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Based on interview and document review, the facility failed to ensure the grievance policy and procedure indicated the specific time frames for the response by the facility and the facility failed to ensure there was a response to a grievance regarding lack of access to medical records (Patient #18).

Findings include:

1. The facility's Grievance Policy and Procedure indicated the following:
"Grievance/Complaint Process (Original dated 3/2006):
POLICY:...3. The facility's Leadership will make certain that after receiving a grievance/complaint that a problem resolution will be sought and will keep the patient/resident informed of the progress toward resolution..."

The policy did not include the time frame for the facility to respond to the grievance.

On 8/18/11 and 8/19/11, the Director of Nursing (DON) and the Administrator verified the facility lacked a provision in the Grievance Policy regarding a specific time of response to the complainant.

On 8/18/11 and 8/19/11, the DON and the Administrator indicated a reasonable time of response to a grievance was within 2 days. The DON stated, "We try to get them addressed within the first 48 hours. We try to contact the complainant within 48 hours and let them know we received it. Then we try to resolve it within 7 calendar days."

2. Based on interview and review of facility flow sheets, it was determined the facility failed to respond to a grievance regarding lack of access to medical records of Patient #18:

Patient #18 was admitted 5/31/11 with diagnoses including Alzheimer's disease, hypertension, esophageal reflux, osteoarthritis, dementia with behaviors, hypercholosteremia, hyperlipidemia, and nonorganic psychosis. Patient #18 was discharged 6/23/11.

Interview with the family member of Patient #18 via telephone on the morning of 8/19/11 revealed the following:
-On 6/20/11, the family member requested copies of all medical records for Patient #18.
-On 7/7/11, the family member received a telephone call from the Medical Records Clerk and was told they did not have the medical records for the patient prior to 6/13/11, and to speak with the DON for the records. The family member indicated she called and left a message for the DON.
-On 7/11/11 the family member called the facility to request the medical records again. The family member spoke with the Director of Medical Records, who stated the facility could not find the medical records for 5/31/11 through 6/13/11.

On 8/19/11, an interview with the DON was conducted and revealed the following:
-The DON indicated she spoke with the family member of Patient #18 via telephone regarding the loss of the medical records for the initial 2 weeks of the patient's stay, and the delay of copies of medical records. The DON indicated she did not know the date she spoke with the family member, and verified she did not follow up with the Medical Records Department regarding resolution of the problem. The DON stated, "I did speak with the wife. I directed her to the Supervisor. I have no idea how the medical records appeared after 12 days."

The Grievance Log of all grievances documented by the facility from January 2011 through August 2011 revealed there were only 7 entries ("Date Rec'd (received): 1/27/11, 1/26/11, 1/25/11, 2/6/11, 6/15/11, 6/22/11, and 7/28/11). the Grievance Log did not list Patient #18.


29140


According to the Director of Quality and Compliance the following outlined the process:

A complaint could be received from any staff member and the complaint was expected to be addressed. The complaint went to the department head so the issue can be addressed and the problem solved. It can be turned into a formal grievance if the matter continued. For example: an issue with cold food would be addressed by the Dietary Department. The Director of Quality and Compliance stated the facility did not maintain a complaint log.

On 8/18/11 at 12:00 PM, the Social Worker stated, a grievance was a more formal process which can be written or oral. The staff initiate a grievance form and contacted the department the grievance involved and the individual with the grievance. The concern was evaluated and the facility worked to resolve the problem/issue. The individual with the grievance would be contacted with the results either in person or over the telephone. The grievance process from start to finish was 3-5 days at the most to be resolved.

Based on interviews and observation, the facility failed to ensure the safety of 1 of 21 sampled patients was met (Patient #4).

Findings include:

Patient #4

Patient #4 was admitted to the facility on 8/18/2011, with diagnoses to include cellulitis of the lower right extremity with intravenous antibiotic therapy.

On 8/19/2011 in the afternoon, Patient #4 indicated he had an oversized bed. The bed was situated so that the doorway to the bathroom opened only 16 inches. The patient indicated he had to squeeze in sideways through the door way of the bathroom to get inside. The patient indicated he could not use his walker to get inside the bathroom.

Based on observation, interview and policy review, the facility failed to ensure 1) patient's basic rights to personal privacy during care for 1 of 21 (Patient # 15) sampled patients. 2) Staff knocked or announced themselves before entering an occupied patient's room. 3) Patient's requests for care and services were respected, dignified and provided in a safe environment for 6 of 21 (Patient #5, #7, # 11, #12, #15 and #16) sampled patient's and one non-sampled resident (Resident #22).

