HospitalInspections.org

Based on policy review, document review, and interview the Critical Access Hospital (CAH) failed to ensure 1. patient rights were provided in accordance with applicable state law affecting all patients and 2. policies and procedures implemented an established mechanism to recognize and investigate patient complaints and grievances for one of 10 patients reviewed (Patient 5). These deficient practices have the potential to prevent patients from receiving all Patient Rights and delays timely response to grievances hindering the facility's opportunity to discover and address problems that may lead to harm or other adverse outcomes.

Findings Include:

1. Patient Rights

Review of Kansas Administrative Regulations (KAR) showed, 28-34-3b. Patient rights. (a) Policies and procedures. The governing body shall ensure that the facility establishes policies and procedures which support the rights of all inpatients and outpatients. At a minimum, each facility shall ensure that: ...(5) each patient has the right to formulate advance directives and appoint a surrogate to make health care decisions on the patient's behalf to the extent permitted by law; ...(8) each patient or patient's legally designated representative has access to the information contained in the patient's medical records within the limits of state law; ...

Review of the CAH's document titled, "Your Rights as a Patient at [CAH]," revised 06/03/16, showed a three-page document that included patient rights, access to care, privacy and confidentiality, right to refuse treatment and the patient's responsibilities as a patient.

The document failed to include the required patient rights:

1. Each patient or patient's legally designated representative has access to the information contained in the patient's medical records within the limits of state law.

2. Each patient has the right to appoint a surrogate to make health care decisions on the patient's behalf to the extent permitted by law.

During an interview on 11/09/21 at 3:02 PM Staff B, Director of Quality and Risk Management (DQRM) reviewed the patient rights document and acknowledged that it did not include the right for the patient or the patient's representative to the content of the patient's medical record. Staff B stated that the right to appoint a representative is in the advance directive document but is not on the patient rights document. Staff B stated that she would have to add it to the list of patient rights. Staff B stated that the State Agency's hotline for complaints would be added to the Patient's Rights document as well as the grievance and complaint form.


2. Patient Complaints and Grievances

Review of the CAH's policy and procedure titled, "Grievance Procedure," dated 09/2014, showed "[CAH] shall provide and adhere to this procedure for receiving, responding and resolving patient complaints, grievances, and concerns brought forward by a patient or their authorized representative in a timely, reasonable, and consistent manner. All patients will be informed of this policy and who to take these matters to including the names, addresses, and phone numbers of those persons and/or entities." Further review showed, "Immediate attention must be given to complaints or situations that endanger the patient."

Review of the CAH's policy and procedure titled, "Patient Identification Accuracy," dated 07/2010, showed "all [CAH] patients (inpatients and outpatients) will be accurately identified . . . to assist with positive patient identification, each patient (inpatient and outpatient) receiving care and services at [CAH] will have an identification armband placed on their wrist at the time of registration.

During an interview on 11/09/21 at 1:12 PM, a staff member from Facility B stated that Patient 5 returned from the emergency department at above-named facility with an identification bracelet that had the information for another patient that included the name, age, and date of birth. The staff member stated that the bracelet identified a much younger woman named [Patient 9]. The Staff Member stated that she was concerned about privacy and the care Patient 5 received as she was acting different than she normally did the following day. The Staff Member stated that a call was made to the above-named hospital's director of nursing (DON) regarding the concern that the identification bracelet Patient 5 was wearing had the information for another patient.

Review of Patient 5's medical record showed that Patient 5 presented to the Emergency Department (ED) on 06/22/21 at 9:35 AM for assessment and treatment after a fall at her long-term care facility. Patient 5 had a computerized tomography (also known as a CAT scan, a series of x-rays taken from different angles around your body) which showed no injuries. Patient 5 did not receive any medications while she was in the ED. Patient 5 was diagnosed with lower back pain and hip pain and discharged at 12:14 PM.

Review of Patient 9's medical record showed that Patient 9 presented to the ED on 06/22/21 at 6:39 AM for assessment and treatment of a leg injury. Patient 9 was diagnosed with a strained left quadricep (large muscle at the front of the thigh) tendon and muscle, was given pain medication at 7:01 AM and was discharged at 8:00 AM.

Review of the complaint and grievance log showed that there was no documentation regarding the call or concern that Patient 5 was wearing an identification bracelet that belonged to someone else.

During an interview on 11/10/21 at 11:45 AM Staff P, DON, stated that she does not recall receiving a telephone call regarding Patient 5 having an incorrect bracelet placed on her wrist.

During an interview on 11/09/21 at 3:02 PM Staff B, Director of Quality and Risk Management (DQRM) stated that Patient 5 and Patient 9 are well known, and it would be difficult to confuse them. Staff B stated that the hospital is in a small community and most patients are known and well established. She stated that if this happened, it would go onto an incident report and go through the privacy officer as well as risk management. Staff B acknowledges that the incident did not go through the grievance procedure .

During an interview on 11/10/21 at 12:25 PM Staff A, Chief Executive Officer (CEO) acknowledged that a patient identification bracelet was placed on the wrong patient. Staff A stated that he is concerned that the wrong identification bracelet was placed on a patient, and was not escalated to the privacy officer or risk management team for review and that procedures for reporting needed to be reviewed.