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.

Based on interviews and record review the facility failed to ensure patients were notified by staff of the resolution after a complaint investigation was conducted in 1 of 1 complaints reviewed (Patient #3).

Facility Policy

According to the policy, Patient Complaint and Grievance Process, the Responsibilities of the Patient Representative is to serve as the liaison between the patient, family, community, medical staff and the facility in responding to complaints expressed by a patient, family member or other interested person. The primary function is to receive and investigate patient complaints and provide communication regarding the resolution to the patient and/or designated patient's representative. Patient Representatives have delegated authority to resolve patient complaints and grievances and communicate findings to the patient. Every reasonable effort will be made to provide information in a manner and form that can be understood by the patient, patient's legal representative and significant others. The information to be provided will include but is not limited to an explanation of the grievance process, which will be interpreted in a manner consistent with the policy and taking steps, as needed, to effectively communicate with the patient.

1. The facility failed to ensure Patient #3 was informed of the resolution of his complaint.

a. On review the complaint case file, Patient #3 filed a complaint on 9/24/18 at 9:15 a.m. According to the complaint description the patient representative (PR) documented the patient felt he was being treated like a criminal. The patient closed his door for privacy but was told to keep it open. The patient stated he had been restrained and could not leave even though he wanted to go home. It is further documented by the PR, the patient stated he lost everything since he has been at the facility. The patient was told he would be here at the facility for one hour but had been here ever since. The patient stated he had told to the unit managers but they do not answer his questions of why he was still at the facility. The patient then stated he was a very clean person, but was not given shampoo when he asked. The patient stated he wanted to go home.

According to the case file, at 9:21 on 9/24/18, the PR documented she contacted the patient's nurse to review the information provided by the patient and the nurse stated she did not know what would be helpful. The PR asked the nurse if the medical team had rounded on the patient and according to the nurse, they had not. The PR then discussed with the nurse, she may want to let them know, so they can discuss during rounds this morning.

According to the case file the issue resolution dates were listed as 9/24/18 and 9/26/18. The PR documented in the outcome notes the issue was addressed at the point of service by medical staff. Care coordination continued to follow up on long term medicaid application.

On review of the case file, there was no evidence Patient #3 was notified and informed of the resolution.

b. On 1/3/19 at 4:07 p.m., an interview was conducted with Patient Representative (PR) #4.
PR #4 stated if an inpatient in the facility had a complaint, the PR would be involved as the liaison between the patient and the medical team during the complaint process. PR #4 stated, as the patient representative, she assisted with communication between the patient and the medical team/staff and provided the medical team/staff with the patient perspective. PR #4 stated each complaint was documented and tracked through a case file. PR #4 stated the PR staff continued to follow up with the medical team/staff and the patient to verify the problems had been addressed and resolved and would document the encounters in the case file.

PR #4 reviewed Patient #3's complaint filed on 9/24/18. After review, PR #4 stated the medical team would follow up with the patient and the resolution would be documented in the patient medical record.

PR #4 then reviewed Patient #3's medical records. PR #4 was unable to find any documentation Patient #3 was notified of the resolution of his complaint filed on 9/24/18.

On continued review of Patient #3's medical record, according to the physician progress notes from 10/11/18 until 12/29/18 the patient continued to speak with staff about his concerns. On 10/11/18, the patient was angry he had been at the facility for over a year and was requesting to be discharged . On 10/31/18, Patient #3 was perseverating on wanting to go home. On 11/17/18, the patient stated he was doing bad and wanting to be discharged . On 12/29/18, Patient #3 felt like he was in jail. On 12/31/18, according to the physician progress note, Patient #3 stated he was a victim and being held here against his will.

After the review, PR #4 confirmed there was no resolution of Patient #3's complaint documented in the medical record. PR #4 then stated the the PR office was a patient driven office and it was the patient responsibility to reach out again to the patient representative if he was not satisfied.

This was in contrast to what PR #4 had originally stated in her interview and facility policy which read the primary function of the PR was to receive and investigate patient complaints and provide communication regarding the resolution to the patient and/or designated patient's representative.
Based on observations, interviews, and document review the facility failed to protect patient rights and protected health information (PHI) during observations in the patient care areas.

Findings include:

Facility policies:

The Patient Rights and Responsibilities Policy read, a patient has the right to receive quality care that is considerate and respectful of the patient's dignity, personal values, beliefs, and life philosophy. Be interviewed, examined, and treated in a safe setting that provides personal privacy.

The Physical Security of Electronic Protected Health Information Policy read, electronic Protected Health Information (PHI) is defined as health information protected under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Standards' Use and Disclosure provisions which is stored on electronic media such as a computer system. It is individually identifiable health information that is transmitted or maintained electronically. Individually identifiable health information is defined as health information that: Is created or received by a health care provider, health plan, employer, or clearinghouse; Relates to the past, present, or future physical or mental health condition of an individual, or the past, present, or future payment for the provision of health care to an individual; Identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

All workforce members must take reasonable precautions to protect the confidentiality, integrity, and availability of electronic PHI and sensitive information. Therefore, workforce members are responsible for ensuring that electronic media (and electronic PHI contained therein) is protected.


The Patient Right and Responsibilities handout read, you have the right to respect: To receive care and treatment that is respectful, recognizes personal dignity, and provides for personal privacy to the extent possible during the course of treatment. You may be interviewed or examined in reasonable privacy. You must sign an authorization form and show proof of identification to inspect or request copies of your medical records.

