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The hospital failed to ensure patients are provided notice of rights (see A 117); the hospital failed to establish a process for resolution of grievances, including informing patients of contact information and right to contact State Agency and failed to document grievance and failed to document investigation and conclusions or steps taken (see A 118); the hospital failed to provide written notice of decision (see A 123); the hospital failed to ensure patients are provided privacy (See A 143); the hospital failed to ensure care in a safe setting and failed to maintain policies to ensure safe care of patients in the Chest Pain Center (see A 144).

Based on medical record review, review of documents and staff interview it was determined the hospital failed to ensure patients were provided with a notice of patient rights. This failed practice impacted ten (10) of ten (10) patients (patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) and has the potential to violate the rights of all patients who present to the Emergency Department (ED).

Findings include:

1. Review of the ED records for patients #1 through #10 revealed no documentation to reflect the patients were informed of Patient Rights.

These records were reviewed and discussed with the ED Director at 1:30 p.m. on 10/8/14 and she concurred with these findings.

2. The policy Rights and Responsibilities of Patients, revised 5/14, was provided for review. It states in part: "It is the responsibility of the Admissions Clerk to provide the patient with a copy of his/her rights upon admission to the facility...Patient rights are posted in the Emergency Department...patient rights are listed in the patient guide that is distributed upon admission."

3. Tour and observation of the ED was conducted between 10:20 a.m. and 11:45 a.m. on 10/6/14. Patient Rights were noted to be posted on the wall in the Zone I area of the ED.
This posting was noted to lack any information related to the patient's right to report grievances to the State Agency (SA) or any contact information for the SA.

4. An interview conducted with Registration Clerk #1 on 10/7/14 at 11:30 a.m. confirmed Patient Rights are available in the file cabinet but are not routinely provided to ED patients.

5. A phone interview was conducted with the Director of Registration at 3:35 p.m. on 10/8/14. She also acknowledged the ED records lacked documentation to reflect patients were informed of patient rights.

A. Based on review of medical records, documents and staff interview it was determined the hospital failed to establish a process for prompt resolution of patient grievances which includes informing patients of the phone number and addresses of the State Agency (SA) and that a patient grievance may be lodged with the SA. This failure impacted ten (10) of ten (10) ED patients reviewed and creates the potential for the rights of all patients to be violated (patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10).

Findings include:

1. Review of the ED records for patients #1 through #10 revealed no documentation to reflect the patients were informed of Patient Rights.

These records were reviewed and discussed with the ED Director at 1:30 p.m. on 10/8/14 and she concurred with these findings.

2. Tour and observation on the ED was conducted between 10:20 a.m. and 11:45 a.m. on 10/6/14. Patient Rights were noted to be posted on the wall in the Zone I area of the ED. This posting was noted to lack any information related to the patient's right to report grievances to the State Agency (SA) or any contact information for the SA.

3. Review of the current patient handbook and patient's rights information (revised 2/09) provided at admission, revealed no contact information for the SA or information informing patients of the right to report grievances to the SA.

4. This information was discussed and reviewed with the Director of Performance Improvement (PI), Risk Manager/Patient Safety Officer (RM/Patient Safety Officer) at 1:10 p.m. on 10/8/14. He agreed with these findings.

B. Based on review of documents and staff interview it was determined the hospital failed to document the complaint of patient #1 and failed to document an investigation of this complaint and any conclusions or steps taken to resolve the complaint. This failure impacted one (1) of one (1) complaints (patient #1) received and investigated by the State Agency (SA). This failure has the potential to violate the rights of all patients who lodge a complaint with the hospital.

Findings include:

1. The SA received a complaint regarding the ED care provided to patient #1. A complaint investigation was conducted related to this complaint from 10/6 through 10/9/14.

2. All the ED complaints for the third quarter of 2014 (July through September) were provided. There was no complaint recorded regarding the complaint received by the SA related to patient #1.

3. On 10/7/14 at 10:00 a.m. an interview was conducted with ED Physician number #1. He stated he was aware a complaint was made and he responded with a letter of apology after his supervisor discussed the complaint with him.