Findings include:

1) On 8/18/11 at 8:05 AM, a staff member entered occupied patient room 107 without knocking or announcing herself before entering the room.

On 8/18/11 at 9:10 AM, a Registered Nurse (RN) used hand sanitizer and entered occupied patient room 111 without knocking or announcing himself before entering the room.

On 8/18/11 at 9:12 AM, a staff member entered occupied patient room 111 without knocking or announcing herself before entering the room

On 8/18/11 at 9:15 AM, a Licensed Nurse (LN) entered occupied patient room 111 without knocking or announcing himself before entering the room.

On 8/18/11 at 9:25 AM, a Respiratory Therapist entered occupied patient room 108 without knocking or announcing herself before entering the room.

On 8/18/11 at 9:13 AM, Patient #15 stated staff did not knock before entering the room. Patient #15 stated she would like staff to knock and state who they want to visit. The patient verbalized when staff do not knock she felt that she was not entitled to privacy. Patient #15 verbalized it made her frustrated and angry staff did not have the decency to knock.

On 8/18/11 at 9:40 AM, Patient #22 stated sometimes the staff knocked before entering and some times they don't. The patient stated she would like them the knock so "I know some ones coming in."

On 8/18/11 at 10:10 AM, an RN stated she was taught to wash her hands, and knock on the door before entering. The RN stated staff knocked to provide for patient privacy and so they know someone was coming in the room.

The facility's policy entitled Call Lights-Answering Of, dated 7/09, indicated
1. Respond to patient's/resident's call lights in a timely manner.
2. Answer emergency light immediately.
3. Knock before entering and evaluate the patient's/resident's needs.
4. Turn off the call light in the room so that others know it is answered.
5. Complete (if able) the task the patient/resident/family requests.
6. If unable to compete the request, inform the patient/resident/family and notify the appropriate discipline.
7. When leaving room, be sure the call light is placed within the patient's/resident's reach.

2) On 8/18/11 at 8:07 AM, Patient #12 verbalized it took 30 minutes for her call light to be answered yesterday to go to the bathroom. Patient #12 stated she required assistance to get in and out of the bed. The patient verbalized she felt frustrated and scared she would "mess herself". The patient stated there was a clock over the bathroom door. Patient #12 was able to see the clock from her bed.

On 8/18/11 at 8:15 AM, Patient #11 stated it takes 30 minutes to get the call light answered, or staff will come in and ask what you need, leave the room and never come back. Patient #11 stated there was a clock on the wall so she knew the time it took for the call light to be answered. Patient #11 verbalized when the call light was not answered she would get "panicky, I start to stress and say please help me." Patient #11 stated yesterday Patient #12 was yelling for help to go to the bathroom. Patient #11 stated Patient #12 was almost in tears, so she put on her call light to try and help her.

On 8/18/11 at 9:13 AM, Patient #15 verbalized the staff do not answer call lights timely. The patient stated she had a clock on the wall in her room and was able to see how long it took to get assistance from staff. The patient stated she had been put on the bed pan before breakfast at 7:30 AM and was still on the bed pan. Patient #15 verbalized she had been on the bed pan during breakfast and the staff had walked in and out. Patient #15 stated she had asked to get off the bed pan, but staff walked out. Patient #15 verbalized her bottom was very sore from sitting on the bed pan and they will "probably need some kind of surgery to get me out of this. It's very uncomfortable and its starting to cut into my legs." At 9:27 AM, a Licensed Nurse (LN) entered Patient #15's room. The LN advised she was aware the patient was still on the bed pan.

During the conversation with Patient #15 on 8/18/11 at 9:30 AM, Patient #15 verbalized she had asked staff not to put her on the bed pan because she wanted to use the bedside commode. Patient #15 stated she was able to get to the commode by herself, if the commode was positioned right by her side rail and staff gave her a walker. Patient #15 stated when she was not allowed to use the bedside commode she was angry because she thought the goal was for her get her up.

On 8/18/11 at 9:40 AM, Patient #22 verbalized it took 35-45 minutes for her call light to be answered. The patient stated the call light would be on because the machine was beeping or she needed to use the bathroom. The patient indicated she required assistance to use the bathroom. The patient verbalized she felt annoyed waiting for the call light to be answered and if she really had to go, she would be become more annoyed.

On 8/18/11 at 10:00 AM, Patient #16 verbalized he had to wait 20-30 minutes for his call light/bell to be answered at the change of shift. Patient #16 stated, "No one wants to be bothered to help, they were doing their paper work." Patient #16 verbalized he had to lay in his own stool for over 40 minutes. The patient stated when he asked for assistance the staff told him to "hang on" and then left the room. Patient #16 stated when the staff returned to the room he asked to be taken care of and he received the same response. Patient #16 verbalized he felt humiliated, frustrated and after while he gave up on the fact anyone would help him.

