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Based on document review, observation and staff interview it was determined the hospital failed to provide prompt resolution of a patient grievance (A 118), failed to provide informed consent (A 131), failed to ensure privacy was met (A 142), failed to ensure patient had the right to personal privacy (A 143) and failed to ensure the patient had the right to be free of all forms of abuse (A 145).

Based on document review and staff interview it was determined the hospital failed to follow their grievance and safety reporting process in one (1) out of thirty (30) medical records reviewed (patient #3). This failure led to the possible missed abuse of patient #3.

Findings include:

1. A review of the medical record for patient #3 revealed a thirty-seven (37) year old female that was admitted to the emergency department (ED) at General Division on 9/6/20 with a fracture of the mandible and subdural hematoma status post an all-terrain vehicle (ATV) accident. The patient had surgery and was placed in the Surgical Trauma Intensive Care Unit (STICU) and then eventually transferred to the step-down unit on Five (5) South until her time of discharge on 9/15/20. On the date of discharge she complained to the Nurse Practitioner (NP) that she couldn't talk and pointed to one of the nurses taking care of her.

2. An interview was conducted with Registered Nurse (RN) #1 on 12/1/20 at 10:55 a.m. She stated she had no recollection of patient #3 or the patient saying she was too rough with her. When questioned if the Manager of the unit spoke to her about the incident, she denied any knowledge of being questioned about the incident.

3. A telephone interview was conducted with the Manager of Five (5) South on 12/2/20 at 8:30 a.m. When questioned if she spoke with RN #1 about incident with patient #3, she stated she had spoke with her about the incident. She stated the mother had filed a formal complaint and during the investigation RN #1 was questioned.

4. A telephone interview was conducted with the Director of Patient Experience on 12/2/20 at 10:00 a.m. She stated anytime there was a complaint we want to start the recovery process before they leave the hospital if at all possible. She stated, "You do not want to wait until the patient goes home. The patient should be talked to before they leave the hospital."

5. A telephone interview was conducted with NP #1 on 12/2/20 at 10:25 a.m. During the interview she stated, "I did not witness any abuse of the patient but what I did see when I came in the room the patient was sobbing, crying and shaking. When I asked what was wrong she shook her head and pointed to RN #1. She begged me to just get her out of there. She said she wanted to go and she did not want to be there anymore. She begged me not to leave her alone in the room so I stayed with her. She reminded me of someone that was terrified." When questioned if she reported the incident to anyone she stated, "I told the Coordinator on the unit and reported it to her Manager." She further reported the patient had a Glasgow coma scale (GCS) of fifteen (15) at the time of discharge.

6. A telephone interview was conducted with the Clinical Coordinator #1 on 12/2/20 at 10:50 a.m. During the interview she stated, "NP #1 came to me and told me she was concerned because a patient was pretty shaken up. I walked down to the unit and asked the nurses what was going on with the patient and they said she was crazy and she was fine so I left the unit and never went in to question the patient." When told the patient was documented as being alert and oriented with a GCS of fifteen (15), she stated she should have gone in and talked to the patient.

7. A follow-up telephone interview was conducted with the Manger of Five (5) South on 12/2/20 at 11:10 a.m. She stated she was never made aware of the instance until the complaint was filed by the mother. When asked if she had spoken to the NP about the instance, she stated not until today (12/2/20). She agreed that the Clinical Coordinator should have went into the room and spoken with the patient.

8. A review of the hospital document entitled 'Patient Safety Event Reporting,' publication date 3/6/19, states: "Employees are expected and empowered to report any unsafe conditions of which they are aware via the ESERS (Electronic Safety Reporting System), even if the condition has not resulted in an actual event."

