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Based on patient and staff interview and record review the staff failed to follow their established process for resolution of patient grievances and timely referral of the patients' concerns regarding quality of care to the Quality Department for 1 patient. (Patient #1). Findings include:

Per record review the facility failed to implement the process for grievance resolution in accordance with established policies, for Patient #1, who contacted the Patient-Family Advocacy Program to voice concerns regarding an incident of mistaken identity. The Customer Feedback Policy stated, as it's purpose, 'To provide a consistent, coordinated process for responding to customer feedback......, and to encourage and use customer feedback to drive improvement in the provision of patient care.' The policy stated....'FAHC is committed to ensuring that concerns are addressed in a timely, consistent and effective manner. At FAHC the Office of Patient and Family Advocacy has been designated to coordinate the review of complaints.' The policy further stated; 'Feedback and Suggestions, 6. Office of Patient and Family Advocacy staff shall:....Facilitate the resolution of complaints as appropriate; Refer complaints to appropriate department managers/health care service leaders;....Provide reports to the Quality Council for use in the planning, design and implementation of performance improvement strategies as requested.'

Per interview, at 8:40 AM on 9/3/13, Patient #1 stated that during a March or April 2013 visit to his/her Primary Care Provider (PCP), who, as part of the FAHC system, had access to all FAHC records, the PCP questioned the patient about a visit to the ED on 2/5/13. Patient #1 told the PCP that s/he had not made a visit to the ED on that date. Subsequently, Patient #1 received a bill for diagnostic testing done in the ED on 2/5/13. When the patient received a copy of the EMR from his/her PCP, which contained inaccurate information, including a CT scan and lab results, referencing the ED visit on 2/5/13, s/he recognized that Patient #2, who had a similar name and who had been escorted by law enforcement to the ED, had mistakenly been identified as Patient #1. The patient contacted the Patient-Family Advocacy Program at the hospital at the end of April 2013 and explained his/her concern about the mistaken identity and the receipt of a bill for diagnostic testing. The patient expressed feeling disrespected by the Patient Advocate with whom s/he had spoken, feeling the Advocate did not believe him/her. Although the Advocate recommended Patient #1 contact the police to request help in confirming the mistaken identity issue, there was no further assistance provided by the Advocacy program, to help resolve the issue. The wrong identity was confirmed when Patient #1 presented to the police station and a law enforcement official confirmed Patient #1 was not the patient escorted by that officer to the ED on 2/5/13. The patient stated there had been no further contact with the hospital and described feeling anxious and great emotional distress related to feeling his/her integrity was in question when the hospital did not offer assistance to help resolve the issue, but rather, the patient felt, left it up to him/her to resolve it on their own. The patient also expressed distress that the inaccurate information might be accessible to other FAHC employees.

Patient-Family Advocate #1 confirmed, during interview at 11:03 AM on 9/4/13, that Patient #1 had contacted him/her to express concerns around mistaken identity and billing. S/he stated that since the patient name, address and medical record number were correct on Patient #1's EMR, s/he had assumed the photo identity had been used at the time of registration, on 2/5/13, to confirm the patient's identity. The advocate stated the only plan s/he could think of to assist Patient #1 was to recommend the patient talk with the police to help confirm Patient #1 was not the person escorted to the ED on 2/5/13. The Advocate stated that s/he told the patient to contact Patient-Family Advocacy with any further concerns and felt Patient #1 had agreed with the plan. The advocate further confirmed that there had been no further contact with Patient #1 and s/he confirmed s/he did not refer the complaint to ED or Registration management or leadership staff, and no further follow up had been done by the Patient-Family Advocacy Program.

Based on patient and staff interviews and record review the facility failed to assure care was provided in a safe manner for two patients, when identity was not verified prior to treatment, and for one vulnerable patient who was able to elope from the facility unsupervised. (Patients #1, #2 and #5). Findings include:

1. Per record review the facility failed to assure safe care was provided for Patient #2 when s/he presented to the Emergency Department (ED), on 2/5/13, in a condition that prevented him/her from providing accurate information. Staff failed to follow facility policy to confirm the patient's identity through review of 3 data elements, including name, date of birth, address and or social security number, and failed to use the patient's previously scanned photo ID to confirm the patient's identity. The only form of identification used appeared to be patient name, and, as a result, the inaccurate information from the EMR for Patient #1 (a patient with a similar name) was used to assess and treat Patient #2.