4. An interview was conducted with the Director of PI, RM/Patient Safety at 12 noon on 10/7/14. He was told Physician #1 stated a letter of apology was sent as a result of the complaint received regarding patient #1. He confirmed he was responsible for logging complaints and stated the complaint was called into administration and given to the ED Director. He stated he had just heard about the physician's letter and he would followup and get more information.

At 1:10 p.m. the Director returned and confirmed the complaint was not recorded. He also confirmed he had no results or actions taken as a result of this complaint.

Based on review of documents and staff interview it was determined the hospital failed to provided a written notice of its decision for two (2) of two (2) complaints involving physician conduct, which were received in the third quarter of 2014 (complaints related to patient #1 and complaint #19). This failure creates the potential for a violation of rights for all patients who file complaints.

Findings include:

1. The ED complaints for the third quarter of 2014 were provided for review. Review of these complaints revealed one (1) complaint, #19, which was called in on 9/19/14 regarding physician conduct.

Further review revealed this complaint was forwarded to the ED Director and then the complaint was closed with no conclusion and no letter of response sent to the complainant. The section of the documentation for noting letter sent was noted as non applicable.

2. During the course of the survey it was learned a complaint was filed on 9/5/14 regarding the care of patient #1 while in the ED. This complaint was not recorded and no letter of response was sent to the complainant.

3. The policy "Patient Complaints," last reviewed 8/14, was provided for review. The policy states in part: "The Director of Performance Improvement will ensure a written response is provided for each grievance."

4. These complaints were reviewed and discussed with the Director of Performance Improvement, Risk Management/Patient Safety at 1:10 p.m. on 10/8/14. He stated there was no letter of response sent for either complaint.

Based on observation and staff interview it was determined the hospital failed to ensure Zone II patients (Emergency Department/Endoscopy) are afforded personal privacy in the Endoscopy Unit. This failure creates the potential for the privacy rights of all patients who receive care in the Endoscopy Unit to be violated.

Findings include:

1. Tour and observation on 10/6/14 at 10:30 a.m. revealed a half wall and open walk through area with no door between the Zone II waiting area and Endoscopy Unit. Patients in the Unit were easily observed from the waiting area. Multiple patients were observed from the waiting area which is utilized by patients and visitors for both the outpatient procedure patients and emergency department patients.

This information was reviewed and discussed with both the Chief Nursing Officer and Director of Emergency Services at the time of the observation. They acknowledged patients in the unit were visible to visitors in the waiting area.

A. Based on observation, review of documents and staff interview it was determined the hospital failed to ensure patients in the Zone II Endoscopy Unit receive care in a safe setting. The placement of Emergency Department (ED) patients in the Unit with Endoscopy patients increases the risk of transmission of infections between the two (2) patient populations. The Zone II space was determined to lack adequate space to meet the needs of ED patients. This failure places all ED and Endoscopy patients at risk for an adverse outcome.

Findings include:

1. Tour and observation in the ED was conducted between 10:20 a.m. and 11:45 a.m. on 10/7/14. The surveyors were accompanied on the tour by both the Emergency Dept (ED) Director and Chief Nursing Officer (CNO). The ED Director stated the ED was divided into two (2) Zones. She stated Zone I includes the sixteen (16) bed ED and the Waiting Area directly outside the Triage rooms. Zone II was observed to include another Waiting Room, which opened off a hallway behind the Zone I Waiting Area. This area was observed to be a shared space with the Outpatient Endoscopy Department. The carpeted waiting room was observed to have no EMTALA Signage. It was also noted there was only a half-wall between the Waiting Area and the Outpatient Endoscopy unit. There was no door covering the entrance to the Outpatient Endoscopy Unit. Multiple patients were observed from the Waiting Area. The Outpatient unit was observed to have thirteen (13) patient areas; two (2) of these glass doors. One space had an actual door and the rest had curtains. It was noted there were two (2) spaces utilized as #12. The ED Director confirmed the Outpatient Endo patients are prepared for the procedure in this unit. She stated they go to the procedure room, then to the Post Anesthesia Unit (PACU) then return to the Outpatient Endo Unit where they remain until ready for discharge home.