9. A review of the hospital document entitled 'Response to Patient Abuse, Neglect, and Exploitation,' publication date 1/20/20, states in part: "Any event or occurrence of possible abuse, neglect, or exploitation that is observed, made known to, or reported to CAMC staff, is to be reported to the department manager and Associate Administrator (or Administrator on call) of the patient care area at the time the possible abuse, neglect, or exploitation is identified ...Any medical, safety, or security needs of the patient or other persons involved in the suspected event shall be immediately addressed. The department manager or designee, will assure the safety of the patient, notify the attending physician, and take immediate employee action. The department manager shall ensure that a Safety Report is completed on all reported or identified events ... The caregiver involved in the allegation may be reassigned or removed from duty pending investigation. Any time a potential case of abuse, neglect, or exploitation is reported, an investigation will be initiated. The following departments will be notified of a report of an abuse allegation and will collaboratively initiate/conduct an investigation: Human Resources, Risk Management/Safety, Security, Professional Nursing and Office of General Council."

10. An interview was conducted with the Director of Corporate Compliance on 12/2/20 at 4:25 p.m. During the interview she concurred the hospital failed to follow their incident reporting and grievance process.

Based on document review and staff interview it was revealed the facility failed to have a proper informed consent form signed prior to providing services in the emergency department (ED). This failure was identified in one (1) of thirty (30) medical records reviewed (patient #4). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #4 revealed patient #4 arrived at the ED on 7/23/20 at 2:47 a.m. by emergency medical services. It is documented patient #4 arrived intubated and sedated. The physician's documentation showed patient #4 was in respiratory failure. Patient #4 had a Glasgow coma score of three (3), no verbal response and no motor response was documented by the triage nurse. A nursing note entered on 7/23/20 at 6:59 a.m. stated in part: "Patient arrived on floor via ER RN. Pt. on vent." A consent for treatment signed by the patient and dated 7/23/20 at 3:30 a.m. was located in the medical record. Patient #4 was intubated and sedated at this time and no documentation was noted in the medical record who signed the consent. Social Services documented on 7/23/20 at 2:11 p.m. a call was made to the medical power of attorney with no answer.

2. An interview was conducted with the Coordinator Regulatory Agency on 12/3/20 at 9:02 a.m. When asked who signed the patient's consent for treatment, she stated they do not know. She stated they have asked the registration clerk but she doesn't remember due to the patient was seen in July and the video of registration only goes back to September 2020. She concurred the patient did not sign the consent due to the patient was intubated and sedated.

Based on document review, observation and staff interview it was determined the hospital failed to ensure the privacy of patient #2 and patients waiting to be seen by the Provider In Triage (PIT). This failure has the potential to lead to a patient/patient's personal information being compromised.

Findings include:

1. A review of the medical record for patient #1 revealed a thirty-nine (39) year old male that presented to the emergency department (ED) on 11/1/20 with a complaint of sharp, right sided groin pain. The patient was diagnosed with kidney stones and discharged to home. At the time of discharge the patient was provided the discharge instructions by the staff for patient #2. He was discharged from the ED at 8:00 p.m. A signature was not found in the record stating the patient received his discharge instructions.

2. A review of the medical record for patient #2 revealed a sixty-three (63) year old female that presented to the ED on 11/1/20 with a complaint of right sided flank pain. The patient was diagnosed with an acute urinary tract infection and right ureteral stone. She was discharged from the ED at 8:05 p.m. She was provided with discharge instructions that were signed for by the patient.

3. A review of the hospital document entitled 'ED Discharge Instructions,' publication date 4/7/20, states, "Have the patient or other legally responsible person sign the signature page of the discharge instruction form."

4. An interview conducted with the Director of Corporate Compliance on 11/30/20 at 3:00 p.m. revealed there was not a signed form in the medical record showing patient #1 received his discharge instructions.

5. An interview was conducted with the Director of ED on 11/30/20 at 3:35 p.m. During the interview she stated, "I contacted the patient on 11/2/20 and apologized for the error. I told him I would have his discharge instructions waiting to be picked up and asked him to bring the other patient's discharge instructions back. He did pick up his discharge instructions but he refused to return the other patient's." She stated she notified the privacy officer and the privacy officer contacted patient #2 about the breach in privacy. She stated she coached the nurse about proper discharge procedure.

