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Based on policy review and interviews the facility failed to ensure patients in the outpatient and Emergency Department (ED) settings were informed of their patient rights during their treatment process. The census of the ED at the time of the survey was eight. This had the potential to affect all patients treated in the ED and outpatient areas. The facility census was 45.

Findings included:

1. Record review of Policy #0232 titled "Patient's Rights" dated 04/05 (without further revision) showed no direction on how or when patient rights were to be given and/or discussed with patients or their legal representatives.

2. During an interview on 03/30/11 at 11:55 AM, Staff G, ED Director, stated that patients are not given information about their rights as part of treatment in the ED.

3. During an interview on 03/30/11 at 3:25 PM, Staff K, Patient Representative, stated that he/she registered patients for the Laboratory, Wellness Center (Cardiac Rehabilitation), direct admission, surgery, Senior Mental Health Services, GI (Gastrointestinal) Lab, Sleep Study Center- everywhere in the facility except ED. Staff K stated that the Patient Information Guide, which contains information on patient rights, was given to patients who are being admitted as inpatients, but it was not given to patients being treated as outpatients.

Based on record review, policy review and interview, the facility failed to provide written response to grievants in four (4) of four (4) grievances reviewed. The facility provided a letter of acknowledgment to the grievants, but did not accurately inform the grievant of the facility's decision, the steps taken on behalf of the patient to investigate the grievance, the results of grievance process or the date of completion for four (4) of four (4) grievances reviewed. The facility census was 45.

Findings Included:

1. Record review of the facility's policy titled, "Customer Issue Resolution Process," dated 12/31/07 showed the following direction:
The Hospital Quality Improvement Council ensures the patient is provided written notice of its decision regarding the grievance. . .The written notice shall contain the following:
a. Name of hospital contact person
b. Steps taken on behalf of the patient to investigate the grievance
c. Results of the grievance process
d. Date of completion

2. Review of grievance investigations and responses on 03/31/11 at 11:00 AM, showed the following:
- A grievance was received from a patient's husband on 08/22/10 concerning care of his wife in the ED (Emergency Department) on 08/19/10. The husband complained that the ED physician misdiagnosed his wife's condition. There was a note that indicated Staff N, ED Medical Director, would have the chart reviewed in this weeks ED committee meeting. There was no evidence that the patient or her husband were informed the results of the grievance investigation by written notice as of 03/31/11.
- A grievance was received 11/24/10 regarding the attitude of an ED RN (Registered Nurse). A note indicated that the concern was handed over to Staff G, ED Director. An additional note indicated that staff was counseled. There was no evidence that the patient was informed of the results of grievance investigation by written notice as of 03/31/11.
- A grievance was received 01/19/11 regarding a patient's concern of misdiagnosis in the ED. A letter was sent to the patient on 01/20/11 promising the grievance would be investigated. There was no evidence that the patient was informed of the results of complaint investigation by written notice as of 03/31/11.
- A grievance was received on 02/11/11 regarding the length of time it took for respiratory therapy to respond to a patient's room during an asthma attack. Staff M, Risk Manager, did visit the patient while he/she was in the hospital, but there was no evidence that the patient was informed the results of the grievance investigation by written notice as of 03/31/11.

3. During an interview on 03/31/11 at 1:40 PM, Staff C, Quality Management Director, stated that he/she was not aware of the elements required in the written notice to close a grievance.

4. During an interview on 03/31/11 at 2:45 PM, Staff M stated that grievance investigations were completed, but written notices were not always sent to the patients. Staff M stated that he/she was not aware that a written notice needed to always be sent, and was not aware of all the elements required in the written notice.

Based on policy review, record review and interview, the facility failed to determine if each patient and/or patient's representative in the Emergency Department (ED) had an advance directive, or were offered the opportunity to establish an advance directive, until the patient was being discharged from the ED. The facility treats about 1150 patients per month in the ED. The facility census was 45.

Findings included:

1. Record review of the facility's policy #0272 titled "Advanced Directives", revised 01/11, showed the following direction:
-As part of the admission process, the individual will be provided with written information concerning the individual's right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives.

The policy makes no distinction between inpatient, outpatient or ED admissions.

2. During an interview on 03/31/11 at 11:55 AM, Staff G, ED Director, stated that the staff does not ask patients or their representatives if they have an advanced directive at the time of initial registration. Staff G stated that information on advanced directives is obtained as the patient is processed out at discharge.

3. During an interview on 03/31/11 at 1:55 PM, Staff A, Chief Nursing Officer, stated that the facility needed to make adjustments to their advance directive process in the ED.

4. Record review of discharged Patient #9's medical record showed that he/she arrived at the ED on 08/19/10 around 11:00 PM. Discharge paperwork, including the answers to questions about advance directives was signed by Patient #9 on 08/20/10 at 01:45 AM.

5. Record review of discharged Patient #7's medical record showed that he/she arrived at the ED on 11/21/10 around 10:45 PM. Discharge paperwork, including the answers to questions about advance directives was signed by Patient #7 on 11/22/10 at 00:20 AM.

6. Record review of discharged Patient #8's medical record showed that he/she arrived at the ED on 01/15/11 around 7:45 PM. Discharge paperwork, including the answers to questions about advance directives was signed by Patient #8 on 01/16/11 at 2:00 AM.

Based on policy review, record review and interview the facility failed to have documentation that showed the training requirements for physicians in the use of restraint or seclusion had been met. The facility census was 45.

Findings included:

1. Review of the facility restraint policy #0402 titled, "Patient Restraints" dated 08/09 showed directive that physicians ordering restraint and seclusion must have a working knowledge of hospital policy regarding restraint and seclusion as evidenced by review and/or education on the hospital restraint policy.

2. During an interview on 01/31/11 at 1:40 PM, Staff C, Quality Director, stated that he/she is not aware if the facility has completed specific education addressing the training requirements for physicians regarding the use of restraint or seclusion.

3. During an interview on 01/31/11 at 1:55 PM, Staff A, Chief Nursing Officer, stated that the facility has not completed specific education addressing the training requirements for physicians regarding the use of restraint or seclusion. Staff A stated that there is no tracking mechanism to ensure physicians were trained.

4. Record review of the credentialing file on 03/31/11, for Staff N, ED Medical Director, showed no evidence that this physician was trained on the facility's restraint policy.

Based on interview, restraint training review, and personnel file review, the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to restraint use. This facility failure has the potential to affect all patients placed in restraints. The facility census was 45.

Findings included:

1. During an interview on 03/31/11 at 1:40 PM, Staff C, Quality Director, stated that staff is not trained in first aid as related to restraint use. Staff C stated that he/she was not aware of this requirement.

2. During an interview on 03/31/11 at 1:55 PM, Staff A, Chief Nursing Officer, stated that staff is not trained in first aid as related to restraint use.

3. Review of the facility's restraint training binder showed no training in the use of first aid as related to restraint use.

4. Review of eight (8) personnel records for registered nurses and clinical nursing assistants showed no evidence of first aid training related to restraint use.