HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 6 patients (Patient #2) in the medical record review sample, the facility failed to inform the patient, or patient's representative, of the patient's rights in advance of furnishing patient care. Findings included:

The policy entitled "Patient Rights and Responsibilities" stated, "...The patient has the right to reasonable informed participation in decisions involving health care..."

The hospital document entitled "Consent to Hospital Admission and Medical Treatment" stated, "...Right to Participate In and Direct Health Care Decisions..."

Medical record review revealed no evidence to support that Patient #2 was informed of their rights in advance of furnishing care.

This finding was confirmed by Quality Management Nurse A on 8/1/19 at 10:11 AM.

Based on policy and document review and staff interview, it was determined that for 2 of 3 patients (Patient #'s 1 and 6) in the sample with grievances, the hospital failed to provide written notice of the results of the grievance investigation to the complainant. Findings included:

The hospital policy entitled "Customer Complaint or Grievance" stated, "A grievance received from a patient or patient's representative will be responded to, in writing on average within 7 days. If the investigation of a grievance cannot be completed within this timeframe, the patient...patient representative is notified...The written response to a grievance will contain...Steps taken to investigate...Results of the investigation..."

Review of the hospital's "Patient Grievances" report/log and corresponding grievance file documentation on 7/31/19 revealed:

A. Patient #6
1. Verbalized a patient safety concern on 5/1/19
2. Final written notice of resolution, sent on 5/23/19, failed to include the results of the investigation

This finding was confirmed by Patient Experience Director A on 7/31/19 at 1:55 PM.

B. Patient #1
1. An e-mail dated 7/16/19 documented:
- the patient representative reported a complaint to Patient Experience Director A on 7/12/19

No evidence the hospital provided the patient/patient representative with a written response to the grievance.

This finding was confirmed by Patient Experience Director A on 7/31/19 at 1:55 PM.

Based on medical record review, policy and document review and staff interview, it was determined that for 1 of 6 patients (Patient #1) in the medical record review sample, the pharmacist failed to process the practitioner's order for medications, in accordance with policies and procedures. Findings included:

The hospital policy entitled "Medication Orders Policy" stated, "...Complete medication orders include the patient...drug, dosage, frequency, and route...date, time and name of ordering physician...Medication orders shall be reviewed by a pharmacist for clarity and reasonableness...If a pharmacist is unable to contact the prescriber...s/he shall contact a house officer/physician assistant assigned to cover...All medication order changes shall be communicated to the nursing unit and shall be entered into the computer order entry system by the pharmacist..."

The job description entitled "Pharmacist" stated, "...Performs verification of...orders...contacting physicians and providers when necessary for...clarification..."

A. Review of Patient #1's medical record revealed:

1. "Orders"
7/4/19
6:33 PM: Physician A ordered Keppra (an anti-seizure medication) to be administered to the patient twice each day, beginning on 7/4/19 at 9:00 PM
6:48 PM: Pharmacist A voided the order for Keppra

2. "Rapid Response Team Assessment and Intervention Form", dated 7/7/19, documented the response team:
- responded to a call at 8:57 PM for a seizure and that the patient's (family member) reported a seizure also occurred "earlier today"
- recommended a neurology consult

3. "Medication Administration Record" review revealed Patient #1 did not receive Keppra which was ordered to begin on 7/4/19 at 9:00 PM.

4. No evidence to support that Physician A, other medical staff or nursing staff were notified that the 7/4/19 order for Keppra was voided by the pharmacist.

B. During an interview on 8/1/19 between 1:32 PM and 1:40 PM, Physician A:
- confirmed that Keppra was one of the seizure medications s/he ordered for Patient #1 on 7/4/19
- was not aware that the patient had not received the medication as ordered until advised after the patient had a seizure
- had not been notified by pharmacy staff that the order had been voided

C. During review of the medical record and interview on 8/1/19 between 11:45 AM and 12:10 PM, Director of Pharmacy A confirmed no documentation was found to support that Pharmacist A, who voided the Keppra order, adhered to requirements to attempt to:
- obtain clarification of the order
- contact medical/nursing staff
- document a reason for voiding the order

Based on medical record review, hospital policy and document review, and staff interview, it was determined that for 1 of 2 patients (Patient #7) in the sample who were discharged to a skilled nursing facility (SNF), there was no evidence that the hospital provided the patient/representative with a list of available SNF options. Findings included:

The hospital policy entitled "Use of Choice Form" stated, "...inform the patient and patient's family that there is a...network of Skilled Nursing Facilities (SNF's)...The choice of a...SNF...is...the choice of the patient and/or the patient's family...listing of...extended care facilities...option is selected...patient acknowledges...choice...Secure patient's...family member's signature, date, time..."

Review of Patient #7's closed medical record revealed:
- Patient #7 was discharged on 7/20/19 to a SNF
- no evidence to support that the discharge plan included a list of SNFs that were available to the patient, or that the patient/patient family was informed of their freedom to choose among participating Medicare providers of post-hospital care services

These findings were confirmed by Case Management Director A on 8/1/19 at 2:05 PM.