HospitalInspections.org

Based on observation, interview, and record review it was determined that the facility failed to protect and promote the rights of patients resulting in the potential for a loss of rights for all patients seeking treatment at the facility. Findings include: see related A tags also cited below

1. Failure to inform each patient of the patient's rights in advance of furnishing patient care (A-0117).

2. Failure to specify time frames for unresolved grievance follow up and response (A-0122).

3. Failure to protect patient personal information (A-0143).

Based on observation and interview, the facility failed to provide, patients seeking treatment at the facility's off site urgent care, with notification of patient rights, prior to receiving treatment. The facility also failed to provide patient rights to 1 of 1 (#15) patients at the hospital's main emergency department (ED) resulting in a potential loss of patient rights to all patients treated at the off site urgent care and patients of varied ethnicity. Findings include:

On 06/23/2015 at 0845 during observation and interview at the facility's off site urgent care, a query was made to staff M as to how patients are informed of their patient rights. Staff M stated, "We have that posted in the lobby." A review of the document that staff M pointed out revealed that it did not contain patient rights and responsibilities information.

In an interview with staff N (Urgent Care Registration Clerk) on 06/23/2015 at 0850, when queried if she had any documentation that she would provide patients regarding their rights, she stated, "No, I don't have anything like that."

On 06/23/2015 at 0900, staff M went on the computer and printed off a document titled, "Patient Rights and Responsibilities" on the bottom was the hospital's name. When queried if the patients seeking treatment at the facility were given a copy of this prior to treatment, she stated, "No."

On 06/23/2015 at 0940, a review of the facility's policy titled, "Patients' Rights and Responsibilities, Index Code: INST. 10/130, Effective Date: 8/2012, Policy Statement: Information regarding patients' rights and responsibilities is provided at the time of entry into the healthcare setting and before care is initiated whenever possible. Information is provided in a variety of formats including but not limited to booklets, brochures, wall posters and translated materials as appropriate to meet the individual needs of the patient and/or their advocate and family."

On 06/23/2015 at 0945 during an observation in the Emergency Department with staff C, a patient (#15) who was in the waiting room stepped up and approached a staff member with a question using very broken English. It was determined that the patient was of a different nationality other than American or Spanish. When staff C was queried as to how the patient would be provided with patient rights in a language that he would understand, staff C replied, "We have an interrupter service that we can use." When queried if the service was used for the patient and was he informed of his patient rights, staff C stated, "Lets get someone who can answer that for us."

In an interview with staff H, (ED Clinical Nurse Leader) on 06/23/2015 at 1050, when queried if an interrupter was used for patient #15 she stated, "Yes, one came over to interpret for him." When queried as to if the interpreter informed the patient of his patient rights, she stated, "I don't believe that was done. I believe that they only addressed his complaint and his treatment."

Based on document review and interview, the facility failed to provide specific time frames for when complainants can expect a follow-up letter when a grievance is not closed by the seven-day time interval as stated in policy, resulting in the potential for ongoing and unresolved complaints/grievances. Findings include:

On 06/23/2015 at 1315 during review of the facility's policy titled, "Patient Grievance Process, Index Code: INST. 10-107, Effective Date: 03-15-2013" revealed in the section titled, "Explanation: A patient grievance will be responded to in writing (if not resolved at bedside) within 7 days of receipt. If a response cannot be obtained within 7 days, the complainant will be notified as to when a letter will be received, which will provide information as to the findings."

In an interview with staff D on 06/23/2015 at 1330, she confirmed that the policy does not state a time frame as to when the complainant should expect a follow-up letter regarding the continued investigation or closure of their grievance.

Based on observation, interview and record review the facility failed to restrict access to and monitor for misuse of patient information resulting in the potential for patients' personal information to be disclosed incidentally for all patients treated at this facility. Findings include:

On 6/23/2015 at 0800 during the record review of patient #1, who was seen at Facility B on 4/5/2015, complained on 4/8/2015 that the SO obtained her name and contacted her personally on a social media forum, requesting friendship on 4/7/2015.

On 6/23/2015 at 1000 during interview of staff F, Director of Security he stated, when we interviewed the SO involved in the complainant's incident, who worked at [Facility B] on 4/7/2015 he stated he "used his computer system access (First Net ) privileges to access the patient's name." Staff F went on to say, "We are hesitant to restrict the SO's access to patient information, there are times when their presence is really needed. We may have to look at some other process."

On 6/23/2015 at 1030 when staff F was asked if we could interview the SO from Facility B, who misused the personal information of patient #1, this surveyor was informed the SO was no longer an employee.

On 6/22/2015 at 1100 during tour of the emergency department (ED) in Facility A, the security officer (SO) was sitting at a desk by the front door. He was able to greet people entering the facility, give directions and answer general questions. The SO had 2 computer screens available for use. Both computers were password protected. The screens were the white screens used in the ED. The patient information included name, age, chief complaint, triage level, room, doctor, and tests being done.

On 6/22/2015 at 1500 the SO, staff I was interviewed. He stated "I don't need all the information I can see on the screen, I really only use name, location, chief complaint, and whether they want visitors."