Per interview, at 8:40 AM on 9/3/13, Patient #1 stated that during a March or April 2013 visit to his/her Primary Care Provider (PCP), who, as part of the FAHC system, had access to all FAHC records, the PCP questioned the patient about a visit to the ED on 2/5/13. Patient #1 told the PCP that s/he had not made a visit to the ED on that date. Subsequently, Patient #1 received a bill for diagnostic testing done in the ED on 2/5/13. When the patient received a copy of the EMR from his/her PCP, which contained inaccurate information, including a CT scan and lab results, referencing the ED visit on 2/5/13, s/he recognized that Patient #2, who had been escorted by law enforcement to the ED, had mistakenly been identified as Patient #1. The patient contacted the Patient-Family Advocacy Program at the hospital at the end of April 2013 and explained his/her concern about the mistaken identity and the receipt of a bill for diagnostic testing. The patient expressed feeling disrespected by the Patient Advocate with whom s/he had spoken, feeling the Advocate did not believe him/her. Although the Advocate recommended Patient #1 contact the police to request help in confirming the mistaken identity issue, there was no further assistance provided to help resolve the issue. The wrong identity was confirmed when Patient #1 presented to the police station and a law enforcement official confirmed Patient #1 was not the patient escorted by that officer to the ED on 2/5/13. The patient stated there had been no further contact with the hospital and described feeling anxious and great emotional distress related to feeling his/her integrity was in question when the hospital did not offer assistance to help resolve the issue, but rather, the patient felt, left it up to him/her to resolve it on their own. The patient also expressed distress that the inaccurate information might be accessible to other staff members.

Patient-Family Advocate #1 confirmed, during interview at 11:03 AM on 9/4/13, that Patient #1 had contacted him/her to express concerns around mistaken identity and billing. S/he stated that since the patient name, address and medical record number were correct on Patient #1's EMR, s/he had assumed the photo identity had been used at the time of registration to confirm the patient's identity. The advocate stated the only plan s/he could think of to assist Patient #1 was to recommend the patient talk with the police to help confirm Patient #1 was not the person escorted to the ED on 2/5/13. The Advocate stated that s/he told the patient to contact Patient-Family Advocacy if any further concerns and felt Patient #1 had agreed with the plan. S/he stated the patient did not contact the department again and confirmed no further follow up had been done by the Patient-Family Advocacy Program.

During interview, at 11:49 AM on 9/3/13, the Operations Manager for Health Information Management (HIM) confirmed that a data integrity incident had occurred when Patient #2 visited the ED on 2/5/13, was not able to provide clear information and the visit was registered under Patient #1's name, which was similar to Patient #2. S/he stated s/he was not notified of the incident until late April 2013, at which point the information from Patient #1's record was transferred to Patient #2's record and a note which identified the data integrity incident was placed in Patient #1's EMR. This information was verified during review of Patient #1's record, on 9/3/13, which noted; 'Data Integrity Alert: This record was recently involved in a data integrity incident. Please review problem list, meds and allergies carefully with patient at next visit.'

The ED Medical Director and Physician Assistant (PA) #2, who provided direct care to Patient #2, both agreed, during interview at 1:08 PM on 9/4/13, that there was potential for errors to occur if inaccurate health information is used as part of an assessment and treatment of a patient. PA #2, stated that the Registration Department is responsible for confirming the identity of patients in the ED and, as s/he reviewed Patient #2's record, there was nothing that would have alerted him/her, at the time of treatment, to false patient identity. S/he further stated there was nothing s/he would have done differently in the treatment of Patient #2, if the accurate medical record had been used. The Medical Director confirmed that, although Patient #1's record had been mistakenly used to provide care to Patient #2, (indicating that the ED provider's assessment had been based, in part on the inaccurate information from Patient #1's record), Patient #2 received appropriate care and there had been no negative outcome for Patient #2 as a result of the incident. Both the Medical Director and PA #2 stated they had not been aware of the incident until brought to the facility's attention by the surveyor on 9/3/13.