6. A review was conducted of the hospital document entitled 'Safety Event Entry' dated 11/4/20 at 7:05 a.m. The entry states in part: " ...called me 11/3/20 and reported he was coming to pick up his discharge (DC) instructions. I asked him to bring patient #2's DC instructions. He refused to return patient #2's DC instructions." The document was signed by the Director of the ED. A review of a letter dated 11/3/20 revealed patient #2 was notified of the confidentiality breach.

7. A tour of the ED waiting room was conducted on 11/30/20 at 3:40 p.m. During the tour this surveyor overheard a nurse discussing the patient's medical history with the patient in an area referred to as the Provider In Triage (PIT) area. This area is located next to the main ED waiting room entrance. The area is an open area that contains an approximate four (4) foot high divider that is used to provide privacy for the patient being seen by the provider. There are no walls, glass or other measures used to prevent anyone waiting in the ED waiting room from overhearing the patient's personal information. The area is used for the provider to examine patient's who have a lower acuity level.

8. A review of the hospital document entitled 'Confidentiality Policy,' publication date 10/21/19, states: "CAMC Health System, Inc. and its subsidiary companies (hereafter "Company") are entrusted with confidential and sensitive information respecting patient care, personnel and medical staff, as well as financial and proprietary business issues. The Company requires that all confidential information be accessible on a "need to know" basis, and that those persons or entities entrusted to with access to confidential information understand the necessity of maintaining the confidentiality of this information as well as the consequences for violating the Company's confidentiality policies."

9. The document further states: "Examples of confidential information include but are not limited to: Current and past patient and medical service provider information, including patient financial information, medical records, billing records, and hard copy reports."

10. The Director of Corporate Compliance and the Director of ED concurred this was a breach in patient privacy on 11/20/20 at 3:55 p.m.

Based on document review, observation and staff interview it was determined the hospital failed to ensure that patient's personal privacy was met. This failure has the potential to compromise the confidentiality of any patient receiving the services of this emergency department (ED).

Findings include:

1. A review of the medical record for patient #1 revealed a thirty-nine (39) year old male that presented to the ED on 11/1/20 with a complaint of sharp, right sided groin pain. The patient was diagnosed with kidney stones and discharged to home. At the time of discharge the patient was provided the discharge instructions by the staff for patient #2. He was discharged from the ED at 8:00 p.m. A signature was not found in the record stating the patient received his discharge instructions.

2. A review of the medical record for patient #2 revealed a sixty-three (63) year old female that presented to the ED on 11/1/20 with a complaint of right sided flank pain. The patient was diagnosed with an acute urinary tract infection and right ureteral stone. She was discharged from the ED at 8:05 p.m. She was provided with discharge instructions that were signed for by the patient.

3. A review of the hospital document entitled 'ED Discharge Instructions,' publication date 4/7/20, states, "Have the patient or other legally responsible person sign the signature page of the discharge instruction form."

4. An interview conducted with the Director of Corporate Compliance on 11/30/20 at 3:00 p.m. revealed there was not a signed form in the medical record showing patient #1 received his discharge instructions.

5. An interview was conducted with the Director of ED on 11/30/20 at 3:35 p.m. During the interview she stated, "I contacted the patient on 11/2/20 and apologized for the error. I told him I would have his discharge instructions waiting to be picked up and asked him to bring the other patient's discharge instructions back. He did pick up his discharge instructions but he refused to return the other patient's." She stated she notified the privacy officer and the privacy officer contacted patient #2 about the breach in privacy. She stated she coached the nurse about proper discharge procedure.

6. A review was conducted of the hospital document entitled 'Safety Event Entry' dated 11/4/20 at 7:05 a.m. The entry states in part: " ...called me 11/3/20 and reported he was coming to pick up his discharge (DC) instructions. I asked him to bring patient #2's DC instructions. He refused to return patient #2's DC instructions." The document was signed by the Director of the ED. A review of a letter dated 11/3/20 revealed patient #2 was notified of the confidentiality breach.

