HospitalInspections.org

Based on document review observations and interview, the hospital failed to inform all patients, treated in the Adult and Children's Emergency Departments and all inpatients on 8/13/14 with information on how to file a complaint with the State Agency, resulting in all current patients being deprived of information on their right to file a complaint with the State Agency. Findings include:

Policy Review:
On 8/14/14 at approximately 1400, policy review revealed that the facility's policy titled, Patient Complaint/Grievance Process, dated "2/18/13," was reviewed. The policy does not provide a process for informing all patients of the right to file a complaint with the State Agency that has licensure survey responsibility.

Observations & Interviews:
1. On 8/13/14 at 1220, the Adult Emergency Department was toured. No posting with information on filing a complaint with the State survey agency was found.
2. On 8/13/14 at 1310, the patient information packet offered to patients in the Adult Emergency Department by a Patient Registration Specialist (staff G) was reviewed. No information on how to file a complaint with the State survey agency was included in the packet.
3. On 8/13/14 at 1500, the Children's Emergency Department triage and waiting room was toured. No posting with information on filing a complaint with the State survey agency was found.
4. On 8/13/14 at approximately 1510, the patient information packet offered to patients in the Children's Emergency Department was reviewed with Patient Registration Specialist (staff E). No information on how to file a complaint with the State survey agency was included in the packet of materials available to patients and families.
5. The above findings were verified by staff B during tours of the Adult and Children's Emergency Departments on 8/13/14 between 1215 and 1530.
6. On 8/13/14 at 1535, staff F was interviewed in the hospital's Patient Registration Department. Staff H confirmed that the hospital does not provide patients with information on how to file a complaint with the State survey agency, as part of the admission registration process. Staff F stated that a "Resource Guide," in all hospital rooms, provides patients with information on how to file a complaint.
7. On 8/13/14 at 1545 staff H, a Nurse Manager on an Adult Inpatient Unit, stated that the "Resource Guide," available in all patient rooms, provided patients with information on how to file a complaint. A "Resource Guide" from a patient room on the 4 th Floor was provided for review.
8. On 8/14/14 at 0920 staff B confirmed that the "Resource Guide," available in all patient rooms, does not contain information on how to file a complaint with the State survey agency.

Based on observation and interview 1 of 1 patients in the hospital's Adult Emergency Department (patient #1) was not provided with personal privacy during treatment, increasing the risk of loss of privacy for all patients treated in the Emergency Department. Findings include:

Observation:
On 8/14/14 from 1200-1207 patient #1 was observed with a basin in her lap having a blood draw in a treatment bay in the Adult Emergency Department. The privacy curtain was not drawn. A visitor was standing in the same corridor outside patient #1's treatment bay. These observations were confirmed by staff B.

Interview:
On 8/14/14 at 1207 a Nursing Tech (staff C) positioned outside patient #1's treatment bay was asked why the curtain was not closed while the patient was having blood drawn. Staff C stated that patient #1 was one of two patients that he was assigned to watch at all times. Staff C stated that the only way he could monitor two patients at once was to keep their privacy curtains open.