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GEISINGER WYOMING VALLEY MEDICAL CENTER 1000 EAST MOUNTAIN BOULEVARD WILKES BARRE, PA 18711 March 3, 2020
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to adopt a policy that defined the departmental process to have a chaperone present during a physical examination that included a breast and/or inguinal examination.

Findings include:

Review on March 3, 2020, of the "Amended And Restated Bylaws Of Geisinger Wyoming Valley Medical Center," last reviewed June 20, 2018, revealed "... Medical And Dental Staff 9.01 Appointment. A. The Board of Directors, a Boar [sic] Committee or Sub-committee shall (i) appoint each member Staff, which shall be composed of physicians and dentists and specified professionals who are graduates of accredited schools, (ii) require that the Staff be organized in a responsible administrative body and that the Staff adopt, as the Staff Bylaws, rules and regulations for the governance of medical, osteopathic and dental practice in the hospitals operated by the Corporation. The Staff Bylaws shall be subject to approval by the Medical Executive Committee, the Medical Staff and the Board of Directors. Physicians, osteopaths and dentists and specified professionals appointed to the Staff shall be responsible for the care of patients, subject to, and in accordance with, such rules and limitations as are imposed by these Bylaws, the Staff Bylaws and the Board of Directors. B. The process for appointment, reappointment and removal of medical Staff shall be set forth in the Staff Bylaws rules and regulations. 9.02 Duties. The Board of Directors shall delegate to the Staff such authority as it deems appropriate to ensure the quality of professional care provided to the hospital's patients. The Staff shall conduct an ongoing review and appraisal of the quality of professional care rendered in the hospital and shall report such activities and their results to the Board of Directors, a Board Committee or Sub-committee. The Staff shall report and make recommendations to the Board of Directors, a Board Committee or Sub-committee, regarding appointments, reappointments, and other changes in Staff membership and privileges, disciplinary actions, all matters relating to professional competency and patient care, and such other matters as the Board of Director or a Board Committee or Sub-Committee, may from time to time request. ..."

Review on March 2, 2020, of the facility's Patient Advocate Complaint Log from January 2018 to December 2018 revealed documentation dated February 15, 2018, that a patient (MR2) reported they felt uncomfortable after a physical examination completed by CF1 on February 5, 2018.

Review on March 2, 2020, of patient relations documentation dated February 15, 2018, from EMP8 that MR2 felt uncomfortable with the physical exam completed by CF1 on February 5, 2018. Documentation revealed EMP8 spoke with a clinic operations manager and made them aware.

Interview on March 2, 2020, with EMP1 at approximately 9:50 AM revealed it was the department process, when a physician or provider completes a physical examination on a patient that includes a breast exam and/or inguinal exam, a chaperone is present during the physical examination.

A request was made to the facility on [DATE], for a policy stating chaperones were required during physical examinations that included a breast and/or inguinal examination. No policy was provided.

Interview on March 2, 2020, with EMP1 at approximately 9:50 AM confirmed there is no chaperone policy for staff to follow. EMP1 revealed it is the department process, when a physician or provider completes a physical examination on a patient that includes a breast exam and/or inguinal exam, a chaperone is present during the physical examination.
examination.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of facility documents, medical records (MR), staff interview (EMP), it was determined the facility failed to ensure an allegation of abuse reported to staff was made a formal grievance for one of one applicable medical records (MR2).

Findings include:

Review on March 2, 2020, of facility, "Consumer Complaint and Grievance Policy and Procedure," effective December 18, 2019, revealed "Purpose Geisinger strives to deliver consistent, high-quality care and a positive experience with every interaction. In effort to do so, Geisinger supports a culture of safety whereby trust, transparency, empathy, and respect are promoted. ... Grievance: A. Per CMS, a formal patient grievance is a complaint made to the hospital by a patient or authorized representative regarding: ... b. Abuse or neglect ... Guidelines ... 2. Addressing and resolving complaints/grievances ... g. Risk Management/Patient Safety Department is available to consult with the patient liaison staff on any complaint/grievance as requested or as required. The Patient Liaison staff will notify Risk Management/Patient Safety of the following: 1. Allegations of abuse ... h. Grievance Response: Geisinger attempts to resolve all grievances within the following time frame guidelines: 1. Situations that endanger the patient, such as neglect or abuse, are reviewed immediately based on the seriousness of the allegation and the potential for harm to the patient. ..."

Review on March 2, 2020, of the facility's Patient Advocate Complaint Log from January 2018 to December 2018 revealed documentation dated February 15, 2018, that a patient reported they felt uncomfortable after a physical examination completed by CF1 on February 5, 2018.