On 8/18/11 at 10:10 AM, a RN stated a call light was to be answered as soon as possible even if the patient was not assigned to you. The RN verbalized if was not okay for a call light to be on over 15 minutes. The RN stated the Certified Nursing Assistants (CNA) come in a half hour early to be able to answer the call lights during the change of shift.

3) On 8/18/11 at 9:30 AM, Patient #15 stated she had a concern about the privacy curtains in her room. The patient indicated the curtains were not always pulled closed and "people in the hallway can see I have no underwear on."

On 8/18/11 at 2:34 PM, the privacy curtain was not pulled closed in a patient room 111. Patient #15 was sitting on the edge of the bed with no gown on, exposed from her neck down to her bottom. A LN verified the observation and stated the privacy curtain should be closed all the way so the patient was not exposed.

Complaint # NV29047



12211

Review of the "Call Light Audit" sheet revealed call lights are to be answered within a 5 minute time frame.

-Patient #7

Patient #7 was admitted 8/4/11 with diagnoses including pulmonary insufficiency, post-trauma surgery, tracheostomy status, gastrostomy status, respirator dependence, hyperlipidemia, hypersomality/hypernatremia, anemia, hypertension, coronary atherosclerosis, and hemiplegia.

On 8/19/11 from approximately 10:30 AM through 12:00 PM, there were ongoing observations of Patient #7 laying in bed wearing only a hospital gown. A nurse went in and out of the room several times to provide care between 10:30 AM and 12:00 PM and did not pull the curtain closed. The bedsheet was hanging off the bed and was not covering the patient, and the hospital gown was above her knees with her genitals exposed.

Patient #4

Patient #4 was admitted to the facility on 8/18/2011,with diagnoses to include cellulitis of the lower right extremity with intravenous antibiotic therapy.

On 8/18/2011 during the initial tour of the facility in the morning, Patient #4's call light was on the floor in back of his bed. On 8/18/2011 at 10:00 AM; 2:00 PM and 4:00 PM the call light remained on the floor. The patient's right lower extremity was elevated on a pillow.

On 8/18/2011 at 10:00 AM, Patient #4 indicated the call light was always on the floor. The patient indicated if he did not pick it up himself it stayed there on the floor. The patient indicated one evening his roommate was sitting in a chair in the room. The roommate was sliding out of his chair. Patient #4 indicated he could not reach his call bell and so he started yelling for someone to come in and help the other patient.

Patient #4 indicated call lights go unanswered for over an hour.

Patient #5

Patient #5 was admitted to the facility on 8/9/11, with diagnoses of Alzheimer's disease, high blood pressure, debility and deep vein thrombosis.

On 8/18/2011 in the morning, Patient #5 was lying on his bed in a supine position. The patient was wearing a hospital gown and his genitals were exposed. There was no privacy curtain around the patient. In the afternoon of 8/18/2011, Patient #5 was sitting in a chair facing the doorway to his room. The patient's hospital gown was up over his knees and his genitals were exposed.

Based on interview, record review, and document review, the facility failed to provide confidentiality of clinical records for 1 unsampled patient (Patient #23) and 1 unknown patient.

Findings include:

On 8/19/11 in the morning, the family member of Patient #18 was interviewed, and indicated the following breaches of confidential medical records/personal health information:

1. Upon communicating with an Intake Nurse at a skilled nursing facility for potential discharge of Patient #18, the family member was told the records of another patient were sent to the Intake Nurse.

On 8/18/11, the Social Worker verified another patient's medical records (including the patient's name, physician's assessment, tuberculin testing, and history and physical examination) were sent via facsimile to the Intake Nurse at a potential admitting skilled nursing facility. The Social Worker indicated, "The records were accidentally sent to the (name of the skilled nursing facility). I don't know who the other patient was." The Social Worker indicated she did not take any steps to ensure the Intake Nurse at the skilled nursing facility shredded the patient's records after discovering the mistake.

The Social Worker further verified she did not notify the facility's Department of Medical Records of the breach.

2. A second incident of a breach of confidential medical information of another patient was discovered by the family member of Patient #18. The family member of Patient #18 provided evidence to the surveyor that Patient #23's medical records (8 pages of clinical records including the patient's name, medications administered, diagnosis, name of physician, and date of birth.) were sent to her.

On 8/18/11 at approximately 4:30 PM the Director of Medical Records verified Patient #23's records were copied and sent to the family member of Patient #18.

