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.
|WEST VIRGINIA UNIVERSITY HOSPITALS||1 MEDICAL CENTER DRIVE MORGANTOWN, WV 26506||March 24, 2021|
|VIOLATION: PATIENT RIGHTS: GRIEVANCES||Tag No: A0118|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of documents and staff interviews it was revealed the facility failed to follow their complaint and grievance policy. This failure was identified in one (1) of one (1) complaint grievances reviewed. This failure has the potential to adversely affect all patients.
1. A review of the complaint/grievance filed by the wife of patient #1 on 10/15/21 at 12:23 p.m. stated, "Afraid they are going to give up on treating husband, who is COVID positive, nothing but negativity comes from the staff." On 11/2/21 at 3:14 p.m. documentation by the case worker stated in part: "Initial review: wife, expressing concern that she feels providers will give up on taking care of her husband. She indicated every time she speaks with a doctor it is a bad report. She feels that her husband can get better. She was crying and explained she is dealing with [DIAGNOSES REDACTED]; she has another daughter in ICU at another facility and she has feelings of guilt because she gave the COVID to her husband. Does not have care concerns." Complaint summary stated, "Investigation complete, Overall pt. satisfaction: Do not know. Investigation notes: Nov. 2 2020 3:13 PM patient moved out ICU and ready for discharge. Will close."
2. A review of the policy titled "PATIENT AND FAMILY COMPLAINT AND GRIEVANCE MECHANISM, revised 6-9-19, stated in part: "Definition of a Complaint - A Complaint is any issue related to patient care, which can include clinical concerns, or breaches of confidentiality, privacy or security, brought to the attention of hospital personnel in person, etc.... A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. When the complainant is not satisfied, the issue then becomes a patient grievance.
Grievance: If the department staff present, which includes any hospital staff present at the time of the complaint or who can be quickly be at the patient 's location (i.e. nursing, administration, nursing supervisors, patient advocate, etc.) cannot resolve the complaint, the staff will enlist appropriate personnel to assist in resolution of what is now a grievance. The Patient and Professional Advocate or designee will respond in writing to the complainant within seven calendar days. This written response shall, at a minimum, acknowledge the patient's concerns. If the resolution will take longer than seven days the acknowledgment letter will inform the patient or the patient 's representative that the hospital is still working to resolve the grievance and will include the current progress and the time frame for future updates. WVUH will attempt to resolve all grievances as soon as possible. The resolution correspondence (i.e. the written notice of the hospital 's determination regarding the grievance) will include: The name of the hospital contact person. The steps taken on behalf of the complainant to investigate the grievance. The results of the grievance process. The date of completion."
3. A telephone interview was conducted on 3/23/21 at 8:39 a.m. with the Manager of Patient Advocate and Patient Advocate #1. Patient Advocate #1 concurred she was ok with the Manager of Patient Advocate being with her during the interview. When asked about the complaint filed by the wife of patient #1, Patient Advocate #1 stated she felt it was not a complaint, it was an inquiry. She stated she spoke to the wife on 10/15/21 and the wife was crying and tearful. She stated the wife did not have any care concerns. She gave her a phone number to call back and the wife did not call her back. The wife felt doctors would give up on her husband, she felt guilty, she said she gave him COVID. She stated it was just an inquiry on patient care, not a care concern. When asked if she completed any other paperwork related to the complaint, she stated, "No other paperwork was completed. I closed the case when I did not get a return call from the wife."
|VIOLATION: STAFFING AND DELIVERY OF CARE||Tag No: A0392|
|Based on review of the medical record and staff interviews it was revealed the nursing staff failed to follow the facility's policy for personal care services. This failure was identified in one (1) of thirty (30) medical records reviewed. This failure has the potential to adversely affect all patients.
1. A review of the plan of care for patient #1 revealed no bath was offered to the patient from 11/1/21 to 11/3/21, perineal care and back care was offered during this time. The patient was noted as having been shaved on 11/2/21.
2. A telephone interview was conducted with the Nurse Manager of 8NE on 3/23/21 at 3:20 p.m. She concurred there was no documentation the patient refused a bath or was offered a bath from 11/1/21 to 11/3/21.
|VIOLATION: FORM AND RETENTION OF RECORDS||Tag No: A0438|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
A. Based on review of the medical record and staff interviews it was revealed the facility failed to ensure an accurately completed medical record was maintained for all inpatients. This failure was identified in one (1) of one (1) medical records reviewed for patients leaving against medical advice (AMA). This failure has the potential to adversely affect all patients.
1. A review of the medical record for patient #1 revealed patient #1 was discharged AMA on 11/3/21. No AMA form was completed.
2. A review of the policy titled "HEALTHCARE DECISION MAKING, revised 8-23-19, stated in part: "A patient who is requesting to be discharged against medical advice should be asked to sign the AMA form."
3. A telephone interview was conducted with the Nurse Manager of 8NE on 3/23/21 at 3:20 p.m. She concurred no AMA form was completed when patient #1 was discharged .
B. Based on review of medical records and staff interviews it was revealed the facility failed to ensure an accurately completed medical record was maintained for all inpatients and failed to ensure a properly completed consent form was maintained in the medical record. This failure was identified in three (3) of thirty (30) medical records reviewed (patient #2, 9 and 29). This failure has the potential to adversely affect all patients.
1. A review of the medical record for patient #2 revealed patient #2 was admitted on [DATE] and no consent for treatment signed by the patient or patient's representative was noted in the medical record.
2. A review of the medical record for patient #9 revealed patient #9 was admitted on [DATE] and no consent for treatment signed by the patient or patient's representative was noted in the medical record.
3. A review of the medical record for patient #29 revealed patient #29 was admitted on [DATE] and no consent for treatment signed by the patient or patient's representative was noted in the medical record.
4. A review of the policy titled "General Consent, Effective 8-1-2018, stated in part: "POLICY: To maintain federal and state compliance, upon first contact with West Virginia University Hospitals (WVUH) or Ambulatory Services, and no less than annually thereafter, every WVUH/Ambulatory Services inpatient and outpatient, or legally authorized person for the patient, will be asked to sign the WVUH General Consent.
The General Consent will include:
"h General consent to treat.
"h Agreement for payment.
"h Authorization to submit claims to insurance companies.
"h Authorization for release of medical bills and patient care information as needed to any third party for payment, appeals and/or reconsideration.
A. Upon arrival into any WVUH/Ambulatory Services facility the registration staff will obtain signature from all new patients, or patient's authorized representative, as verification that the patient or representative is aware of and agrees to the information outlined within the general consent.
B. After initial signature for general consent, a new consent is required annually.
C. A copy of the consent with the patient's signature, or signature from authorized representative, will be electronically housed within the patient's electronic medical records."
5. A telephone interview was conducted with the Director of Patient Access and two (2) supervisors of Patient Access on 3/24/21 at 9:49 a.m. Supervisor #1 of Patient Access stated verbal consents for patient #2, 9 and 29 were all signed by the staff. She stated, "During COVID this is how we do the verbal consents." She concurred the staff did not state verbal consent on the consent form when signing the patient's name.
6. A telephone interview was conducted with the Regulatory Coordinator on 3/24/21 at 1:30 p.m. He concurred no proper informed consent was noted in the medical record. He concurred the staff signed the patient or representatives name on the consent form.