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Based on staff interview and review of complaint documentation and hospital policies, it was determined the hospital failed to ensure a process for the prompt resolution of patient grievances was established. This affected grievances filed by 4 of 5 patients (#5, #6, #8, and #10) that were reviewed. The lack of a clear grievance process had the potential to interfere with submission and resolution of complaints of all patients receiving care in the hospital. Findings include:

The policy "Patient/Visitor Complaints or Grievances," dated 8/2008, stated the definition of a complaint was an expression of concern or dissatisfaction that could be resolved at the department level within 1 calendar day. The policy stated the definition of a grievance was an expression of concern or dissatisfaction that could not be resolved within 1 calendar day, was presented in writing, or involved allegations of abuse or neglect. The policy stated investigations of grievances would be documented, but it did not state what steps might be taken to investigate grievances.

The hospital's definition of grievance was less restrictive than the CMS definition from the "State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals" revised 11/20/15. Appendix A stated "A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient 's care (when the complaint is not resolved at the time of the complaint by staff present)." The lack of direction in the policy caused confusion for staff responsible for handling complaints and grievances. Examples include:

a. A "Complaint Record" stated a complaint regarding the care provided by physicians to Patient #5 was received on 3/03/16. The document stated Patient #5 had to return to the hospital 24 hours after he was discharged. The document stated "Discussed [with Social Services] and hospitalist need to eval home situation & [Power of Attorney]." The document contained sections labeled "INVESTIGATION" and ACTION/F/U" which were left blank. Patient #5's concerns required an investigation of the medical care provided during his stay and a review of the care he received. This elevated it to the level of a grievance. An investigation and actions taken by the hospital were not documented. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16 beginning at 1:30 PM. She stated the issues related to Patient #5 were not considered grievances because they were handled the day the concerns were presented to staff. She stated steps taken to investigate the concerns were not documented. The PARMC stated an investigation was not conducted. She stated a written response to the complainant was not generated.

b. A "Complaint Record" stated a complaint regarding the care provided by a physician, communication between staff and patients, and incomplete discharge instructions, was received on 2/23/16. The document stated Patient #8's representative called on 2/23/16 and Patient #8 sent an email on 2/24/16 regarding the matter. The document stated hospital staff responded to Patient #8 on 2/23/16 with an email acknowledging the complaint.

Patient #8's concerns required an investigation of the care provided and a review of her discharge process. The submission in writing, and the need for investigation, elevated it to the level of a grievance. An investigation and actions taken by the hospital were not documented. A written response to the complainant, regarding the hospital's findings, was not documented .

The Vice President for Patient Care Services was interviewed on 6/22/16, beginning at 2:10 PM. She stated the issues related to Patient #8 were not investigated. She stated a written response to the complainant was not generated except for the acknowledgement of the grievance.

c. A "Complaint Record" stated a complaint was received on 3/07/16, regarding the care provided to Patient #6 during a recent visit to the Emergency Department. Patient #6's concerns required an investigation of the medical care provided during his stay and a review of the care he received. This elevated the complaint to the level of a grievance. The document stated a staff member from the hospital's psychiatric unit reviewed Patient #6's medical record. The document did not include an investigation of the care provided to Patient #6. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16, beginning at 1:30 PM. She stated the issues related to Patient #6 were not considered grievances because his discharge from the Emergency Department was appropriate. She stated the steps taken to investigate the concerns were not documented. The PARMC stated an investigation was not conducted. She stated a written response to the complainant was not generated.

d. A "Complaint Record" stated a complaint regarding the care provided to Patient #10 was received on 9/19/14. The document stated Patient #10's representative cited problems with nursing, pharmacy services, and discharge planning during a recent inpatient stay. Patient #10's concerns required an investigation of the care provided during her stay and a review of the care she received. This elevated the complaint to the level of a grievance.

The "Complaint Record" stated the PARMC responded to Patient #10's complaint on 9/26/14. The document stated she met with the patient's family and talked with them about the issues. The document contained a section titled "INVESTIGATION:" and a section titled "ACTION/F/U:" Both sections were blank. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16, beginning at 1:30 PM. She stated the issues related to Patient #10 was considered to be a grievance. She stated the steps taken to investigate the concerns were not documented. She stated a written response to the complainant was not generated.

The hospital failed to define grievances accurately and failed to investigate grievances and issue written responses.