The Patient Identification policy, dated 7/1/11, included the Policy Statement: 'Guidelines have been established to maximize patient safety through a universal standard of unique patient identification', and stated, as it's purpose: 'To properly and accurately identify patients so that they may receive appropriate care.' The policy procedure included; 'I. General identification - A. Patient identification....is defined as a positive match to a minimum of 3 distinct data elements. Patients' Legal Name as provided by the patient, DOB and Gender.....social security number and/or mailing address will be considered additional data elements utilized to make a positive match....B. In an emergency, and three data elements are unavailable, an "Unidentified ED" patient number will be issued until data is provided.'

The Registration Supervisor stated during interview, at 4:14 PM on 9/3/13, that patient identification is confirmed by registrars during the registration process for all ED patients. S/he stated the policy includes asking the patient's name, DOB, address or social security number. S/he further stated the expectation is that staff should be looking at photo ID, if available in the record. Both the Supervisor and the Registrar #1, responsible for registration of Patient #2 on 2/5/13, who was also present during the interview, confirmed the policy had not been followed and the photo ID, although available in the EMRs of both Patient #1 and Patient #2, had not been accessed to confirm identity of Patient #2. Both also stated they had been unaware of this incident until notification was made by the surveyor.

The Director of Patient Registration and Customer Service, confirmed, during interview on the morning of 9/4/12, that Patient #2's ID had not been verified in accordance with the facility's policy, which led to the use of Patient #1's EMR in the treatment of Patient #2 on 2/5/13. S/he further stated s/he had not been made aware of the incident until notified through the surveyor.

Although there was no identified negative outcome for Patient #2, the failure to accurately confirm his/her identify created an unsafe setting in which to receive care, and placed the patient at risk for potential medical errors to occur. Despite the fact that Patient #1 did not receive treatment on 2/5/13, the inaccurate identification of Patient #2, by registration staff, subsequently led to a series of events including; misinterpretation of Patient #1's medical information by his/her PCP, inaccurate billing of tests and the failure of the hospital Patient Advocacy staff to assist the patient in resolution of the issue. This ultimately resulted in what Patient #1 expressed as great emotional distress related to his/her perception that their personal integrity had been questioned. And, although there was no evidence that breach of confidentiality of Patient #1's medical information had occurred the patient expressed distress related to the potential for a breach. This has potentially created an emotionally unsafe healthcare setting for Patient #1, who receives the majority of his/her care through the FAHC system.

2. Based on record review Patient #5, who was admitted on 1/24/13, and assessed by nursing, on 2/9/13 as an elopement risk, eloped, during an unsupervised leave from the inpatient unit on which s/he was housed, on 2/18/13. An initial RN Case Manager note, dated 1/28/13, indicated concerns regarding the patient's inability to manage self at home, appears impulsive with limited insight regarding care issues. An initial psychiatry evaluation was requested for the patient on 1/29/13 with the reason noted as "decision making capacity." The evaluation was deemed inconclusive due to psychiatry wanting to perform more cognitive testing. An attending MD note on 1/30/13 states that the patient is distrustful of staff and wants to go home. A social work note on 1/31/13 states that the case management team feels the patient would not be safe in his/her home environment and that the patient is confused and requiring a one to one for safety. Case management decided to then seek guardianship for the patient. Psychiatry re-evaluated the patient on 1/31/13 and concluded that the patient "does not have capacity." The patient's hospital stay was extended related to concerns regarding capacity to safely provide self care and the ongoing pursuit of legal guardianship. On 2/9/13 a Nursing Progress note indicated that the patient was irritable, irrational, and verbalized his/her desire to go home saying "I'm leaving here." Per nursing order on 2/9/13 the patient was subsequently placed on a one to one as an elopement precaution. The patient was transferred to the Baird 4 medical unit on 2/9/13, where, despite lack of evidence that a reassessment of elopement risk had been conducted, the patient was allowed unsupervised leaves from the unit to the cafeteria for specified periods of time. On 2/18/13 the patient signed out on the unit register that s/he was going to the cafeteria. S/he was discovered to have eloped from the unit when s/he did not return within the one hour time duration allowed off of the unit.