An uncovered clean supply cart was observed sitting in the open doorway, partially in the Waiting Area at 11:00 a.m. ED Nurse #1 was interviewed at this time. She stated an ED Registered Nurse and ED Aide work out of the Endo Unit nursing desk area from 11:00 a.m. to 11:00 p.m. She stated the ED usually utilizes cubicles #7 through #12 but the Endo Unit will allow them to use more cubicles if they are not busy. Interview with the Endo Ward Clerk revealed the hospital had twenty-eight (28) Endo procedures scheduled on 10/6/14. She stated the Endo Unit is open Monday through Friday 5:00 a.m. to as late as 10:00 p.m.

The practice of mixing ED patients in the Outpatient Procedure Unit was noted to increase the infection risk of all Outpatient procedure patients. The lack of a full wall and door between the units and the placement of uncovered clean supplies in the doorway, partially sitting on the carpeted floor of the Zone II Waiting Area where all ED patients/visitors pass was noted to be an infection control risk. The clean utility room, which is shared by both ED and Endo staff was noted to open. This room contained saline solution and a variety of clean supplies. This room was observed to also contain an ice machine which was heavily scaled with a white and brown flakey material. The space between the open door of the clean utility room and the walkthrough area to the carpeted waiting area was approximately five (5) feet. The clean supply door was observed to be open during subsequent observations on 10/6/14 at 2:30 p.m. and 3:30 p.m. and 11:30 a.m. on 10/7/14.

During another observation of the Zone II area, conducted at 2:30 p.m. on 10/6/14, Physician's Assistant #1 was noted sitting at the desk area of the Outpatient Endo Unit. She stated she was taking care of ED patients in the Outpatient Unit. Observation revealed the Unit had two (2) bathrooms and she confirmed that both ED and Outpatient/Endo patients may share a bathroom.

The current/undated Triage Guidelines were provided for interview. Review of the Guidelines reveals ED patients with contagious conditions are treated in Zone II. Examples are: poison ivy, scabies, lice, chicken pox, measles, fever less than 103 degrees Fahrenheit, cough, nasal drainage and sore throat and vomiting/diarrhea.

These Triage Guidelines were reviewed and discussed with the ED Director at 1:15 p.m. on 10/8/14. She confirmed these guidelines were being followed for placement of ED patients in the Zone II/Endo Unit for treatment.

2. Interviews with both the Infection Control Officer at 9:05 a.m. on 10/8/14 and the Director of Perioperative Services at 10:10 a.m. on 10/9/14 confirmed the current practice of co-mingling ED and Outpatient Endoscopy patients increased risk of infection. The Perioperative Director stated he was not aware of the Triage Guidelines which indicated patients with contagious conditions are treated in Zone II.

3. Physical Environment survey of the Zone II (ED/Endo) area by the Life Safety Surveyor on 10/9/14 at 10:40 a.m. confirmed Zone II does not meet the minimum space requirements for ED patients.

The hospital has failed to provide care in a safe setting for these patients.

B. Based on observation and staff interview it was determined the hospital failed to maintain policies for the Chest Pain Center (CPC). The failure to maintain policies has the potential to adversely impact the care and condition of all patients who receive care in the CPC.

Findings include:

1. Tour and observation of the Emergency Department (ED) was conducted between 10:20 a.m. and 11:45 a.m. on 10/6/14. The CPC was toured but had no patients at that time. The ED Director stated the CPC opened in April 2013 and is staffed by ED staff. A request was made for CPC policies.

2. Interview was conducted with the ED Director at 10:30 a.m. on 10/7/14. The ED Director stated there were no CPC policies only medical management guidelines for physicians.

Based on record review, staff interview and observation, the hospital does not maintain adequate Emergency Department examination rooms as evidenced by the use of the Endoscopy rooms for Emergency Department when there is "....increased volume...".
Findings include:

1. Review of the floor plan for the Endoscopy Suite- noted as Zone 2, provided by the Director of Facilities & Engineering at ~ 9:35 am on 10/09/14, revealed it is adjacent to the Emergency Department- Zone I.

a. The floor plan for the Endoscopy Suite/ Zone 2 has 12 (twelve) single patient rooms. The square footage of the single patient rooms varies from 60 s.f. (square feet) to 88 s.f.
b. The minimum clear floor area of 120 s.f. (square feet) is required for Emergency care.