7. A tour of the ED waiting room was conducted on 11/30/20 at 3:40 p.m. During the tour this surveyor overheard a nurse discussing the patient's medical history with the patient in an area referred to as the Provider in Triage (PIT) area. This area is located next to the main ED waiting room entrance. The area is an open area that contains an approximate four (4) foot high divider that is used to provide privacy for the patient being seen by the provider. There are no walls, glass or other measures used to prevent anyone waiting in the ED waiting room from overhearing the patient's personal information. The area is used for the provider to examine patient's who have a lower acuity level.

8. A review of the hospital document entitled 'Confidentiality Policy,' publication date 10/21/19, states: "CAMC Health System, Inc. and its subsidiary companies (hereafter "Company") are entrusted with confidential and sensitive information respecting patient care, personnel and medical staff, as well as financial and proprietary business issues. The Company requires that all confidential information be accessible on a "need to know" basis, and that those persons or entities entrusted to with access to confidential information understand the necessity of maintaining the confidentiality of this information as well as the consequences for violating the Company's confidentiality policies."

9. The document further states: "Examples of confidential information include but are not limited to: Current and past patient and medical service provider information, including patient financial information, medical records, billing records, and hard copy reports."

10. The Director of Corporate Compliance and the Director of ED concurred this was a breach in patient privacy on 11/20/20 at 3:55 p.m.

Based on document review and staff interview it was determined the hospital failed to follow their own policy leading to a possible missed case of abuse for patient #3. This failure could lead to episodes of missed abuse for patients being cared for on Five (5) South.

Findings include:

1. A review of the medical record for patient #3 revealed a thirty-seven (37) year old female that was admitted to the emergency department (ED) at General Division on 9/6/20 with a fracture of the mandible and subdural hematoma status post an all-terrain vehicle (ATV) accident. The patient had surgery and was placed in the Surgical Trauma Intensive Care Unit (STICU) and then eventually transferred to the step-down unit on Five (5) South until her time of discharge on 9/15/20. On the date of discharge she complained to the Nurse Practitioner (NP) that she couldn't talk and pointed to one of the nurses taking care of her.

2. An interview was conducted with Registered Nurse (RN) #1 on 12/1/20 at 10:55 a.m. She stated she had no recollection of patient #3 or the patient saying she was too rough with her. When questioned if the Manager of the unit spoke to her about the incident, she denied any knowledge of being questioned about the incident.

3. A telephone interview was conducted with the Manager of Five (5) South on 12/2/20 at 8:30 a.m. When questioned if she spoke with RN #1 about incident with patient #3, she stated she had spoke with her about the incident. She stated the mother had filed a formal complaint and during the investigation RN #1 was questioned.

4. A telephone interview was conducted with the Director of Patient Experience on 12/2/20 at 10:00 a.m. She stated anytime there was a complaint we want to start the recovery process before they leave the hospital if at all possible. She stated, "You do not want to wait until the patient goes home. The patient should be talked to before they leave the hospital."

5. A telephone interview was conducted with NP #1 on 12/2/20 at 10:25 a.m. During the interview she stated, "I did not witness any abuse of the patient but what I did see when I came in the room the patient was sobbing, crying and shaking. When I asked what was wrong she shook her head and pointed to RN #1. She begged me to just get her out of there. She said she wanted to go and she did not want to be there anymore. She begged me not to leave her alone in the room so I stayed with her. She reminded me of someone that was terrified." When questioned if she reported the incident to anyone she stated, "I told the Coordinator on the unit and reported it to her Manager." She further reported the patient had a Glasgow coma scale (GCS) of fifteen (15) at the time of discharge.

6. A telephone interview was conducted with the Clinical Coordinator #1 on 12/2/20 at 10:50 a.m. During the interview she stated, "NP #1 came to me and told me she was concerned because a patient was pretty shaken up. I walked down to the unit and asked the nurses what was going on with the patient and they said she was crazy and she was fine so I left the unit and never went in to question the patient." When told the patient was documented as being alert and oriented with a GCS of fifteen (15), she stated she should have gone in and talked to the patient.