Based on staff interview and review of meeting minutes, it was determined the hospital's Governing Body failed to ensure responsibility and oversight for the effective operation of the grievance process was provided. This resulted in the inability of the hospital to maintain an effective grievance process. Findings include:

The grievance process at the hospital was overseen by the Quality/Patient Safety Council. Minutes from the Council for the time period 6/01/15 - 6/21/16 were reviewed. Ten sets of meeting minutes were provided for review, dated between 6/23/15 and 5/24/16. The Committee did not meet in December 2015. Eight of the minutes simply stated "Complaints" were reviewed. The 2/23/16 minutes did not mention complaints and the 5/24/16 minutes stated "Complaints-[staff name] out of town." No meeting minutes actually mentioned grievances.

The Care Management Director was interviewed on 6/23/16, beginning at 1:15 PM. She stated the Quality/Patient Safety Council was responsible for the hospital's grievance process. She stated there was no documentation of oversight of the grievance process by the Committee.

The Governing Body did not provide oversight for the hospital's grievance process.

Based on staff interview and review of complaint documentation, it was determined the hospital failed to ensure written notice of the actions taken to investigate and resolve grievances was provided to 4 of 5 patients (#5, #6, #8, and #10) whose grievances were reviewed. This resulted in a lack of information being provided to patients. Findings include:

1. A "Complaint Record" stated a complaint regarding the care provided by physicians to Patient #5 was received on 3/03/16. The document stated Patient #5 had to return to the hospital 24 hours after he was discharged. The document stated "Discussed [with Social Services] and hospitalist need to eval home situation & [Power of Attorney]." Patient #5's concerns required an investigation of the medical care provided during his stay and a review of the care he received. This elevated it to the level of a grievance. An investigation and actions taken by the hospital were not documented. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16, beginning at 1:30 PM. The PARMC stated an investigation was not conducted. She stated a written response to the complainant was not generated.

The hospital failed to provide a written respoonse to Patient #5.

2. A "Complaint Record" stated a complaint regarding the care provided by a physician, communication between staff and patients, and incomplete discharge instructions, was received on 2/23/16. The document stated Patient #8's representative called on 2/23/16 and Patient #8 sent an email on 2/24/16 regarding the matter. The document stated hospital staff responded to Patient #8 on 2/23/16 with an email acknowledging the complaint.

Patient #8's concerns required an investigation of the care provided and a review of her discharge process. An investigation and actions taken by the hospital were not documented. A written response to the complainant was not documented regarding the hospital's findings.

The Vice President for Patient Care Services was interviewed on 6/22/16, beginning at 2:10 PM. She stated the issues related to Patient #8 were not investigated. She stated a written response to the complainant was not generated except for the acknowledgement of the grievance.

The hospital failed to provide a written respoonse to Patient #8.

3. A "Complaint Record" stated a complaint was received on 3/07/16, regarding the care provided to Patient #6 during a recent visit to the Emergency Department. The document did not include an investigation of the care provided to Patient #6. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16, beginning at 1:30 PM. She stated the steps taken to investigate the concerns were not documented. The PARMC stated an investigation was not conducted. She stated a written response to the complainant was not generated.

The hospital failed to provide a written respoonse to Patient #6.

d. A "Complaint Record" stated a complaint regarding the care provided to Patient #10 was received on 9/19/14. The document stated Patient #10's representative cited problems with nursing, pharmacy services, and discharge planning during a recent inpatient stay.

The "Complaint Record" stated the PARMC responded to Patient #10's complaint on 9/26/14. The document stated she met with the patient's family and talked with them about the issues. The document contained a section titled "INVESTIGATION:" and a section titled "ACTION/F/U:." Both sections were blank. A written response to the complainant was not documented.

The PARMC was interviewed on 6/22/16, beginning at 1:30 PM. She stated the steps taken to investigate the concerns were not documented. She stated a written response to the complainant was not generated.

The hospital failed to provide a written respoonse to Patient #10.

