of the closed chart for Patient 6 revealed the patient was admitted on 7/14/2018 at 2:32 a.m. with a Left Hip Fracture. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 7 revealed the patient was admitted on 7/15/2018 with a Fall, Left Hip Pain. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 8 revealed the patient was admitted on 7/14/2018 at 1:11 a.m. with Intractable Cyclical Nausea and Vomiting. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 9 revealed the patient was admitted on 7/13/2018 at 11:55 p.m. with Peri-rectal Abscess. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 9:00 a.m. to 1:30 p.m., review of the closed chart for Patient 10 revealed the patient was admitted on 7/14/2018 at 12:45 a.m. with Hip Fracture. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 from 3:30 p.m. to 5:45 p.m., review of the closed chart for Patient 11 revealed the patient was admitted on 7/9/2018 with Renal Failure. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/27/2018 from 9 a.m. to 12:30 p.m., review of the closed chart for Patient 12 revealed the patient was admitted on 7/24/2018 at 8:31 a.m. with End Stage Renal Failure. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/27/2018 from 9 a.m. to 12:30 p.m., review of the closed chart for Patient 13 revealed the patient was admitted on 7/15/2018 at 5:59 p.m. with Acute Appendicitis. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/27/2018 from 9 a.m. to 12:30 p.m., review of the closed chart for Patient 14 revealed the patient was admitted on 7/14/2018 at 1:24 p.m. with a Closed Fracture of Neck R Femur. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 at 5:00 p.m., review of Inpatient Patient 1's chart revealed the patient was admitted on 7/19/2018 with Acute Kidney Injury. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/27/2018 at 10:00 a.m., an interview was conducted with Inpatient 3 and spouse who stated that he/she was present during the patient's entire hospital stay except to leave two times to go home and sleep at night for about 6-8 hours in the patient's hospital room on 6 South. Inpatient 3 stated, "I'm a little tired and deaf, but (he/she) can answer all your questions for me. (He/she) takes care of me when I'm sick." When asked, "When you were admitted to the hospital, did anyone discuss with you about your rights as a patient?" Inpatient 3's spouse replied, "No. They didn't tell us." When asked "Did anyone tell you what to do if you have a complaint about your care?" Inpatient 3's spouse reported "No. They did not give a way to contact or file a complaint."

On 7/27/2018 at 11:15 a.m., review of the Inpatient 2's chart revealed the patient was admitted on 7/23/2018 for Screening for Colorectal Cancer, Sebaceous Cyst Right Axillary. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/27/2018 at 11:45 a.m., review of Inpatient 3's chart revealed the patient was admitted on 7/22/2018 at 6:39 p.m. for Peri-esophageal Hernia. The hospital failed to demonstrate that the hospital's notice of patient rights, and the hospital's grievance procedure(s) were provided to the patient/family prior to the patient receiving care.

On 7/26/2018 and 7/27/218, the findings were verified with Hospital Staff 6, Hospital Staff 20, and Hospital Staff 35 at the time of the findings.

On 7/25/2018 at 2:00 p.m. review of the hospital's "Patient Guide Rights and Responsibilities" regarding grievance procedure, reads "Staff want to know if you or your family has a concern. If you have a concern, please ask to talk with a nurse leader, patient experience partner, or administrator. He or she also can assist you in contacting your doctor if you have a concern, or you may call 512-1414, which is a special hotline to connect you with a patient care coordinator who will be happy to assist you." Staff 6 verified the finding and stated, "No external avenue for patient to voice a complaint is provided."























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On 7/27/18 at 10:15 a.m., review of Closed Patient 15's chart revealed the patient was admitted on 7/13/18 for a Biliary obstruction. Patient 15 was an outpatient admitted for an Esophagogastroduodenoscopy(EGD) and an Endoscopic ultrasound on 7/12/18, and then admitted. There was no documentation that the hospital gave the hospital's patient rights information to the patient prior to providing care. The finding was verified with the Director of Nursing at 10:35 a.m. on 7/27/18.

On 7/27/18 at 10:50 a.m., review of Closed Patient 16's chart revealed the patient was admitted to the hospital as a trauma alert on 7/15/18 for a gunshot wound (GSW) to the right flank and underwent surgery for an exploratory Laparoscopic. There was documentation that the hospital gave the patient's family or the patient the hospital's patient rights information prior to providing care. The finding was verified with the Director of Nursing at 11:15 a.m. on 7/27/18.

On 7/27/18 at 11:25 a.m., review of Closed Patient 17's chart revealed the patient was admitted as a trauma alert on 7/23/18 for a stab wound to the left chest and underwent surgery for an exploratory Laparoscopic with a bowel repair. There was no documentation that the hospital gave the hospital's patient rights information to the patient or family prior to providing care. The finding was verified with the Director of Nursing at 11:35 a.m. on 7/27/18.

On 7/27/18 at 11:55 a.m., review of Closed Patient 18's chart revealed the patient was admitted on 7/13/18 with a femur fracture, and underwent surgery for a femur head repair on 7/13/18. There was documentation that the hospital gave the patient or the patient's family the hospital's patient rights information prior to providing care. The finding was verified with the Director of Nursing at 12:15 p.m. on 7/27/18.

Based on record review and interview the hospital failed to ensure that a properly executed informed consent for the operations was in the patient's chart before surgery for 2 of 3 Inpatient charts (Inpatient 1 and 2) 2 of 19 closed patient charts. (Patient 3 and 12)


The findings are


On 7/26/2018 at 5:00 p.m., review of Inpatient 1's chart revealed the patient was admitted on 7/19/2018 at 6:44 with Acute Kidney Injury. Review of the patient's record revealed the patient underwent a Nephrectomy on 7/23/2018 without a surgical procedure consent form or a progress note documenting that a description of the proposed surgery, the indications for the proposed surgery, and material risks and benefits for the patient related to the surgery. Review of surgery progress note dated 7/21/2018, reads, "We'll check iron studies, may require iron as well as blood replacement prior to surgery for left Nephrectomy. Discussed at length with the patient."

On 7/27/2018 at 11:15 a.m., review of Inpatient 2's chart revealed the patient was admitted on 7/23/2018 at 7:49 a.m. for Screening for Colorectal Cancer and Sebaceous Cyst Right Axillary. Review of the patient's surgical consent form revealed the patient underwent a Right Axillary Mass Excision, Colonoscopy with Biopsy, and Polypectomy on 7/23/2018 without surgical consent form or a progress note documenting a description of the proposed surgery, the indications for the proposed surgery, and material risks and benefits for the patient related to the surgery.

On 7/26/2018 at 10:30 a.m., review of the closed medical record for Patient 3 revealed the patient was admitted on 7/15/2018 at 5:57 a.m. for Acute Cystitis. Review of the patient's surgical consent form revealed the patient underwent a Cystoscopy with Stent on 7/15/2018 and the surgical consent form had no witness signature.

On 7/27/2018 at 11:30 a.m., review of the closed medical record for Patient 12 revealed the patient was admitted on 7/24/2018 at 8:31 a.m. with End Stage Renal Disease. Review of the patient's surgical consent form revealed the patient underwent a Revision of Right Arteriovenous Fistula on 7/24/2018 and the surgical consent form had no description of the surgery or a progress note documenting material risks and benefits for the patient related to the surgery.

The findings were verified by Staff #20.