Per interview, on September 5, 2013 at 3:00 PM, the Baird 4 Nurse Manager confirmed that the patient had been assessed, on 2/9/13 while on Baird 3, as an elopement risk and that the patient's electronic medical record had been flagged to alert staff of the identified elopement risk. The elopement risk flag was on the EMR when the patient transferred that day to Baird 4. The Nurse Manager also confirmed that no reassessment of the elopement risk had been completed following Patient #5's transfer to Baird 4 on 2/9/13, the care plan had not been revised to discontinue the elopement risk and the patient was allowed unsupervised leaves from Baird 4 to the cafeteria, from where s/he eloped on 2/18/13. Patient #5 called the Baird 4 nursing unit to tell them s/he was "at home" and needed assistance with his/her care. The patient then returned to the hospital on the afternoon of 2/18/13.

Based on patient and staff interviews and record review staff failed to utilize the established event reporting system (SAFE) as a means to assess adverse patient events and identify opportunity for improvement and changes that would lead to improvement for an incident involving the mistaken identification of a patient. (Patient #1 and #2). Findings include:

1. Per interview with multiple staff members, there was a failure by staff, on at least three separate occasions, to follow facility policy to complete S.A.F.E event reports related to an incident involving mistaken identity of Patient #2, who was brought to the Emergency Department (ED), on 2/5/13, in a condition that prevented him/her from providing accurate information. The only form of identification used appeared to be patient name, and, as a result, inaccurate information from the EMR for Patient #1 (a patient with a similar name) was used to assess and treat Patient #2.

Per interview, at 8:40 AM on 9/3/13, Patient #1 stated that s/he had been made aware, sometime during a March or April 2013 visit to his/her Primary Care Provider (PCP), who, as part of the FAHC system, had access to all FAHC records, that his/her record indicated a visit to the ED on 2/5/13, which Patient #1 had not made. Subsequently, Patient #1 received a bill for diagnostic testing done in the ED on 2/5/13. When Patient #1 obtained a copy of their EMR, which contained inaccurate information, including a CT scan and lab results, referencing the ED visit on 2/5/13, s/he recognized that Patient #2, who had been escorted by law enforcement to the ED, had mistakenly been identified as Patient #1. The patient contacted the Patient-Family Advocacy Program at the hospital at the end of April 2013 and explained his/her concern about the mistaken identity and the receipt of a bill for diagnostic testing. The wrong identity was eventually confirmed when Patient #1 presented to the police station and a law enforcement official confirmed Patient #1 was not the patient escorted by that officer to the ED on 2/5/13.
The facility policy, Adverse Event/Near Miss Reporting and Analysis, stated; 'Potential hazards or adverse events should be reported at the time of identification and/or occurrence. The Manager/Supervisor/Risk Manager or designee should be informed and appropriate action taken immediately to mitigate the event.....Reported events and near misses will be tracked, trended and analyzed to improve quality and patient safety...'
The ED Medical Director and Physician Assistant (PA) #2, who provided direct care to Patient #2, both agreed, during interview at 1:08 PM on 9/4/13, that there was potential for errors to occur if inaccurate health information is used as part of an assessment and treatment of a patient. PA #2, stated that the Registration Department is responsible for confirming the identity of patients in the ED and, as s/he reviewed Patient #2's record, there was nothing that would have alerted him/her, at the time of treatment, to false patient identity. Both the Medical Director and PA #2 stated they had not been aware of the incident until brought to the facility's attention by the surveyor on 9/3/13.

Patient-Family Advocate #1 confirmed, during interview at 11:03 AM on 9/4/13, that Patient #1 had contacted him/her to express concerns around mistaken identity and billing. S/he stated s/he had assumed the photo identity had been used at the time of registration to confirm the patient's identity and the only plan s/he could think of to assist Patient #1 was to recommend the patient talk with the police to help confirm Patient #1 was not the person escorted to the ED on 2/5/13. The Advocate stated there had been no further follow up regarding the incident by the department of Patient Family Advocacy. S/he confirmed that s/he had not referred the complaint to ED or Patient Registration management or leadership staff.