(Guidelines for Design and Construction of Health Care Facilities 2010 edition, 2.2-3.1.3.6 Examination/ Treatment room or area (2) Single bed treatment rooms refers to 2.1.-3 Diagnostic and Treatment Locations 2.1-3.2.1.1 Each single-patient examination/treatment room shall have a minimum clear floor area of 120 square feet (11.15 square meters) ).

2. Review of the EMERGENCY SERVICES, initial date: OCTOBER, 1984 and Revised: 02/14, documents under HOURS OF OPERATION:

"The Emergency Department is divided into 2 Zones; Zone I and Zone II both areas available 24/7, Zone II is primarily utilized during the time of day with increased volume in Zone 1 exceeds demands and staffing is adjusted according to volume.

a. Thus, the Emergency Department is utilizing the Endoscopy suite rooms at various times of the day.

3. Interview with the PeriOperstive Director, on 10/09/14 at ~ (approximately) 10:15 a.m., revealed half the rooms are used for the Emergency Department and half the rooms for the Endoscopy (use). He stated in the morning most rooms are used by the Endoscopy unit, and the Emergency Department uses rooms #7 to #12.

4. The Director of Facilities & Engineering acknowledged the required square footage for the Endoscopy rooms, being used as emergency rooms, do not meet the minimum 120 square footage required for emergency department rooms, during review of the floor plan and interview on 10/09/14 at ~ 9:35 a.m.

5. Tour of the Endoscopy unit, Zone II, occurred on 10/09/14 at 10:50 a.m., with the CNO, Director of Facilities & Engineering, and Division Director/ Patient Safety Officer. Two (2) of the twelve rooms in the unit have only two walls -with cubical curtains. The two (2) unoccupied rooms, rooms #2 & #6, were observed.

6. The lack of the required s.f. for the Endoscopy rooms (when used as part of the Emergency Department) was discussed at the conference on 10/09/14 at ~11:20 am, with the CEO, CNO, Director of Facilities & Engineering, and the Division Director/ Patient Safety Officer.

The CEO stated the hospital Emergency Department has increased from 20,000 visits to 40,000 visits a year.

Based on observation, review of documents and staff interview it was determined the hospital's infection control officer failed to ensure staff implemented policy related to mitigation of infections risks in the outpatient endoscopy unit. This failure creates the potential for increased risk of infection transmission for patients who receive services in the outpatient endoscopy unit.

Findings include:

1. Tour and observation in the ED was conducted between 10:20 a.m. and 11:45 a.m. on 10/7/14. The surveyors were accompanied on the tour by both the Emergency Dept (ED) Director and Chief Nursing Officer (CNO). The ED Director stated the ED was divided into two (2) Zones. She stated Zone I includes the sixteen (16) bed ED and the Waiting Area directly outside the Triage rooms. Zone II was observed to include another Waiting Room, which opened off a hallway behind the Zone I Waiting Area. This area was observed to be a shared space with the Outpatient Endoscopy Department. The carpeted waiting room was observed to have no EMTALA Signage. It was also noted there was only a half-wall between the Waiting Area and the Outpatient Endoscopy unit. There was no door covering the entrance to the Outpatient Endoscopy Unit. Multiple patients were observed from the Waiting Area. The Outpatient unit was observed to have thirteen (13) patient areas; two (2) of these glass doors. One (1) space had an actual door and the rest had curtains. It was noted there were two (2) spaces utilized as #12. The ED Director confirmed the Outpatient Endo patients are prepared for the procedure in this unit. She stated they go to the procedure room, then to the Post Anesthesia Unit (PACU) then return to the Outpatient Endo Unit where they remain until ready for discharge home.

An uncovered clean supply cart was observed sitting in the open doorway, partially in the Waiting Area at 11:00 a.m. ED Nurse #1 was interviewed at this time. She stated an ED Registered Nurse and ED Aide work out of the Endo Unit nursing desk area from 11:00 a.m. to 11:00 p.m. She stated the ED usually utilizes cubicles #7 through #12 but the Endo Unit will allow them to use more cubicles if they are not busy. Interview with the Endo Ward Clerk revealed the hospital had twenty-eight (28) Endo procedures scheduled on 10/6/14. She stated the Endo Unit is open Monday through Friday 5:00 a.m. to as late as 10:00 p.m.