Review on March 2, 2020, of patient relations documentation dated February 15, 2018, from EMP8 that MR2 felt uncomfortable with the physical exam completed by CF1 on February 5, 2018. Documentation revealed EMP8 spoke with the clinic operations manager and made them aware. Documentation from EMP6 revealed they found MR2 a physician at another facility. No documentation this allegation of abuse was treated as a formal grievance. No documentation the Risk Department or Patient Safety was made aware of this allegation.

Interview on March 2, 2020, at approximately 10:55 AM, with EMP7 revealed MR2 reported this occurrence to EMP8 on February 15, 2018, and EMP8 met with this patient to discuss their concern. EMP7 confirmed EMP8 spoke with the clinic operations manager and made her aware. EMP7 confirmed documentation revealed EMP6 found MR2 a physician at another facility. EMP7 confirmed this allegation of abuse was not treated as a formal grievance. EMP7 confirmed no documentation that the Risk Department or Patient Safety was made aware of this allegation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure an allegation of abuse reported by a patient was investigated as per facility policy for one of three medical records reviewed (MR2).

Findings include:

Review on March 2, 2020, of facility, "Geisinger Patient Rights and Responsibilities" pamphlet, revised September 2018, revealed "Being a good patient does not mean being a silent one. If you have questions, problems, safety concerns or unmet needs, let us know. ... Patient rights 1. A patient has the right to respectful care given by competent personnel. ... 34. A patient has the right to be free from mental, physical, sexual, and verbal abuse; neglect; exploitation; or harassment. ... 41. A patient has the right to receive care in a safe setting. ..."

Review on March 2, 2020, of facility, "Guidelines for Investigation of Patient Allegations of Abuse by Employees," revised July 19. 2019, revealed "Purpose: This policy established guidelines for the investigations of allegation by patients that they have been neglected or abused by Geisinger staff. Geisinger patients have the right to be free from all forms of abuse or neglect. Policy: The policy of Geisinger is to provide a safe, healing environment for all patients. Our patients should be treated with consideration, respect and with full recognition of their dignity and individuality. Any suspected occurrences of abuse or neglect by our staff of patients while in our care must be immediately reported and investigated. This policy does not replace or substitute any legal requirements for reporting a crime or mandatory reporting of suspicion of abuse as mandated by Pennsylvania law. ... Risk Management coordinates any investigation into alleged abuse or neglect with the assistance of clinical managers, the Legal Department, Security and Human Resources as necessary. Investigating Complaints of Abuse 1. All management and staff, including employees, contracted staff, volunteers and students, are responsible to ensure that any complaint, allegation or suspicion of abuse, or witnessed patient abuse are reported immediately to a department supervisor. ... 2. The department supervisor shall take immediate steps to accomplish the following: a. Ensure the patient is safe and receives a medical evaluation with documentation in the medical record as an intervention necessary to treat the symptoms of abuse. b. Remove the alleged abuser from contact with the patient until the investigation is completed. c. Notify hospital Risk Management/assigned Risk Management representative by telephone during regular business hours. After business hours, contact the hospital operator to notify Risk Management staff on call. ..."

Review on March 2, 2020, of the facility's Patient Advocate Complaint Log from January 2018 to December 2018 revealed documentation dated February 15, 2018, that a patient reported she felt uncomfortable after a physical examination completed by CF1 on February 5, 2018.

Review on March 2, 2020, of patient relations worksheet dated February 15, 2018, revealed EMP8 met with MR2 and MR2 told EMP8 that they felt uncomfortable with a physical examination completed by CF1 on February 5, 2018. Documentation revealed EMP8 spoke with the clinic operations manager and made them aware. Continued review revealed no documentation that EMP8 or the operations manager made the Risk Department aware.

Interview on March 2, 2020, with EMP7 at approximately 10:55 AM confirmed documentation on the patient relations worksheet dated February 15, 2018, that revealed MR2 met with EMP8 and told EMP8 they felt uncomfortable with a physical examination that was completed on February 5, 2018. EMP7 confirmed documentation revealed EMP8 spoke with the clinic operations manager and made them aware. EMP7 confirmed there is no documentation that EMP8 or the operations manager made the Risk Department aware.

Interview on March 2, 2020, with EMP4 confirmed the Risk Department was not made aware of MR2's allegation and EMP4 confirmed no investigation was completed by the Risk Department.

Review on March 2, 2020, of MR2 revealed this patient was seen in a clinic on February 5, 2018. Physician documentation revealed CF1 completed a physical examination which included an examination of MR2's breasts and inguinal area. There was no documentation in MR2 indicating a chaperone was present during this physical examination.

Interview on March 2, 2020, with EMP3 confirmed this patient was seen in a clinic on February 5, 2018. EMP3 confirmed physician documentation from CF1 that a physical examination was completed and included an examination of MR2's breasts and inguinal area. EMP3 confirmed there was no documentation in MR2 indicating a chaperone was present during this physical examination.