7. A follow-up telephone interview was conducted with the Manger of Five (5) South on 12/2/20 at 11:10 a.m. She stated she was never made aware of the instance until the complaint was filed by the mother. When asked if she had spoken to the NP about the instance, she stated not until today (12/2/20). She agreed that the Clinical Coordinator should have went into the room and spoken with the patient.

8. A review of the hospital document entitled 'Patient Safety Event Reporting,' publication date 3/6/19, states: "Employees are expected and empowered to report any unsafe conditions of which they are aware via the ESERS (Electronic Safety Reporting System), even if the condition has not resulted in an actual event."

9. A review of the hospital document entitled 'Response to Patient Abuse, Neglect, and Exploitation,' publication date 1/20/20, states in part: "Any event or occurrence of possible abuse, neglect, or exploitation that is observed, made known to, or reported to CAMC staff, is to be reported to the department manager and Associate Administrator (or Administrator on call) of the patient care area at the time the possible abuse, neglect, or exploitation is identified ...Any medical, safety, or security needs of the patient or other persons involved in the suspected event shall be immediately addressed. The department manager or designee, will assure the safety of the patient, notify the attending physician, and take immediate employee action. The department manager shall ensure that a Safety Report is completed on all reported or identified events ... The caregiver involved in the allegation may be reassigned or removed from duty pending investigation. Any time a potential case of abuse, neglect, or exploitation is reported, an investigation will be initiated. The following departments will be notified of a report of an abuse allegation and will collaboratively initiate/conduct an investigation: Human Resources, Risk Management/Safety, Security, Professional Nursing and Office of General Council."

10. An interview was conducted with the Director of Corporate Compliance on 12/2/20 at 4:25 p.m. During the interview she concurred the hospital failed to follow their incident reporting and grievance process.

Based on a tour of the facility and staff interviews it was revealed the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure was identified on a tour of the Emergency Department (ED) and a tour of Three (3) South. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the ED waiting room was conducted on 11/30/20 at approximately 2:30 p.m. The ED registration and triage area had seven (7) transport chairs (wheelchairs) located to the right of the triage area. Five (5) of the seven (7) transport chairs were marked as in use. Two (2) of the chairs had no tags on them. A dirty laundry hamper with dirty supplies laying on the hamper was located with the transport chairs. During the tour a security guard brought a transport chair, which was located outside the EKG room, and placed it with the other transport chairs. No one cleaned the transport chair. Five (5) of the transport chairs had visible debris located on the chairs. One (1) of the transport chairs had a dirty blanket on the seat. During the tour the surveyor asked the Director of Regulatory Compliance if the transport chairs were cleaned before placing them together. She stated the chairs are to be cleaned after each use. When the Director of the ED joined the tour, she was asked about cleaning the transport chairs and she stated all transport chairs are to be cleaned after each use. She stated she is unsure why a dirty laundry hamper was located with the transport chairs. She stated the staff do not tag when a transport chair is cleaned but they know to clean between patients. The triage nurse cleaned a transport chair before returning it to the location of the other transport chairs and put clean and dirty transport chairs together. The Director of the ED had a staff member to start cleaning the transport chairs during the tour.

2. A tour of Three (3) South was conducted on 11/30/20 at 4:30 p.m. The unit is a COVID-19 unit only. During the tour this surveyor observed an aide come out of a COVID patient room with a control air purifying respirator (CAPR) on. The aide was observed touching the shield and helmet on the CAPR, then touching the desk and going over to a table laying the CAPR down. The CAPR was never cleaned. The aide then went over to pick the CAPR back up and walked down the hall to another patient room never cleaning the CAPR.

3. An interview was conducted with the Director of Corporate Compliance on 11/30/20 at 4:40 p.m. and she concurred this was a breach in the infection control process.