The practice of mixing ED patients in the Outpatient Procedure Unit was noted to increase the infection risk of all Outpatient procedure patients. The lack of a full wall and door between the units and the placement of uncovered clean supplies in the doorway, partially sitting on the carpeted floor of the Zone II Waiting Area where all ED patients/visitors pass was noted to be an infection control risk. The clean utility room, which is shared by both ED and Endo staff was noted to open. This room contained saline solution and a variety of clean supplies. This room was observed to also contain an ice machine which was heavily scaled with a white and brown flakey material. The space between the open door of the clean utility room and the walkthrough area to the carpeted waiting area was approximately five (5) feet. The clean supply door was observed to be open during subsequent observations on 10/6/14 at 2:30 p.m., 3:30 p.m. and 11:30 a.m. on 10/7/14.

During another observation of the Zone II area, conducted at 2:30 p.m. on 10/6/14, Physician's Assistant #1 was noted sitting at the desk area of the Outpatient Endo Unit. She stated she was taking care of ED patients in the Outpatient Unit. Observation revealed the Unit had two (2) bathrooms and she confirmed that both ED and Outpatient/Endo patients may share a bathroom.

The current/undated Triage Guidelines were provided for interview. Review of the Guidelines revealed ED patients with contagious conditions may be treated in Zone II. Examples are: poison ivy, scabies, lice, chicken pox, measles, fever less than 103 degrees Fahrenheit, cough, nasal drainage and sore throat and vomiting/diarrhea.

2. Interviews with both the Infection Control Officer on 10/8/14 at 9:05 a.m. and the Director of Perioperative Services on 10/9/14 at 10:10 a.m. confirmed the current practice of co-mingling ED and Outpatient Endoscopy patients increased risk of infection. The Perioperative Director stated he was not aware of the Triage Guidelines which indicated patients with contagious conditions are treated in Zone II.

B. Based on observation and staff interview it was determined hospital failed to ensure the emergency department complied with policy/expectation to refrain from eating and drinking in the triage area. This failure increases the risk of cross contamination of supplies and increases infection risk to all patients.

Findings include:

1. Tour and observation of the Emergency Department was conducted between 10:20 a.m. and 11:45 a.m. on 10/6/14. The ED Director accompanied the surveyors on this tour.

2. Observation in the triage area revealed a 16 oz. bottle of soft drink and coffee cup in the cabinet beside the suture supplies.

3. The ED Director removed the drink and cup. She stated the staff is prohibited by policy from eating or drinking in the triage area but that it remains a chronic problem.

Based on observation, review of policies and staff interview it was determined the outpatient endoscopy unit failed to ensure services were provided in an area free from risk of infection transmission per policy. This failure increases the infection risk for all endoscopy patients.

Findings included:

1. Tour and observation in the ED was conducted between 10:20 a.m. and 11:45 a.m. on 10/7/14. The surveyors were accompanied on the tour by both the ED Director and Chief Nursing Officer (CNO). The ED Director stated the ED was divided into two (2) Zones. She stated Zone I includes the sixteen (16) bed ED and the Waiting Area directly outside the Triage rooms. Zone II was observed to include another Waiting Room, which opened off a hallway behind the Zone I Waiting Area. This area was observed to be a shared space with the Outpatient Endoscopy Department. The carpeted waiting room was observed to have no EMTALA Signage. It was also noted there was only a half-wall between the Waiting Area and the Outpatient Endoscopy unit. There was no door covering the entrance to the Outpatient Endoscopy Unit. Multiple patients were observed from the Waiting Area. The Outpatient unit was observed to have thirteen (13) patient areas; two (2) of these had glass doors. One (1) space had a door and the rest had curtains. It was noted there were two (2) spaces utilized as #12. The ED Director confirmed the Outpatient Endo patients are prepared for the procedure in this unit. She stated they go to the procedure room, then to the Post Anesthesia Unit (PACU) then return to the Outpatient Endo Unit where they remain until ready for discharge home.

