HospitalInspections.org

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Based on record and staff interviews and review of policy and procedures the Acute Care Hospital failed to provide patient rights information to 2 of 15 (Patients 1 and 2) sampled patients on admission. This had the potential to affect all patients being admitted to the facility. The facility census was 464 on entrance.

Findings are:
A. A record review revealed the following medical records lacked the signed acknowledgement of receipt of the Patient Rights and Responsibilities information on admission:
-Patient 1 admitted 8/11/18 for surgery following an accident.
-Patient 2 admitted 7/27/18 for lung cancer.

B. A review of the "Conditions of Treatment" policy and procedure dated 5/8/18 revealed:
-"All patients or their guardians presenting to Nebraska Medicine for services shall sign the Conditions of Treatment Form." Guidelines for explanations of Sections of the Conditions of Treatment Form to the patient/guardian include: "Receipt of Nebraska Medicine Patient Rights and Responsibilities; All patients shall be given a copy of Nebraska Medicine Patient Rights and Responsibilities."
-"The Patient or his or her guardian must sign the Condition of Treatment Form unless he/she lacks the capacity to consent."
-As noted on the inpatient Condition of Treatment Form, "It is understood that this agreement shall take effect upon registration even though it may be signed prior there to."

C. A staff interview with the Registered Nurse A on 9/12/18 at 10:30 AM, verified that Patients 1 and 2 lacked a signed acknowledgement of receiving the Patient Rights and Responsibilities on admission.

Based on record reviews, staff interviews and review of policy and procedures the Acute Care Hospital failed to follow their policy to resolve patient grievances for 2 of 4 ( Patient 3 and 4) patient grievances reviewed. This had the potential to affect all patients filing grievances with the facility. The facility census was 464 on entrance.

Findings are:

A. A review of the grievance log revealed the facility received a grievance from Patient 3 on 7/5/18 related to a concern that the patients wrists were restrained (secured with a soft tie) to prevent the patient from pulling out or dislodging intravenous lines or a breathing tube while waking up from anesthesia following heart surgery. A review of the process to resolve the grievance lacked a thorough investigation of the incident and follow up actions if needed. This grievance was sent to Risk Management for their information.

B. A review of the grievance log revealed the facility received a grievance from the family of Patient 4 on 5/31/18 related to a concern that the during the night the patient's beard and mustache was shaved. Patient 4 was not responsive and could not give permission for this to occur and no one reached out to a family member to get permission. Patient 4's daughter expressed that in this patients religion having the beard is important. A review of the process to resolve the grievance lacked a thorough investigation of the incident and follow up actions if needed.

C. A review of the "Patient Complaint and Grievance Management" policy and procedure dated 8/2017 revealed:
-Patients, their families, and visitors have the right to communicate any complaint or concerns that arise in the provision of their care without the threat of discrimination or reprisal.
-A concern received in writing is always considered a grievance. The grievance is referred to Patient Relations for follow-up and resolution.
-The Patient Relations liaison will be assigned and make contact with the grievance within 5 working days to acknowledge receipt.
-The Patient Relations liaison will initiate and conduct an investigation of the grievance.
-Risk Council, when applicable, will review grievance findings and recommended resolution which will then be communicated in writing to the grievance. The written response will include steps taken to address the grievant.
-Documentation of the grievance, investigation, resolution and response will be maintained by Patient Relations.

D. A staff interview with the Public Relations Manager and the Compliance Manager on 9/11/18 at 3:00 PM, revealed that the "Current Summary Multiple Issues Feedback Forms" that were identified as the grievance, investigation and response is the only documentation that is available. There is no further documented paperwork of the investigation.

Based on review of the Patient Guide booklet, staff interview and review of the Visitation Policy, the Acute Care Hospital failed to include the information related to domestic partners (including a same-sex domestic partner) in their Patient Guide Booklet and their Visitation Policy. The facility census was 464 on entrance.

Findings are:

A. Review of the Patient Guide Booklet which provides information to all patients on admission regarding Visiting Information includes; "Visits from family and friends are important to the health and recovery of our patients. Nebraska Medicine defines the term "family as anyone who plays a significant role in a patient's life."

B. Review of the Visitation Policy and Procedure dated 5/18 revealed the lack of verbiage related to domestic partner visitation.

C. Interview with Registered Nurse A on 9/12/18 at 3:30 PM verified that the Visitation Policy and the Patient Guide booklet lacked the verbiage related to domestic partner visitation.