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Based on document review and interview, the facility failed to ensure that copies of the notice of patient rights were available at all times and provided to all ED (emergency department) patients or their representative for 2 of 10 medical records (MR) reviewed (patient #s 1, 10).

Findings include:

1. The policy/procedure Patient Rights / Responsibilities (revised 9-14) indicated the following: "A written statement outlining patient rights at (the facility) is provided in the patient admit folder..." and no documentation indicated a provision for ensuring all outpatients including ED patients were informed of their patient rights before care was provided.

2. Review of the ED MR for patient #1 dated 10-28-16 failed to indicate a copy of the notice of patient rights was provided to patient #1 at the time of registration at 1827 hours.

3. Review of the ED MR for patient #10 dated 10-30-16 failed to indicate a copy of the notice of patient rights was provided to patient #10 at the time of registration at 1801 hours.

4. On 12-29-16 at 1430 hours, the director of Patient Access, staff A11 confirmed the MR on 10-28-16 for patient #10 and the MR on 10-30-16 for patient #1 failed to indicate a copy of the notice of patient rights was provided to either patient prior to obtaining treatment in the ED.

5. During a tour of the ED waiting room on 12-29-16 at 0915 hours, in the presence of the associate vice president (AVP) of Quality and Risk Management, staff A1, the ED registration clerk on duty, staff A8 was requested to provide a copy of the facility notice of patient rights titled Patient Rights and Information Guide. The registration clerk, staff A8 confirmed that copies of the Patient Rights and Information Guide were currently unavailable to provide to patients requesting to be seen in the ED and indicated that copies of the brochure had been reordered. The AVP of Quality and Risk Management, staff A1 confirmed that copies of the Patient Rights and Information Guide were not available to provide to patients arriving to the ED.

Based on document review and interview, the facility failed to follow its grievance policy for 1 of 6 grievances reviewed (patient #1).

Findings include:

1. Review of the policy/procedure Patient/Visitor Complaints and Grievances and HIPAA (Health Information Portability and Accountability Act) Complaints (revised 8-16) indicated the following: "Grievance: A patient/visitor concern that falls into one or more of the following categories: (1) is in writing; (2) is expressed verbally but is not resolved within 7 days; (3) alleges patient abuse, neglect, or harm; (4) alleges issues related to (the facility's) compliance with the CMS (Centers for Medicare and Medicaid) Hospital Conditions of Participation (CoP); or (5) is a Medicare beneficiary billing complaint..."

2. Review of administrative documentation dated 11-16-16 indicated the patient advocate, staff A7 was contacted by telephone and requested to register a formal complaint regarding the recent death on 10-28-16 of patient #1 in the ED (emergency department). The file entry on 11-18-16 at 0946 hours by the patient advocate, staff A7 failed to indicate the formal complaint request was filed as a grievance and indicated an acknowledgement was sent on 11-18-16 at 0956 hours to the medical director of the ED, physician MD18. No documentation indicated a formal investigative process was initiated or completed in response to the formal request for a review and resolution of the concerns.

3. On 12-28-16 at 1450 hours, the patient advocate, staff A7 confirmed that a disposition letter was sent on 11-18-16 in response to the complaint regarding patient #1.

4. On 12-29-16 at 0930 hours, the associate vice president of Quality and Risk Management, staff A1, confirmed the formal complaint regarding patient #1 had not been forwarded to the risk and quality department for investigation and review before the letter of determination was sent on 11-18-16 by the patient advocate, staff A7.

Based on document review and interview, the facility failed to ensure the written notice of the grievance determination included the steps take to investigate the grievance, the results of the grievance process and date of completion for 1 of 6 grievances reviewed (patient #1).

Findings include:

1. Review of the policy/procedure Patient/Visitor Complaints and Grievances and HIPAA (Health Information Portability and Accountability Act) Complaints (revised 8-16) indicated the following: "Resolution of all grievances will be followed up with an acknowledgement letter..."

2. Review of administrative documentation dated 11-16-16 indicated the patient advocate, staff A7 was contacted by telephone and requested to register a formal complaint regarding the recent death on 10-28-16 of patient #1 in the ED (emergency department). The file entry on 11-18-16 by the patient advocate, staff A7 indicated a copy of disposition letter addressed to the complainant and the letter failed to indicate the investigative steps taken, the results, and the determination with a date of completion.

3. On 12-28-16 at 1450 hours, the patient advocate, staff A7 confirmed that a disposition letter was sent on 11-18-16 in response to the complaint regarding patient #1.

4. On 12-29-16 at 0930 hours, the associate vice president of Quality and Risk Management, staff A1, confirmed the letter of determination sent on 11-18-16 by the patient advocate, staff A7 failed to indicate the steps take to investigate the grievance or the results of the grievance process and date of completion.

Based on document review and interview, the facility failed to ensure a consent for treatment was obtained from the patient or the patient 's representative for 2 of 10 ED (emergency department) MR (medical records) reviewed (patient #s 1 and 10).

Findings include:

1. The policy/procedure Informed Consent (revised 3-15) indicated the following: "A general consent is contained in the "Authorization for Treatment, Release of Information, Photographs, Valuables Responsibility, Medicare Benefits, Assignment of Benefits, and Guarantee of Payment" signed by all patients receiving treatment. This authorizes the administration of medical care and is obtained upon registration."

2. Review of the ED MR for patient #1 dated 10-28-16 lacked documentation of a consent for treatment was obtained from patient #1 at the time of registration at 1827 hours.

3. Review of the ED MR for patient #10 dated 10-30-16 lacked documentation of a consent for treatment was obtained from patient #10 at the time of registration at 1801 hours.

4. On 12-29-16 at 1430 hours, the director of Patient Access, staff A11 confirmed the MR on 10-28-16 for patient #1 and the MR on 10-30-16 for patient #1 lacked documentation of a consent for treatment was obtained for either patient prior to obtaining treatment in the ED.