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Based on staff interview, and review of medical records, it was determined the hospital failed to inform 26 of 26 surgical patients (#s 1-6 and #s 11-30), whose records were reviewed, of their rights. This prevented the hospital from promoting and protecting each patient's rights. Findings include:

1. Medical records for 26 of 26 surgical patients (#s 1-6 and #s 11-30) contained a form labeled "PATIENT RIGHTS AND RESPONSIBILITIES." The form did not contain the following rights:

* The patient has the right to participate in the development and implementation of his or her plan of care.
* The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
* The patient has the right to personal privacy.
* The patient has the right to receive care in a safe setting.
* The right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

The DON was interviewed on 2/02/11 at 9:25 AM. She confirmed the above rights were not listed on forms given to patients.

The hospital failed to inform patients of all of their rights.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure 26 of 26 surgical patients (#1-6 and #11-30), whose records were reviewed, were informed of whom to contact to file a grievance. This decreased the likelihood that patients who were dissatisfied with their care would be able to file a grievance. Findings include:

The hospital's policy "CONCERNS, COMPLAINTS, GRIEVANCES," revised 2/07, stated "All patients have a right to file a grievance, obtain information on how to file a grievance...B. Notification: All patients are notified of their right to file a grievance and the procedures to follow should they desire to do so. Patient information is provided at the time of admission and is used for the notification."

The form "PATIENT RIGHTS AND RESPONSIBILITIES," that Patients #1-#6 and #11-#30 were given on admission, stated patients had the right "To express complaints concerning your care and have such complaints resolved in a timely manner." The form did not mention grievances and did not include a process to file a grievance, nor did it identify whom to file the grievance with. In addition, the form stated patients could notify the "Idaho Department of Health" if they felt their complaints had not been answered. The "Idaho Department of Health" did not regulate the hospital and was not an appropriate agency to notify. The form did not include contact information for the state survey agency.

The DON was interviewed on 2/02/11 at 9:25 AM. She confirmed the patient rights form did not mention grievances or whom patients could contact to file a grievance.

The hospital did not notify patients whom to contact to file a grievance.

Based on staff interview and review of complaint logs, grievance reports, and hospital policies, it was determined the hospital failed to ensure a written response was provided to 3 of 4 complainants who filed grievances. This impacted 3 of 4 patients (#31, #32, and #33), who's grievance files were reviewed. This resulted in a lack of clarity and closure about the resolution of the grievances and had the potential to interfere with patient understanding and satisfaction. Findings include:

1. The policy "CONCERNS, COMPLAINTS, GRIEVANCES," revised 2/07, stated all patients had a right to file a grievance. The policy stated a written response to the grievance would be generated within 60 days. This policy was not followed. Examples include:

a. The complaint log documented a grievance related to the care of Patient #31 was received on 8/03/10. A report of the grievance documented it had been investigated. A written response to the complainant was not documented.

The DON was interviewed on 2/02/11 at 9:25 AM. She stated she had spoken with the complainant related to the grievance for Patient #31 but had not provided that person with a written response. She stated if complainants seemed satisfied with a verbal response, they were not provided with a written response to grievances.

b. The complaint log documented a grievance related to the care of Patient #32 was received on 3/17/10. A report of the grievance documented it had been investigated. A written response to the complainant was not documented.

The DON was interviewed on 2/02/11 at 9:25 AM. She stated she had spoken with the complainant related to the grievance for Patient #32 but had not provided that person with a written response.

c. The complaint log documented a grievance related to the care of Patient #33 was received on 5/03/10. A report of the grievance documented it had been investigated. A written response to the complainant was not documented.

The DON was interviewed on 2/02/11 at 9:25 AM. She stated she had spoken with the complainant related to the grievance for Patient #33 but had not provided that person with a written response.

The hospital did not provide written responses to persons who filed grievances.

Based on staff interview and review of medical records, it was determined the hospital failed to ensure the medical records for 26 of 26 surgical patients (#s 1-6 and #s 11-30), whose records were reviewed, contained documentation of personal care. This resulted in the inability of the hospital to determine if care had been provided. Findings include:

The hospital had 2 nursing units, the Monitored Care Unit and the Inpatient Unit. "NURSE PROGRESS NOTES," used by nurses to document care on the Inpatient Unit, did not contain specific spaces to document personal cares, such as bathing and oral care. The medical records of 26 surgical patients (#s 1-6 and #s 11-30) were reviewed. None of these records contained documentation of all personal care being provided. For example, occasionally, the nurse would document personal care in narrative form in progress notes but this was sporadic in all of the inpatient medical records.

The Director for Quality and Risk Management of the hospital's parent corporation was interviewed on 2/02/11 at 2:45 PM. She stated personal cares were being provided. She said the "NURSE PROGRESS NOTES" for the Inpatient Unit did not include specific places for staff to document personal care and agreed staff did not document personal care.

The hospital failed to document personal care for patients.

Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to develop a system to identify patients who were likely to suffer adverse health consequences upon discharge if there was not adequate discharge planning. This affected 5 of 6 patients (#13, #23, #24, #28, and #30), whose records were reviewed for discharge planning screening. The lack of a system to identify patients with discharge planning needs at an early stage had the potential to delay discharge planning. Findings include:

The policy "DISCHARGE PLANNING POLICY," effective 9/01/03, stated "Discharge planning and educational needs will be evaluated as part of the admission assessment. Patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning are identified and appropriate discharge planning personnel are notified." The policy included 11 indicators to identify patients who needed discharge planning, such as patients over 70, patients who might require durable medical equipment at home, pregnant minors, etc.

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She stated nurses assessed patients on admission to identify potential discharge planning needs. She stated nurses used the "Initial Nursing Assessment" forms to identify patients who needed discharge planning. This was not the case, however. Examples of patients who were not screened for discharge planning needs include:

a. Patient #23's medical record documented a 65 year old female who had a section of her sigmoid colon removed. She was admitted on 11/24/10 and discharged on 12/15/10. Her "Initial Nursing Assessment," dated 11/24/10 at 10:00 AM, contained boxes labeled "Case Management: Notified Discharge Planning" and "Identified potential needs upon discharge." These boxes were marked "no."

The PACU Manager was interviewed on 2/04/11 at 10:05 AM. She stated she often completed the "Initial Nursing Assessment" form when patients were assessed pre-operatively. She reviewed Patient #23's "Initial Nursing Assessment." She stated the boxes marked no, which related to discharge planning, meant the questions about discharge planning had not been asked.

b. Patient #24's medical record documented a 77 year old male who was admitted on 12/27/10 and discharged on 12/30/10 for a post-surgical infection of his right knee. A medical record of his prior admission documented he was hospitalized at Northwest Specialty Hospital from 12/21/10-12/22/10. A screen to identify if he may need a discharge planning evaluation was not present in his record.

The Discharge Planner was interviewed on 2/09/11 at 11:45 AM. She confirmed a screen to identify if he needed a discharge planning evaluation had not been completed.

c. Patient #28's medical record documented a 58 year old male who had a tracheostomy performed to treat sleep apnea. He was admitted on 11/09/10 and discharged on 11/13/10. His "Initial Nursing Assessment," dated 11/09/10 at 8:57 AM, contained boxes labeled "Case Management: Notified Discharge Planning" and "Identified potential needs upon discharge." These boxes were marked "no."

The PACU Manager was interviewed on 2/04/11 at 10:05 AM. She reviewed Patient #28's "Initial Nursing Assessment." She stated the boxes marked no related to discharge planning meant the questions about discharge planning had not been asked.

d. Patient #30's medical record documented an 84 year old male who had left total shoulder replacement surgery. He was admitted on 1/17/11 and discharged on 1/20/11. His "Initial Nursing Assessment," dated 1/17/11 at 9:17 AM, contained boxes labeled "Case Management: Notified Discharge Planning" and "Identified potential needs upon discharge." These boxes were marked "no."

The PACU Manager was interviewed on 2/04/11 at 10:05 AM. She reviewed Patient #30's "Initial Nursing Assessment." She stated the boxes marked no, which related to discharge planning, meant the questions about discharge planning had not been asked.

e. Patient #13's medical record documented a 68 year old female with ovarian cancer who had surgery to repair a perforated bowel and remove the tumor. She was admitted on 12/27/10 and discharged on 12/30/10. Her "Initial Nursing Assessment," dated 12/27/10 at 1:45 PM, contained boxes labeled "Case Management: Notified Discharge Planning" and "Identified potential needs upon discharge." These boxes were marked "no."

The PACU Manager was interviewed on 2/04/11 at 10:05 AM. She stated the boxes marked no, which related to discharge planning, meant the questions about discharge planning had not been asked.

The hospital failed to screen patients for potential discharge planning needs at an early stage.

Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to evaluate the likelihood of patients needing post-hospital services and of the availability of those services. This affected 4 of 6 patients (#13, #23, and #24, and #28), whose records were reviewed for discharge planning and had the potential to affect all inpatients. The lack of a system to evaluate the likelihood of patients needing post-hospital services had the potential to impede appropriate discharge planning. Findings include:

1. Patient #13's medical record documented a 68 year old female with ovarian cancer who had surgery to repair a perforated bowel and remove the tumor. She was admitted on 12/27/10 and discharged on 12/30/10. The only note by the Case Manager, dated 12/29/10 at 10:30 AM, stated Patient #13 had been referred for possible placement to a long term acute care hospital.

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #13. She stated an evaluation of discharge needs had been done but was not documented.

2. Patient #24's medical record documented a 77 year old male who had irrigation and debridement of a right knee wound. He was admitted on 12/21/10 and discharged on 12/29/10. An evaluation of the likelihood of Patient #29 needing post-hospital services and of the availability of the services was not documented. The only discharge planning note on the record was documented on 12/29/10 at 11:00 AM. It stated "Met [with] pt re: D/C planning. Will have PICC line placed & then return here for Q12 hr [Vancomycin] over the weekend-Pt [illegible]-Will cont. to follow as needed."

