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.
| CJW MEDICAL CENTER | 7101 JAHNKE ROAD RICHMOND, VA 23235 | April 16, 2014 |
| VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS | Tag No: A0117 | |
| Based on observation and interview the hospital failed to inform the patients of their rights for two of five patients (Patient #31 and Patient #33). The findings included: Five patient interviews (Patient #31, #32, #33, #34, and #35) were conducted on April 15, 2014 and April 16, 2014. Two (Patient #31 and #33) of the five patients interviewed indicated they had not received information relating to patient rights. Patient #31 was interviewed on April 15, 2014 at 2:00 pm. Patient #31 was admitted through the emergency room . Patient #31 reported he/she did not recall receiving any information on patient rights. Patient #31 reported he/she received no Patient Guide Booklet (patient rights information and patient relations information on pages 12-15) or admission packet paperwork. Patient #31 reported he/she did not receive a Patient Relations Letter (letter which informs a patient how to make a complaint/grievance). Patient #33 was interviewed on April 15, 2014 at 2:20 pm. Patient #33 reported he/she received no Patient Guide Booklet, brochure (additional information relating to patients and Patient Relations), or a Patient Relations Letter upon admission. Staff #1 and Staff #6 were interviewed multiple times during the survey. Staff #6 reported again on April 16, 2014 at approximately 11:40 am each patient receives a letter upon admission with Patient Relations Information. This letter contains the contact number of the hospital's Patient Relations Department and the contact information of the Complaint Unit of the Office of Licensure and Certification. A copy of this letter was provided to the survey members. Staff #6 reported this letter is "generated" each time a patient is registered. Staff #6 reported each patient receives a Patient Guide Hospital Booklet at admission. A copy of the Patient Guide Hospital Booklet was provided to the surveyors. Patient Advocacy Information is found on pages 12-15. This information includes patient rights and the contact information for Patient Relations and the Complaint Unit of the Office of Licensure and Certification (OLC). Staff #6 provided a brochure which patients receive at admission which contains information relating to patients while hospitalized and how to contact Patient Relations. No patients interviewed had this additional brochure. Staff #23 was interviewed on April 16, 2014 at 10:40 am. Staff #23 reported he/she gives the patient rights information and the Patient Relations letter when the patient is admitted . Staff #22 was interviewed on April 16, 2014 at 10:45 am. Staff #22 reported he/she gives the patient admission packet (includes Patient Guide Booklet and brochure) and Patient Relations letter to the patient during registration. Informs the patient it is a resource. Reported "patient rights" is part of the packet if admitted but he/she does not go over the rights with the patient. Multiple staff interviews were conducted April 15, 2014 and April 16, 2014. The following information was revealed during the interviews: Staff #9- Staff #9 was interviewed on April 15, 2014 at approximately 1:45 pm. Staff #9 reported he/she was not sure of how a patient would make a formal hospital complaint. Staff #9 was not aware of the Complaint Unit of the Office of Licensure and Certification. Staff #9 was able to report how he/she would help the patient to initially solve the complaint. Staff #10- Staff #10 was interviewed on April 15, 2014 at approximately 1:55 pm. Staff #10 reported he/she would help the patient resolve the complaint at the lowest level. Staff #10 reported he/she was not sure how the patient receives the patient rights. Staff #10 reported he/she does not go over patient rights with the patient. Staff #10 was not aware patients receive information on how to file a complaint or grievance. Staff #11- Staff #11 was interviewed on April 15, 2014 at approximately 3:30 pm. Staff #11 stated patients do get the admission information. Staff #11 was not aware of the Patient Relations Information letter. Reported he/she has never seen the letter. Staff #12- Staff #12 was interviewed on April 15, 2014 at approximately 3:45 pm. Staff #12 reported patients get the Patient Guide Booklet 75 percent of the time. Staff #12 reported he/she has never been inserviced on patient rights. Staff #12 reported he/she has not seen a letter titled Patient Relations Information with the admission information. Staff #13- Staff #13 was interviewed on April 15, 2014 at approximately 4:00 pm. Staff #13 reported he/she would try to solve the complaint themselves and then go up the chain of command. Staff #13 reported he/she has never seen the Patient Relations Information letter. Staff #13 was unable to report how he/she would advise a patient to file a complaint to an agency outside of the hospital. Staff #14- Staff #14 was interviewed on April 15, 2014 at approximately 4:10 pm. Staff #14 reported he/she has seen the Patient Relations Information letter come up with some patients. Staff #15- Staff #15 was interviewed on April 15, 2014 at approximately 4:15 pm. Staff #15 reported he/she would try to resolve a complaint at the bedside