HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the hospital failed to follow their own policy to provide the complainant with a written response regarding the resolution of the complaint for one (1) of one (1) charts reviewed (patient#1). This has the potential to negatively affect all patients from having the right to receive a written response as to the outcome of the hospital investigation.

Findings include:

1. Review of the hospital into patient #1's complaint revealed the hospital failed to send the patient a written reply to his grievance.

2. Review of the policy titled "Patient Grievances", with a created date of 01/01/15, states "For the majority of the grievances, an average response time of within seven (7) working days from receipt of the grievance is considered appropriate".

3. A joint interview was conducted with six (6) south Nurse Manager and the Hospital's Associate Administrator on 6/22/16 at 8:30 a.m. revealed a letter was not sent to patient #1 within seven (7) days of the receipt of the complaint.

Based on observation it was determined the agency failed to ensure the confidentiality of patient records and failed to ensure unauthorized individuals cannot gain access to or alter patient records. This deficient practice was identified in eighteen (18) of twenty-six (26) unsecured patient medical records. This failure has the potential for all patients' medical information to have unauthorized access.

Findings include:

1. A tour of 6 South Orthopedic unit was conducted on 06/20/2016 at 10:35 a.m. During the tour, eighteen (18) of twenty-six (26) patient medical records were found to be unsecured in chart boxes outside patient rooms.

2. An interview was conducted with the Unit Coordinator on 06/20/2016 at 10:45 a.m. She concurred with the above findings.

3. An interview was conducted with the unit Nurse Manager on 06/20/2016 at 10:50 a.m. She concurred with the above findings. She stated: "The entire hospital has charts in unsecured chart boxes with the exception of 6 East."

4. Review of Paper Chart, Location, and Maintenance Policy, last reviewed 6/13/16, states, in part: "...The patient's chart will be kept in unit designated area...Documents from thinned charts will be stored on the unit in a secured location."

Based on observation, policy review and staff interview it was determined the Nurse Manager failed to supervise the care of the registered nurse on securing patient medication in one (1) of twenty-six (26) unsecured wall chart cabinets. This has the potential for all medication to be unsecured and the potential for non-prescribed medication to be available to all staff, visitors and patients.

Findings include:

1. Observation during a tour of unit six (6) south orthopedics on 6/20/16 at approximately 10:15 a.m. revealed that in an unsecured chart box outside of room six hundred (600) two (2) caplets with a medication label documented as Astrovastatin were left unlocked and unsecured.

2. Review of the policy titled, "Procurement and Storage of Medication", last reviewed 5/17/16, states: "Medications are secured at all times in a manner to prevent tampering and diversion when health care provider not present. This includes, but not limited to, patient hallside medication boxes...If locked medication rooms are not available, medications must be secure and under constant surveillance."

3. An interview was conducted on 6/20/16 at approximately 10:30 a.m. with the Nurse Manager and she concurred with the above findings.

Based on observation, it was determined the agency failed to ensure medications were kept in a secure area. This deficient practice was identified in one (1) of twenty-six (26) chart boxes. This failure has the potential for all medications to be unsecured and the potential for unauthorized persons to have access to non-prescribed medication.

Findings include:

1. A tour of 6 South orthopedic unit was conducted on 06/20/2016 at 10:35 a.m. During the tour, an unsecured chart box located outside patient room six hundred (600), bed one (1), revealed a plastic bag containing two (2) caplets with a medication label for Atorvastatin.

2. An interview with the Unit Coordinator was conducted on 06/20/2016 at 10:45 a.m. She concurred with the above findings.

3. An interview with the unit Nurse Manager was conducted on 06/20/2016 at 10:50 a.m. She concurred with the above findings.

4. Review of the policy titled, "Procurement and Storage of Medication", last reviewed 5/17/16, states: "Medications are secured at all times in a manner to prevent tampering and diversion when health care provider not present. This includes,but not limited to, patient hallside medication boxes...If locked medication rooms are not available, medications must be secure and under constant surveillance."