HospitalInspections.org

Based on observation, interview, record review, and policy review, the facility failed to ensure that patients received their notification of Patient's Rights for two of four outpatient clinics observed. This had the potential to affect all patients who received care at an outpatient clinic. The facility provides outpatient services for a total of 13 clinics. These 13 clinics had a total of 101,357 patient visits from 01/2018 to 09/2018.

Findings Included:

1. Review of the facility policy titled, "Patient Rights and Responsibilities," revised 06/2016, showed that all patients utilizing the services of the medical center are informed of their rights and responsibilities.

Observation on 11/07/18 at 10:30 AM showed Staff BB, Orthopedic (medical specialty concerned with the correction of deformities or functional impairments of the skeletal system) Clinic Registration, asked Patient #18 if she wanted a copy of the Patient's Rights. Patient #18 declined a copy and the Patient's Rights were not explained. There was not a designated area in the Electronic Medical Record (EMR) that addressed if the Patient's Rights were given or explained.

During an interview on 11/07/18 at 10:35 AM, Staff BB stated that she did not provide a copy of the Patient's Rights to the patient because the patient declined. Staff BB stated that a copy of the Patient's Rights were given one time a year with the new patient packet, but stated that there was not a designated area in the EMR to document that the notification of Patient's Rights were given. Staff BB stated that the patient did not sign the notification of Patient's Rights.

During an interview on 11/07/18 at 10:50 AM, Staff DD, Clinic Director (Orthopedic Clinic, Urology [medical specialty concerned with the function and disorders of the urinary system] Clinic, General Surgery Clinic and Neurosurgery [surgery performed on the nervous system, especially the brain and spinal cord] Clinic), stated that it was expected that the notification of Patient's Rights were given at the patient's initial visit to the clinic and annually. Staff DD stated that there was not a designated place to document that a patient received their Patient's Rights.

During an interview on 11/07/18 at 2:40 PM, Staff FF, Rheumatology (medical specialty concerned with disorders of the joints, muscles and ligaments) Clinic Registration, stated that the clinic did not have a way to document a patient had been given their Patient's Rights at their new patient visit or annually.

During an interview on 11/07/18 at 3:05 PM, Staff HH, Clinics Director (Rheumatology Clinic, Pain Management Clinic, Internal Medicine and Urgent Care), stated that there was not a place to document that a patient had received their Patient's Rights. Staff HH stated that it was expected that the Patient's Rights be reviewed with the patient and it be documented that the notification was given and explained to the patient.

Based on interview, record review, and policy review, the facility failed to provide written notice to patients or complainants regarding the steps taken to investigate a grievance, and the result of the grievance investigation process for one patient (#12) of three patient grievance and complaint files reviewed. This had the potential to affect all individuals who filed a grievance or complaint. The facility census was 54.

Findings included:

1. Review of the facility's policy titled, "Complaints/Grievances, Patients," revised 05/2012 showed the following:
- The Grievance Committee investigates grievances within one week of receipt.
- Investigations may include interviews with patient's families and staff, department directors and physicians as well as review of the medical record.
- If the resolution takes more than one week to complete, a letter is sent to the complainant acknowledging that their complaint has been received and that it is being investigated as well as a date when the patient can expect the response to be mailed.
- A written follow up of the grievance is made to the patient and appropriate facility staff as determined by the Grievance Committee at the conclusion of the investigation with the name of the hospital contact, the steps taken on behalf of the patient to investigate the complaint, the results of the process and date of completion.

Review of discharged Patient #12's medical record showed she was admitted to the facility's NeuroPsych (a science concerned with the integration of psychological observations on behavior and the mind with neurological observations on the brain and nervous system) Unit (NPU) on 10/19/18 for inpatient psychiatric (relating to mental illness) care.

Review of the facility document titled, "Occurrence/Follow-up Form," dated 10/29/18 showed the following documentation by Staff W, Safety Risk Manager:
- Date of the call: 10/29/18;
- Event date: Past week;
- Involved parties: NPU Staff;
- Patient #12's nephew reported that he was denied seeing his aunt the prior week while she was a patient on the NPU because he had been a patient on the NPU the previous six months;
- Staff W informed the complainant that he would be allowed to see his aunt in the future if she was admitted and that he should contact him (Staff W) if he had an issue with the visitation; and
- Complainant agreed to close out the grievance.

Review of the facility response letter to the complainant showed that Staff W replied to the complainant on 10/29/18. Staff W informed the complainant that this was in response to his phone call and that the investigation was completed on 10/29/18. Staff W stated that as discussed on the telephone conversation if the complainant had any difficulty in the future visiting family members in the NPU he would be there to assist.

The facility response letter failed to identify the steps taken to investigate the complaint and the resolution of the investigation.

During an interview on 11/07/18 at 10:00 AM, Staff W stated that he was new to this position and that he had called the NPU charge nurse and asked if there had been any problems with the complainant visiting. He stated that the charge nurse informed him that the staff knew the complainant because he had been a former patient within the last six months.

During an interview on 11/07/18 at 3:50 PM, Staff II, Risk Director stated that Staff W was new to his position and he was to review all complaint/grievance letters prior to sending them out but he failed to review this letter with her. Staff II stated that the response letter to the complainant did not contain all of the elements that it should have.