and notify the director of the unit. Staff #15 reported he/she had no knowledge of the Patient Relations letter. Staff #15 reported the role of the Patient Advocate is "for and with the patient." Staff #16- Staff #16 was interviewed on April 15, 2014 at approximately 4:20 pm. Staff #16 reported he/she has never been inserviced on the admission packet information. Staff #16 reported any complaint response letters sent to a patient only have her phone contact information on them. Staff #16 reported he/she was not sure of the difference between a Patient Care Representative and a Patient Advocate. Staff #18- Staff #18 was interviewed on April 15, 2014 at approximately 2:25 pm. Staff #18 reported when asked how to handle complaints he/she is sure there is a group of people that would take care of that but he/she is not sure who would take care of it. Staff #18 reported he/she would go to the case manager. Staff #19- Staff #19 was interviewed on April 15, 2014 at approximately 2:25 pm. Staff #19 stated he/she would try to fix the problem or complaint first and then go up the chain of command. Staff #19 did not mention any outside resources a patient could use to file a complaint. Staff #26- Staff #26 was interviewed on April 15, 2014 at approximately 2:30 pm. Staff #26 reported he/she would try to resolve the complaint and then go to the next person in the chain of command. Staff #26 did not mention any outside resources a patient could use to file a complaint. Staff #27- Staff #27 was interviewed on April 16, 2014 at approximately 11:10 am. Staff #27 reported he/she would apologize to the patient and try to solve the problem at the bedside if the patient had a complaint. Staff #27 reported he/she would report the incident to Staff #21 if the patient was not satisfied. Staff #27 was aware patients receive the Patient Relations Information letter. Staff #27 reported he/she does not go over patient rights. Staff #27 reported he/she would use the "language line" if the patient was unable to understand the patient rights in English. Staff #28- Staff #28 was interviewed on April 16, 2014 at 11:15 am. Staff #28 reported he/she would apologize to the patient if the patient had a complaint. Staff #28 stated he/she would try to resolve the complaint and inform Staff #21. Staff #29- Staff #29 was interviewed on April 16, 2014 at 11:30 am. Staff #29 reported he/she would use the "language line" if the patient needed to be advised of patient rights in a language other than English. Staff #29 reported he/she does not go over patient rights upon admission. Staff #29 reported he/she was not aware of a Patient Relations Information letter. Staff #29 reported he/she was unaware a patient could contact an outside agency to file a formal hospital complaint. Staff #1 was present at multiple staff interviews. Staff #1 and Staff #6 aware of the findings. |
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| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on interview and observation the facility failed to ensure information relating to patient grievances was received by two of five patients (Patient #31 and #33). The findings included: Five patient interviews (Patient #31, #32, #33, #34, and #36) were conducted on April 15, 2014 and April 16, 2014. The following information was found during the interviews: Patient #31- Patient #31 was interviewed on April 15, 2014 at 2:00 pm. Patient #31 reported he/she was admitted through the emergency room . Patient #31 reported he/she received no Patient Guide Booklet or Patient Relations Information. Patient #31 reported he/she received no information on patient rights or how to file a complaint or grievance (information is provided in the Patient Guide Booklet pages 12-15). Patient #32- Patient #32 was interviewed on April 15, 2014 at 2:15 pm. Patient #32 reported he/she received the Patient Guide Booklet. Patient #32 reported he/she did not receive the Patient Relations Information letter. Patient #33- Patient #33 was interviewed on April 15, 2014 at 2:20 pm. Patient #33 reported he/she was admitted through the emergency room . Patient #33 reported he/she had received no Patient Guide Booklet or Patient Relations Information letter at admission. Patient #34- Patient #34 was interviewed on April 16, 2014 at approximately 10:30 am. Patient #34 reports he/she "loves" the hospital and has been in the hospital for two weeks. Patient #34 reports he/she was admitted through the emergency department. Patient #34 initially reported he/she did not receive any information relating to the hospital upon admission. Patient #34 was asked if he/she had received a Patient Guide Booklet and a letter relating to the complaint/grievance process. Patient #34 reported he/she thought a booklet may have been given to him/her upon admission. Patient #34 reported the book was in the closet with his/her clothes. Patient #34 reported he/she is aware of his/her patient rights. Staff #21 was present and retrieved the hospital information book from the closet. No Patient Relations Information letter was found. Patient #34 reported he/she did not receive any letter relating to whom the patient could contact to file a grievance. Staff #21 was present during the interview. Patient #36- Patient #36 was interviewed on April 16, 2014 at approximately 10:10 am. Patient #36 reports