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Based on staff interview and documents review, it was determined that the hospital did not ensure that all patients are provide with a written notice of its decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This finding was noted in 1 of 10 applicable medical records reviewed.

Findings include:

MR #4
This patient was admitted to the facility on 1/3/10 for acute care. The documents presented for review noted the patient spoke with a representative of the Patient Centered Care Department on 1/4/10 regarding issues of privacy. The patient felt that at least three staff members who had no part in her care had access to her medical record. The patient stated that on 1/19/10, she met with two hospital staff members for discussion regarding her hospitalization. On 2/9/10, she sent a written correspondence with certified return receipt to three staff at the facility, the Director of Human Resources, Director of Compliance and the VP of Nursing. The complaint was investigated by the hospital and it was determined there was a breach in confidentiality. The facility implemented corrective actions; however, the facility failed to provide the patient with a written response to her complaint upon conclusion of the investigation.

Based on staff interview and the review of documents, it was determined that the hospital did not ensure confidentiality of patient records.This finding was noted in 1 of 10 applicable medical records reviewed.

Findings include:

The patient in MR #4 was admitted to the facility on 1/3/10 for acute care. Review of file ID # 3342 on 1/11/11 showed that the patient spoke with a representative of the Patient Centered Care Department on 1/4/10 regarding issues of privacy. The patient stated that at least three persons who had no part in her care had access to her medical record. The patient indicated that on 2/9/10, she sent a written complaint with a certified return receipt to three staff members, the Director, Human Resources; Director of Compliance and the VP of Nursing.
The audit log documentation for the period 1/3/10 to 1/5/10 revealed that three staff not involved in the patient's care accessed her electronic medical record. During staff interview conducted on 1/11/11, it was revealed that an attempt by a fourth worker to access the paper record was foiled.

Based on interviews, the review of medical records and other documents, it was determined that the medical staff failed to conduct prompt assessment of each patient to ensure that care provided met accepted standard of medical practice. This finding was noted in 3 of 10 applicable records.

MR #1
The patient was admitted on 2/23/10 for BEAM therapy and a second autologous bone marrow transplant. On 3/20/10 at 11.25 AM, the nurse noted the patient was found on the floor while ambulating to the bathroom with his daughter. The patient and daughter both confirmed that he did not hit his head. The nurse noted vital signs were stable and no immediate complaint by the patient. Although, the nurse indicated that two physicians were informed of the incident, there was no evidence of prompt evaluation of the patient by the medical staff. On 3/24, the patient experienced rigors immediately following a platelet transfusion. He began complaining of worsening headache on 3/25 that resolved with Tylenol. Again on 3/26, he complained of persistent headaches accompanied by vomiting. A CT scan of the head on 3/26 showed bilateral subdural hematomas with dependent acute products, likely representing acute-on-chronic versus subacute subdural hematomas. Neurosurgery recommended no intervention at the time; however, a Repeat CT scan on 3/27 at 4:17 showed slight increase in size of the subdural hematomas. The patient was emergently taken to the OR on 3/27 for a right and left parietal craniotomy with placement of drains.

Based on interview with the patient's physician on 1/12/11, he stated the subdural hematomas were likely spontaneous related to thrombocytopenia but could also have resulted from the fall incident.


MR #2
This elderly patient was admitted on 7/13/09 and underwent pleural biopsy and drainage with placement of a right pleural catheter. The patient had multiple medical conditions including ischemic cardiomyopathy, hypertension, A-fib with cardioversion and a right pleural effusion suspicious for mesotelioma. Postoperatively, the patient was alert and oriented x 3, saturating well with stable vital signs. On 7/14, the patient developed crepitus to the right anterior chest, face and eyes requiring a reconnection of the pleural catheter back to suction. The patient's oxygen saturation improved with 50% mist mask.

On 7/15/09, the patient became increasingly confused. The medical staff did not document all assessments, observations and interventions provided to the patient during the acute period before she went into hypotensive/pulmonary arrest at 2251. At 1200, nurse noted the patient was slightly confused. Chest x-ray at 1306 revealed extensive bilateral subcutaneous emphysema with interval worsening on the left. ABG at 1329 showed a PH of 7.4. PCO2 47, PO2 84, Bicarbonate 29.1, Base Excess 3.6. Thoracic surgery note at 1325 indicated the placement of a right chest tube for worsening subcutaneous emphysema as pleurex catheter was inadequately draining air.

The nurse reported increasing confusion and agitation to the Nurse Practitioner (NP) at 1800, 1820 and 1827. The NP ordered Seroquel 25mg PO at 1756 and Haldol 2mg, IM stat at 1826. This was an attempt to treat the patient's symptoms rather than further investigate the underlying cause of changes in mental status. There were no follow up ABG' s and no evidence of assessment by the medical staff until 2251 when patient was found unresponsive with hypotensive/pulmonary arrest. During cardiopulmonary resuscitation, attending physician found pleurx catheter disconnected from pleurovac.

MR #3
Review of MR #3 on 1/11/10 noted that the patient was assessed on admission as a risk for fall. The patient was found on the floor at 4:30 PM on 5/10/10. The fall incident was not witnessed. Nursing staff noted the patient's physician was made aware and called to bedside. There was no documented evidence of a post fall evaluation by the medical staff.