The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GOSHEN GENERAL HOSPITAL 200 HIGH PARK AVE GOSHEN, IN 46526 Feb. 10, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review and interview, the facility failed to demonstrate that the notice of patient rights was provided to a patient or the patient's representative for 6 of 12 (patients # 21, 22, 23, 27, 29 and 32) medical records (MR) reviewed.

Findings:

1. The policy/procedure Patient Rights and Responsibilities (reviewed 6-13) indicated the following: "Patients receive a copy of the Patient's Bill of Rights at registration."

2. Review of the MR document for patients # 21, 22, 23, 27, 29 and 32 titled Admission/Treatment Consents, Releases, Authorizations, and Acknowledgements failed to indicate an entry in the space for a YES response following the statement "I have received the booklets explaining the patient's rights and responsibilities (the Patient's Bill of Rights)..." under the Section 7 heading titled Patient Rights.

3. During an interview on 2-10-15 at 1525 hours, the chief nursing officer A2 and the director of performance improvement A3 confirmed that the consent documentation for patients# 21, 22, 23, 27, 29 and 32 failed to indicate that the notice of patient rights was provided at the time of registration.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, the facility failed to develop and maintain its grievance process and assure that all allegations of abuse are investigated for 1 of 20 (patient 29) complaints and grievances reviewed.

Findings:

1. The policy/procedure Patient Complaints/Concerns (patient care related) (revised 12-14) indicated the following: "All patient care concerns will be reviewed, investigated and resolved within a reasonable timeframe. All facts of the situation will be documented ...All patient care complaints and concerns will be closed in a timely manner and communicated to the patient or their representative ..."

2. During an interview on 2-09-15 at 1525 hours, the 4th floor medical/surgical unit director A6 indicated that after receiving the complaint report alleging patient abuse by a male staff, the director contacted the nurse N16 for information regarding the allegation of abuse. Director A6 confirmed that they (A6) failed to document the interview date or time or any results of the telephone investigation or other investigation findings in the on-line reporting system in accordance with facility policy.

3. The 1-14-15 grievance documentation provided for review lacked evidence of a formal investigative process including documentation of interviews with staff identified in the MR or related to a resolution of the issues.

4. Review of the determination letter documentation dated 1-26-15 failed to indicate that the abuse allegation was investigated.

5. During an interview on 2-09-15 at 1440 hours, the director of performance improvement A3 confirmed that the determination letter failed to indicate that the abuse allegation was investigated.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, the facility failed to follow its process and document the investigation of an allegation of abuse and failed to ensure that the steps taken to investigate the allegation were included in a written notice of the determination for 1 of 20 (patient 29) complaints and grievances reviewed.

Findings:

1. The policy/procedure Patient Complaints/Concerns (patient care related) (revised 12-14) indicated the following: "All patient care concerns will be reviewed, investigated and resolved within a reasonable timeframe. All facts of the situation will be documented ...All patient care complaints and concerns will be closed in a timely manner and communicated to the patient or their representative ..."

2. During an interview on 2-09-15 at 1335 hours, the director of performance improvement A3 confirmed that the policy/procedure lacked a requirement to provide written notice of the grievance determination including the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

3. Grievance process documentation initiated 1-14-15 regarding an allegation of patient abuse for patient 29 was made.

4. Review of the determination letter associated with the grievance initiated 1-14-15 failed to indicate that the abuse allegation was investigated to resolve the grievance or the date of completion.

5. During an interview on 2-09-15 at 1440 hours, the director of performance improvement A3 confirmed that the determination letter failed to indicate that the abuse allegation was investigated or indicate the date that the grievance investigation was completed.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review and interview, the center failed to ensure that consent for treatment was obtained from the patient or the patient's representative for 3 of 12 MR (patient PT22, PT29, and PT32) reviewed.

Findings:

1. The policy/procedure Health Care Consent (revised 6-13) indicated the following: "Except when emergency treatment is necessary, valid consent, under provisions of Indiana's Health Consent Law, will be obtained before patient treatment is given. When immediate danger to life or major health risk requires emergency treatment without available consent, the circumstances and efforts to obtain consent must be documented."

2. Review of the MR document for patients PT22, (2 admissions for) PT29 and PT32 titled Admission/Treatment Consents, Releases, Authorizations, and Acknowledgements failed to indicate the signature of the patient or the patient's representative and no MR documentation indicated additional efforts to obtain consent from the patient or the patient's representative (including a spouse, domestic partner, adult child, sibling or other family member) were made during the hospital stay.

3. During an interview on 2-10-15 at 1115 hours, the chief nursing officer A2 confirmed that the health care consent documentation for patient 29 failed to indicate the signature of the patient or the patient's representative and confirmed that no documentation of attempts to obtain consent from a representative acting on behalf of the patient was available.