he/she was admitted through ambulatory surgery. Patient #36 reports he/she received the Patient Guide Booklet and the Patient Relations Information letter. Staff #30 was present during the interview. Staff interviews were conducted on April 14, 2014 through April 16, 2014 relating to the grievance process. The results of these interviews are as follows: Staff #1 and Staff #6 were interviewed multiple times during the survey. Staff #6 reported again on April 16, 2014 at approximately 11:40 am each patient receives a letter upon admission with Patient Relations Information. This letter contains the contact number of the hospital's Patient Relations Department and the contact information of the Complaint Unit of the Office of Licensure and Certification. A copy of this letter was provided to the survey team members. Staff #6 reported this letter is "generated" each time a patient is registered. Staff #6 reported each patient receives a Patient Guide Hospital Booklet at admission. A copy of the Patient Guide Hospital Booklet was provided to the surveyors. Patient Advocacy Information is found on pages 12-15. This information includes patient rights, contact information for Patient Relations and contact information for the Complaint Unit of the Office of Licensure and Certification (OLC). Staff #6 provided a copy of a brochure patients receive at admission. No patients interviewed had this additional brochure. |
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| VIOLATION: SECURE STORAGE | Tag No: A0502 | |
| Based on observation and interview the facility failed to secure medications for one of two patients observed during a medication pass (Patient #35). The findings included: Two (Patient #35 and #36) medication passes were observed on April 16, 2014. One (Patient #35) medication pass was observed on April 16, 2014 at approximately 10:15 am. Upon entering Patient #35's room two containers of prescription medications were observed on the counter top near the sink. The prescription medications were identified as eye drops and Mesalamine (medication used to treat ulcerative colitis) 500 milligrams. The medications had been brought from home. Staff #1, Staff #30, and Staff #21 were present during the medication pass. The hospital policy relating to the storage of home medications was requested and reviewed. Policy # Titled Patients Personal Medications states medications will be sent home with a family member or sent to the pharmacy. Medications from home can be taken with a physicians order after being identified by a pharmacist. Staff #21 was interviewed on April 16, 2014 at approximately 11:40 am. Staff #21 verified the medications were present during the medication pass. Staff #21 reported he/she had seen the medications in the room earlier in the day and had requested them to be removed. Staff #21 verified the medications had been brought from home. Staff #21 verified with Staff #30 the medications had been removed from Patient #35's room. Staff #21 verified the medications would be sent to the pharmacy. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation and interview the facility failed to: 1. Properly perform cleaning/sanitizing techniques for one of one patient room (Staff #8). 2. Ensure staff follow appropriate use of personal protective equipment for two of thirty one staff (Staff #8 and Staff #31). The findings included: 1. Staff #8 was observed performing a terminal cleaning (thorough cleaning and disinfection of isolation room) on April 15, 2014 at approximately 11:00 am. Staff #1 was observed donning gloves without performing any hand hygiene. Policy #7.05 titled Isolation Discharge Room Cleaning Procedure was reviewed on April 15, 2014. The policy states follow "proper hand hygiene protocol" after putting on appropriate personal protective equipment. Staff #8 was observed approximately three (3) times leaving the isolation room gowned and gloved to go to the housekeeping cart outside the room in the hallway. Staff #8 reported when asked about leaving the room he/she is not suppose to leave the room gowned and gloved. Staff #8 was observed washing the walls of the room. Staff #8 failed to wash the walls closest to the door to the hallway. Staff #8 failed to wipe down the light switch near the door to the hallway. Staff #1 was present during the terminal cleaning. Staff #7 was present in the hallway directly outside the room being cleaned. Staff #1 made aware of the findings. 2. Unidentified Staff #31 was observed in the hallway outside the surgical conference room on the fourth floor at approximately 11:00 am on April 16, 2014. Staff #31 was observed passing the 4th (fourth) floor conference room with one hand gloved holding 2 (two) syringes. The other hand was ungloved. Staff #31 used ungloved hand to open the door and proceed down the stairs. Staff #31 was observed by surveyor and Staff #6 at 11:10 am with both hands gloved and holding 2 syringes (not in a plastic bag). Staff #31 was observed opening the door to the stairs with the gloved hand. Staff #6 witnessed incident and stated gloves are not to be worn in the hallways unless transporting a patient that requires the use of gloves. Staff #6 attempted to find Staff #31 but was unable to locate. Staff #31 appeared to be carrying a specimen. |
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