Based on observation, policy review, facility document review, and staff interviews, it was determined the facility failed to safeguard the personal privacy of patients on the Medical Floor. This had the potential for violations of patients' privacy during personal hygiene activities and treatments without patients' knowledge or consent. Findings include:

During a tour of the Medical Floor on 6/22/16, beginning at 11:30 AM, it was observed that 15 out of 22 patient rooms had stationary, fixed surveillance cameras located inside and to the upper left wall corner above the door. The surveillance cameras were aimed at the patients' bed and surrounding area. The surveillance cameras were controlled, and viewed, from the nurse's station on a single monitor. The monitor could display one or more live surveillance camera feeds from patient rooms on the Medical Floor. The monitor was directly visible to other staff and visitors standing in front of the nurse's station and from down the pathway.

The facility failed to protect patients' personal privacy as follows:

1. A facility policy "PATIENT RIGHTS AND RESPONSIBILITIES GUIDELINES," revised 8/10/05, was reviewed. The policy stated "The patient has the right to considerate and respectful care, with recognition of his personal dignity, value, and belief systems." Additionally, it stated "The hospital respects the need of patients for confidentiality, privacy, and security." The policy also stated "The patient has the right to refuse care, treatment, and service to the extent permitted by law, and to be informed of the medical consequences of his/her action." The policy did not outline how the facility would protect patients' privacy and security.

A facility policy "FALL PREVENTION GUIDELINES and High Risk," revised 2/23/15, was reviewed. The policy stated "High risk [patients designated as high fall risk] interventions which must be in place unless documented otherwise: A. Use of surveillance cameras for patients on Medical." The policy did not include scope or criteria for surveillance camera use. The policy did not provide direction to staff regarding the protection of privacy. Additionally, the policy did not explain how patients would be informed of the surveillance.

A facility document "CONSENT FOR ADMISSION, TREATMENT & SERVICES," was reviewed. The document did not mention or explain patient consent for room-based camera surveillance.

A facility document, "St. Joseph Patient Handbook," was reviewed. The document did not include language regarding patient consent for room-based camera surveillance or patient privacy.

2. The Care Management Director was interviewed on 6/22/16, at 1:40 PM. She stated she was unaware whether a consent was signed by patients when they were placed in a room with a surveillance camera. The Care Management Director stated the surveillance cameras were a tool used for fall prevention on the Medical Floor, but was unable to provide a hospital policy governing the surveillance cameras and their scope. She confirmed a written consent was not documented in the patients' medical record regarding room-based surveillance cameras.

The Medical Floor Nurse Manager was interviewed on 6/22/16, at 3:10 PM. She confirmed a written consent was not documented in the patients' medical record regarding room-based surveillance cameras. The Nurse Manager stated patients consented verbally for surveillance camera use. She stated this verbal consent was not documented.

The Director of Patient Care Services was interviewed on 6/22/16, at 3:45 PM. She stated a written consent was not documented in the patients' medical record regarding room-based surveillance cameras. The Director of Patient Care Services verified the monitor at the nurses station, which displayed the patients' surveillance camera images, was easily visible to other patients, visitors, and staff. She stated the surveillance cameras were a tool used for fall prevention on the Medical Floor, but was unable to provide a hospital policy governing the surveillance cameras and their scope.

A Medical Floor Charge RN was interviewed on 6/23/16, at 10:10 AM. She stated there were 24 beds on the Medical Floor, where the surveillance cameras were located. The Charge RN was unsure how many of the 24 beds had surveillance cameras. She stated there were 5 patients on the Medical Floor designated as "high risk" for falls, but none were in rooms with surveillance cameras.

When asked if patients consented to camera surveillance, the Charge RN stated the consent was verbal and was not documented in the medical record. When asked to explain how the surveillance camera system worked, the Charge RN stated "the cameras are activated by a wall switch in the patients' room." She stated the surveillance cameras were switched on manually when staff entered the room and switched off manually when staff left the room. The Charge RN stated it was the staff's responsibility to ensure the surveillance cameras were turned off when exiting the room.

A Medical Floor Unit Secretary was interviewed on 6/23/16, at 10:25 AM. She stated the surveillance cameras were turned on from the time a patient was admitted to their room to the time the patient was discharged. Additionally, she stated individual patient room images could be switched via the monitor at the nurses station and the surveillance camera system was the Unit Secretary's responsibility. She stated one or more patient's rooms could be toggled on the screen at one time. The Unit Secretary confirmed the monitor at the nurses station could easily be viewed by other staff, visitors, and patients.

Staff interviews were not consistent in describing the use of the surveillance cameras.

The facility failed to protect the personal privacy of patients.