During interview, at 11:49 AM on 9/3/13, the Operations Manager for Health Information Management (HIM) confirmed that a data integrity incident had occurred. S/he stated s/he had not been notified of the incident until late April 2013, at which point the information from Patient #1's record was transferred to Patient #2's record, though no event report had been completed.

The Registration Supervisor stated during interview, at 4:14 PM on 9/3/13, that patient identification is confirmed by registrars during the registration process for all ED patients. Both the Supervisor and Registrar #1, responsible for registration of Patient #2 on 2/5/13, who was also present during the interview, confirmed the policy had not been followed and the photo ID, although available in Patient #2's EMR, had not been accessed to confirm identity of Patient #2. Both also stated they had been unaware of this incident until notification was made by the surveyor, and the Supervisor agreed that the lack of timely notification of the issue "seems like a missed opportunity to improve on process."

The Director of Patient Registration and Customer Service, confirmed, during interview on the morning of 9/4/12, that Patient #2's ID had not been verified in accordance with the facility's policy. S/he further stated s/he had not been made aware of the incident until notified as a result of the current survey process. S/he stated that when data integrity incidents occur, the usual process is to notify the Registration department, which would trigger a need for an event report, and an investigation to identify and rectify the issue. S/he stated that a police officer reported the mistaken identity issue, providing positive identification of Patient #2 at the same time, to a Customer Service Representative (CSR) in the Billing Department, in late April. The Director stated the CSR failed to complete an event report, which should have occurred and would have provided notification to Patient Registration of the error. S/he agreed that a timely opportunity to improve patient care outcomes did not occur as a result of staff failure to complete the SAFE report.

During interview, at 12:37 PM on 9/5/13 the VP of Quality stated that the event reporting system is a piece of the overall quality assessment program. The information obtained is reviewed, analyzed and used to identify opportunities for improvement. S/he stated there was no evidence that an event report had been completed by anyone regarding this issue and agreed reports should have been completed by the CSR involved, the data integrity team, as well as the Patient Family Advocacy Department.

Based on staff interviews and record review the facility failed to supervise and evaluate the nursing care for one patient at the time of discharge, and for one patient, # 5, who eloped from his care unit.

Based on record review Patient #5, who was admitted on 1/24/13, and assessed by nursing, on 2/9/13 as an elopement risk, eloped, during an unsupervised leave from the inpatient unit on which s/he was housed, on 2/18/13. An initial RN Case Manager note, dated 1/28/13, indicated concerns regarding the patient's inability to manage self at home, appears impulsive with limited insight regarding care issues. An initial psychiatry evaluation was requested for the patient on 1/29/13 with the reason noted as "decision making capacity." The evaluation was deemed inconclusive due to psychiatry wanting to perform more cognitive testing. An attending MD note on 1/30/13 states that the patient is distrustful of staff and wants to go home. A social work note on 1/31/13 states that the case management team feels the patient would not be safe in his/her home environment and that the patient is confused and requiring a one to one for safety. Case management decided to then seek guardianship for the patient. Psychiatry re-evaluated the patient on 1/31/13 and concluded that the patient "does not have capacity." The patient's hospital stay was extended related to concerns regarding capacity to safely provide self care and the ongoing pursuit of legal guardianship. On 2/9/13 a Nursing Progress note indicated that the patient was irritable, irrational, and verbalized his/her desire to go home saying "I'm leaving here." Per nursing order on 2/9/13 the patient was subsequently placed on a one to one as an elopement precaution. The patient was transferred to the Baird 4 medical unit on 2/9/13, where, despite lack of evidence that a reassessment of elopement risk had been conducted, the patient was allowed unsupervised leaves from the unit to the cafeteria for specified periods of time. On 2/18/13 the patient signed out on the unit register that s/he was going to the cafeteria. S/he was discovered to have eloped from the unit when s/he did not return within the one hour time duration allowed off of the unit.

Per interview, on September 5, 2013 at 3:00 PM, the Baird 4 Nurse Manager confirmed that the patient had been assessed, on 2/9/13 while on Baird 3, as an elopement risk and that the patient's electronic medical record had been flagged to alert staff of the identified elopement risk. The elopement risk flag was on the EMR when the patient transferred that day to Baird 4. The Nurse Manager also confirmed that no reassessment of the elopement risk had been completed following Patient #5's transfer to Baird 4 on 2/9/13, the care plan had not been revised to discontinue the elopement risk and the patient was allowed unsupervised leaves from Baird 4 to the cafeteria, from where s/he eloped on 2/18/13. Patient #5 called the Baird 4 nursing unit to tell them s/he was "at home" and needed assistance with his/her care. The patient then returned to the hospital on the afternoon of 2/18/13.