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #24. She stated an evaluation of discharge needs had been done but was not documented.

3. Patient #23's medical record documented a 65 year old female who had a section of her sigmoid colon removed. She was admitted on 11/24/10 and discharged on 12/15/10. An evaluation of the likelihood of Patient #23 needing post-hospital services and of the availability of the services was not documented. Two discharge planning notes by the Case Manager were documented. The first was dated 12/09/10 and was not timed. It stated the patient had chosen a home health agency for services after discharge. The second note was dated 12/15/10 at 3:00 PM. It stated home health was not appropriate for Patient #23 and she was being admitted to a long term care facility.

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #23. She stated an evaluation of discharge needs had been done but was not documented.

4. Patient #28's medical record documented a 58 year old male who had a tracheostomy performed to treat sleep apnea. He was admitted on 11/09/10 and discharged on 11/13/10. An evaluation of the likelihood of Patient #28 needing post-hospital services and of the availability of the services was not documented. A case management note dated 11/09/10 at 2:00 PM, stated Patient #28 had a specific DME company before surgery but it did not include what services he might need after hospitalization.

The Case Manager was interviewed on 2/09/11 at 11:45 AM. She confirmed the documentation for Patient #28. She stated an evaluation of Patient #28's discharge planning needs had been done but was not completely documented. She stated a much more thourough evaluation of discharge planning needs was done than was documented on all patients. She conceded a system to ensure a consistent discharge planning evaluation was conducted had not been developed.

The hospital failed to evaluate the likelihood of patients needing post-hospital services and of the availability of the services.

Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to evaluate patients' capacity for self-care and the possibility of patients being cared for in their home environment after discharge. This affected 4 of 6 patients (#13, #23, #24, and #28), whose records were reviewed for discharge planning screening, and had the potential to affect all inpatients. The lack of a system to evaluate patients' capacity for self-care had the potential to interfere with the timely discharge of patients. Findings include:

1. Patient #13's medical record documented a 68 year old female with ovarian cancer who had surgery to repair a perforated bowel and remove the tumor. She was admitted on 12/27/10 and discharged on 12/30/10. The only note by the Case Manager, dated 12/29/10 at 10:30 AM, stated Patient #13 had been referred for possible placement to a long term acute care hospital. An evaluation of her capacity for self-care or of the possibility of her being cared for in her home environment was not documented.

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #13. She stated a discharge planning evaluation had been done but was not documented.

2. Patient #24's medical record documented a 77 year old male who had irrigation and debridement of a right knee wound. He was admitted on 12/21/10 and discharged on 12/29/10. An evaluation of his capacity for self-care or of the possibility of his being cared for in his home environment was not documented. The only discharge planning note on the record was documented on 12/29/10 at 11:00 AM. It stated "Met [with] pt re: D/C planning. Will have PICC line placed & then return here for Q12 hr [Vancomycin] over the weekend-Pt [illegible]-Will cont. to follow as needed."

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #24. She stated an evaluation of discharge needs had been done but was not documented.

3. Patient #23's medical record documented a 65 year old female who had a section of her sigmoid colon removed. She was admitted on 11/24/10 and discharged on 12/15/10. An evaluation of her capacity for self-care or of the possibility of her being cared for in her home environment was not documented. Two discharge planning notes by the Case Manager were documented. The first was dated 12/09/10 and was not timed. It stated the patient had chosen a home health agency for services after discharge. The second note was dated 12/15/10 at 3:00 PM. It stated home health was not appropriate for Patient #23 and she was being admitted to a long term care facility.

The Case Manager was interviewed on 2/03/11 at 3:00 PM. She confirmed the documentation for Patient #23. She stated an evaluation of discharge needs had been done but was not documented.

4. Patient #28's medical record documented a 58 year old male who had a tracheostomy performed to treat sleep apnea. He was admitted on 11/09/10 and discharged on 11/13/10. An evaluation of his capacity for self-care or of the possibility of his being cared for in his home environment was not documented.

The Case Manager was interviewed on 2/09/11 at 11:45 AM. She confirmed the documentation for Patient #28. She stated an evaluation of Patient #28's discharge planning needs had been done but was not completely documented. She stated a much more thourough evaluation of discharge planning needs was done than was documented on all patients. She conceded that a system to ensure a consistent discharge planning evaluation was conducted had not been developed.

The hospital failed to evaluate patients' capacity for self-care and the possibility of patients being cared for in their home environment.

Based on staff interview and review of quality improvement documents and hospital policies, it was determined the hospital failed to ensure the discharge planning process was reassessed on an on-going basis. This prevented the hospital from identifying deficiencies with its discharge planning process. It also prevented the hospital from determining whether or not staff were following its discharge planning policies. Findings include:

The hospital's quality improvement program was reviewed with the DON on 2/03/11, beginning at 11:30 AM. The DON stated she was responsible for the hospital's QAPI program. The DON stated discharge plans had not been reviewed in the past year in order to assess the hospital's discharge planning process.

The hospital failed to assess the discharge planning process.