An uncovered clean supply cart was observed sitting in the open doorway partially in the Waiting Area at 11:00 a.m. ED Nurse #1 was interviewed at this time. She stated an ED Registered Nurse and ED Aide work out of the Endo Unit nursing desk area from 11:00 a.m. to 11:00 p.m. She stated the ED usually utilizes cubicles #7 through #12 but the Endo Unit will allow them to use more cubicles if they are not busy. Interview with the Endo Ward Clerk revealed the hospital had twenty-eight (28) Endo procedures scheduled on 10/6/14. She stated the Endo Unit is open Monday through Friday 5:00 a.m. to as late as 10:00 p.m.

The practice of mixing ED patients in the Outpatient Procedure Unit was noted to increase the infection risk of all Outpatient procedure patients. The lack of a full wall and door between the units and the placement of uncovered clean supplies in the doorway, partially sitting on the carpeted floor of the Zone II Waiting Area where all ED patients/visitors pass was noted to be an infection control risk. The clean utility room, which is shared by both ED and Endo staff was noted to be open. This room contained saline solution and a variety of clean supplies. This room was observed to also contain an ice machine which was heavily scaled with a white and brown flakey material. The space between the open door of the clean utility room and the walkthrough area to the carpeted waiting area was approximately five (5) feet. The clean supply door was observed to be open during subsequent observations on 10/6/14 at 2:30 p.m., 3:30 p.m. and 11:30 a.m. on 10/7/14.

During another observation of the Zone II area, conducted at 2:30 p.m. on 10/6/14, Physician's Assistant #1 was noted sitting at the desk area of the Outpatient Endo Unit. She stated she was taking care of ED patients in the Outpatient Unit. Observation revealed the Unit had two (2) bathrooms and she confirmed that both ED and Outpatient/Endo patients may share a bathroom.

The current/undated Triage Guidelines were provided for interview. Review of the Guidelines reveals ED patients with contagious conditions may be treated in Zone II. Examples are: poison ivy, scabies, lice, chicken pox, measles, fever less than 103 degrees Fahrenheit, cough, nasal drainage and sore throat and vomiting/diarrhea.

These Triage Guidelines were reviewed and discussed with the ED Director at 1:15 p.m. on 10/8/14. She confirmed these guidelines were being followed for placement of ED patients in the Zone II/Endo Unit for treatment.

2. Interview was conducted at 10:10 a.m. on 10/9/14 with the Director of Perioperative Services. The above findings were reviewed and discussed. He stated he was not aware of the Triage Guidelines which direct that contagious patients may be placed in Zone II of the ED which is in the Endo Unit. He also acknowledged these types of patients pose an infection risk to the Endo patients.

3. The Infection Control Department Policy "Prevention of Healthcare Associated Infections," revised 12/13, was provided for review. It notes in part: "The Infection Control Department will identify practices that may affect the risk of transmission of microorganisms within Weirton Medical Center...adequate space between patients will be provided. Patients who are susceptible to infection will be separated from those who are likely to have reservoirs for microorganisms (those with draining lesions, fecal incontinence)."

The Infection Control Policy, "Policy and Procedure for the Out Patient Center," last revised 1/14, was provided for review. It notes in part: "Scope: All persons performing procedures and/or participating in the activities in the Out Patient Center. All persons will be responsible for the knowledge of and adherence to all polices and procedures in the Infection Control Manual."

Based on observation, policy review and staff interview it was determined the Emergency Department (ED) failed to maintain documentation for checking the automated external defibrillator (AED) per policy. The failure to maintain emergency equipment as required has the potential to adversely impact the care and condition of any person who experiences a medical emergency.

Findings include:

1. A tour of the ED on 10/6/14 at 10:30 a.m. revealed an emergency cart with AED which was located in the triage area. A request was made for the AED log which reflects staff is checking the emergency equipment. The ED Director indicated the AED is checked by another department. Another request for the log was made on 10/7/14.

2. The policy "AED-First Save," last reviewed 9/13, was provided for review. The policy notes in part a requirement for: "Daily inspection of the unit to ensue that the status indicator light is green."

3. This failure to provide a log was discussed with the Director of Performance Improvement, Risk Manager/Patient Safety at 11:30 a.m. on 10/8/14. He stated that previously the Cardiopulmonary Department was responsible to check all AEDs in the hospital. He stated that approximately two (2) years ago that practice changed and at that time the ED was responsible to check the AED. He confirmed no log has been maintained by the ED.