Based on patient and staff interview and record review the facility failed to ensure the accuracy of the medical record for two patients: one whose record was erroneously used to document health information of another patient, and the second patient, for whom inaccurate information was used in the clinical assessment during an Emergency Department (ED) visit. Findings include:

Per interview, at 8:40 AM on 9/3/13, Patient #1 stated that his/her medical record had contained inaccurate information that was accessed by the patient's Primary Care Provider (PCP), in March or April of 2013, and resulted in the PCP questioning the patient about activity that led to an Emergency Department (ED) visit on 2/5/13. The patient informed the PCP that s/he had not been to the ED on 2/5/13. The patient subsequently received a bill for diagnostic testing that had been performed during the ED visit on 2/5/13. S/he then obtained a copy of his/her medical record, which contained inaccurate information including the fact that the patient had been escorted to the ED by police, as well as results of lab tests and CT scan. Patient #1 suspected his/her record had been used in the treatment of another patient (Patient #2) and contacted the Patient-Family Advocacy Department to inform them of the error. When no resolution was forthcoming from the facility Patient #1 presented to the police department and the police officer who had escorted Patient #2 to the ED on 2/5/13, confirmed that Patient #1 had not been the same person the officer had escorted to the ED. The police officer then notified the hospital of the mistaken identity of Patient #2.

During interview, at 11:49 AM on 9/3/13, the Operations Manager for Health Information Management (HIM) confirmed that a data integrity incident had occurred when Patient #2 visited the ED on 2/5/13, was not able to provide clear information and the visit was registered under Patient #1's name, (which was similar to Patient #2). S/he stated s/he was not notified of the incident until late April 2013, at which point the information from Patient #1's record was transferred to Patient #2's record and a note which identified the data integrity incident was placed in Patient #1's EMR. This information was verified during review of Patient #1's record, on 9/3/13, which noted; 'Data Integrity Alert: This record was recently involved in a data integrity incident. Please review problem list, meds and allergies carefully with patient at next visit.'

Based on staff interviews and record review the facility failed to assure implement an appropriate discharge plan for one patient. (Patient #4). Findings include:

Per review of the medical record for patient #4, was admitted through the facility emergency department on 5/23/2013 approximately one month post total colectomy and ileostomy complicated by post-operative pelvic abscess. The initial general surgeon progress note on 5/29/13 states that the patient has a rectal tube in place for drainage and it is to be removed prior to the patient's discharge. A subsequent progress note dated 5/30/13 states that the plan is to discharge the patient that day (5/30/13) and to remove the rectal tube prior to discharge. Despite the physician documented intent for the rectal tube to be removed prior to discharge, there were no physician orders reflecting that plan. A Nursing Progress note, dated 5/30/13, indicated that RN #1, who was responsible for the patient's discharge, demonstrated irrigation of the rectal tube for a home health aide who would be providing care post discharge and the tube was not removed prior to the patient's discharge. Further review of the patient record, post discharge, revealed that the patient presented at his/her primary care physician office (PCP) to have the rectal tube removed on 6/7/13. Per PCP documentation on 6/7/13, s/he removed the rectal tube from the patient and stated also that the attending surgeon at the facility from where the patient was discharged was unaware that the patient had been discharged with the rectal tube still in place.

During interview, on 9/5/2013 at 2:00 PM, RN #1 confirmed there were no physician orders to discontinue the rectal tube and no orders for use and care of the rectal tube post discharge. The RN Unit Manager, who was also present during the interview, confirmed that the expectation is there would be a physician order for both the continued use of, and care of, the drain. In addition, RN #1 further confirmed the lack of discharge instructions for use and care of the rectal tube.

Despite the physician intent for the rectal tube to be removed, prior to discharge, there was a lack of communication regarding that discharge plan and the patient was discharged without a plan for continued use and care of the open drain.