1. The facility failed to close doors and curtains to protect the personal privacy of patients receiving care.

a. On 1/2/19 at 10:30 a.m., an observation was made of Patient #4 lying on her left side in her bed with her hospital gown open to her back, with her buttocks exposed, while two staff members provided care. While Patient #4's buttocks were exposed to a male visitor whom was walking in the hall to visit another patient and walked past her door. The observation was made due to the door being ajar and no curtain being pulled to protect her privacy. After approximately three minutes of observation, Registered Nurse (RN) #1 closed the door.

On 1/2/19 at 4:57 p.m., an interview with RN #1 was conducted. RN #1 stated the normal process when providing patient care was to close the door or pull the curtain to protect a patient's right to personal privacy. RN #1 stated she should not have provided care to Patient #4 with the door open. Additionally, RN #1 stated she had not protected Patient #4's right to personal privacy and should have closed the door in order to maintain her integrity.

b. On 1/2/19 at 9:27 a.m., an observation was made of a patient in room 1059 sitting on the side of her bed while a staff member had her back exposed performing an ultrasound (diagnostic imaging of internal body structures). The door to room 1059 was open and the curtain was not closed allowing the patient to be in view to visitors walking past her room.

c. On 1/4/19 at 8:35 a.m., an interview with RN #2 was conducted. RN #2 stated he ensured personal privacy when performing patient care by closing the curtains and doors. RN #2 stated it was important that visitors walking past a patient room could not see care being provided to protect each patient's right to privacy. RN #2 stated he received on the job training as well as computer training when he was hired on how to protect a patient's right to privacy.

d. On 1/4/19 at 11:28 a.m., an interview with a regulatory RN (RN #3) was conducted. RN #3 stated it was important to protect each patient's right to privacy. RN #3 stated the expectation was for doors or curtains to be closed when care was being provided. RN #3 stated dignity was not ensured if care was provided with the door or curtain open.

2. The facility failed to secure protected health information (PHI) on documents and computers in patient care areas.

a. On 1/2/19 at 9:27 a.m., during a tour of the medical intensive care unit, two computer screens were observed to be unsecured with no staff present between rooms 1056 and 1057. Rooms 1056 and 1057 were located at the entry to the medical intensive care unit along the main hallway in which visitors and staff entered the unit. RN #5 was in room 1056, as well as RN #6, whom was providing patient care. Upon further inspection both computers revealed an unlocked screen in which people passing by could visualize a patient's name, date of birth, medical record number, and diagnosis.

RN #5 returned to the unlocked computers and stated he was training RN #6 and stated both computers were unlocked so he could assist RN #6 with his documentation of the care he provided for the patient. RN #6 stated the screen which was unlocked pertained to the patient's dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) treatment. RN #5 stated both computers should have been secured when he or RN #6 walked away from them.

On 1/2/19 at 9:29 a.m., a second observation was made of an additional computer in the medical intensive care unit which PHI was displayed and unsecured. RN #7 walked away from the computer, put an isolation gown on, entered room 1076 and then closed the door. Inspection of the computer revealed it was unlocked with PHI unsecured.

On 1/2/19 at 11:14 a.m., an observation was made of Benefits Coordinator (Coordinator) #8 placing a binder on an isolation cart and then entering room 973. Upon further inspection, the binder was clear and contained PHI which was visible to visitors or staff passing in the hallway. The paper which was unsecured showed a patient name, date of birth, medical record number, phone number, address, and health insurance information.

On 1/2/19 at 11:20 a.m., an interview with Coordinator #8 was conducted. Coordinator #8 stated the unsecured document contained the next patient's PHI which she was going to counsel. The PHI included the patient's name, date of birth, phone number, address, and insurance information. Coordinator #8 stated her normal process when entering an isolation room was to leave her binder unsecured on the top of the isolation cart outside of the patient's room. Coordinator #8 stated the expectation was to secure PHI, but she did not know how to properly secure PHI when a patient was in an isolation room. Coordinator #8 further stated her process of placing unsecured PHI on the isolation cart outside of the patient room was the way she was trained upon employment and therefore the way she had always stored PHI.

c. On 1/2/19 at 4:57 p.m., an interview with RN #1 was conducted. RN #1 stated anything that identified a patient was supposed to be kept confidential and protected. RN #1 stated each patient had the right to have their confidential information secured and not shared if they had not consented to the information. RN #1 further stated if information was not secured there was the risk of a visitor seeing the PHI without the patient's consent. Additionally, RN #1 stated computers were to be locked each time staff walked away from them to secure PHI. RN #1 further stated that even when documenting on the computer in a patient room, the expectation was to turn the computer away from visitors to protect PHI and ensure the patient's right to privacy.

d. On 1/4/19 at 8:35 a.m., an interview with RN #2 was conducted. RN #2 stated he was trained during his orientation period on how to ensure the security of PHI. He stated the expectation to secure computers was to lock them when staff left them to ensure no unauthorized access to a patient's PHI. RN #2 stated the expectation for papers or medical records which contained PHI was to cover them so unauthorized people did not have access to PHI. RN #2 stated it was a patient's right to have their information protected to ensure their privacy.

e. On 1/4/19 at 11:28 a.m., an interview with Regulatory RN #3 was conducted. RN #3 explained examples of PHI would include patient name, date of birth, health information and any identifying factors. RN #3 stated the expectation was for staff to secure PHI on their computers by locking their computers or logging off each time they left them. Additionally, RN #3 stated the expectation was to secure paper PHI by placing it in a secured area or to cover it so you could not see the PHI. RN #3 stated paper PHI should not be left unsecured in a general area with visitor access. RN #3 stated patients had the right to privacy which included securing PHI and stated an unsecured computer would be a breach in securing PHI. RN #3 examined the insurance document Coordinator #8 had left unsecured in the hallway and stated the document contained PHI and should have been secured to protect that patient's right to privacy.