On 8/18/11 in the afternoon, the Director of Medical Records indicated there was no policy in place regarding notification to a patient or patient representative when a breach of confidential medical records occurred. The Supervisor further acknowledged there was no action taken to inform the above patients or patient representatives of the breach.

The Bill of Rights (page 2, undated) indicated, "The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records."

Based on observation, interview, record review, and document review, the facility failed to ensure 1 legal representative had the right to access 1 of 21 sampled patient's (Patient #18) medical records. The facility failed to meet the request for medical records in a reasonable time frame.

Findings include:

The Health Information Management Policy and Procedure, "Patient's/Resident's Access to Protected Health Information/Medical Record", dated 3/2006 indicated:

"POLICY: Each patient/resident has the right to access his/her own Protected Health Information (PHI) as specified in the Notice of Privacy Practices...
PROCEDURES: "1. A patient/resident or his/her legal representative has the right to access, inspect and request copies of his/her own Designated Record Set unless State Law allows for restrictions.
2. The Health Information Management (HIM) Department manages all requests for patient/resident access to PHI.
3. Requests for Copies of the Medical Record
A. The Code of Federal Regulations and the State Operations Manual (SOM) require that the facility provide copies within 48 hours (excluding weekends and/or holidays) unless State law mandates a shorter period. If State Law mandates a shorter period for responding, then you are obligated to meet the State's more stringent requirement.
B. Upon receiving a request from a patient/resident to receive a copy of his/her PHI, HIM staff may provide a copy of the Authorization & Request for Release of Information (FFIP020) for completion and execution. HIM Staff may also accept any written request that is signed by the patient/resident or legal representative if the records are being released directly to the patient/resident or legal representative.
C. Review the Authorization for accuracy and completeness against the Authorization Checklist below.
D. If any of these steps above are incomplete, ask the patient/resident or the legal representative to fill in the missing information.
E. Once it is determined that the Authorization is complete:
1) Document the request on the HIPAA Correspondence Log in The HIM Department. (See HIPAA (Health Insurance Portability and Accountability Act) Documentation Policy).
2) Continue with Step 2 of policy Disclosure of Protected Health Information (PHI) / Medical Records.

The Patient Handout (undated) indicated, "Your rights regarding your medical information: Although your health record is the property of the health care center, the information belongs to you. Federal law gives you the rights described below regarding your medical information. Right to inspect and copy: With some exceptions, you may review and copy your medical information."

The Bill of Rights (Patient Handout, undated) indicated, "...The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law..."

On 8/19/11 in the morning, an interview with the family member of Patient #18 via telephone on the morning of 8/18/11 revealed the following:
-On 6/20/11 the family member requested a copy of all Patient #18's medical records.
-On 7/7/11, the family member received a telephone call from the Medical Records Clerk and was told they did not have the medical records for the patient prior to 6/13/11, and to speak with the DON for the records. The family member indicated she called and left a message for the DON.
-On 7/11/11 the family member called the facility to request the medical records again. The family member spoke with the Director of Medical Records, who stated the facility could not find medical records for 5/31/11 through 6/13/11.

On 8/19/11 at approximately 2:00 PM, an interview with the Director of Medical Records revealed the following:
-The original request for the medical records by the family member was 6/22/11 but the POA (Power of Attorney) was incomplete and something was missing.
-The Medical Records Clerk gave the request to the Corporate HIPAA Department via facsimile 6/23/11.
-The family member spoke with the Director of Medical Records on 6/24/11. The Director of Medical Records spoke with the representative from the Corporate HIPAA Department and within the next day the family member got the POA to the Director of Medical Records.
-On 7/7/11 the family member received the first set of copies of medical records dated from 6/14/11 through the date of discharge. Then the family member requested the diabetic flow sheets (2 sheets). The Director of Medical Records faxed these 2 pages on 7/8/11.
The Director of Medical Records stated, "We never did find out where the records were, they just showed up one day."
-The facility's process for the release of copies of medical records was the release of information/responsible party was completed. Then there was a written request for the medical records. The Director of Medical Records stated, "There is no time frame indicated in the policy for the medical records copies, we just say reasonable. Seven to 14 days is reasonable". "Once in a while for whatever reason we get pieces of the chart missing. No, it wasn't formally addressed in the Performance Improvement Meetings. There was no root cause analysis done."

The Director of Medical Records completed a flow sheet on the morning of 8/18/11 which indicated the actions taken by the Department of Medical Records on the following dates:
6/22/11: Initial request for Medical Records. Received Release of Information. Received Durable POA.
6/23/11: Patient discharged.
6/24/11: Supervisor talked to (name of family member). (Name of family member) was informed of the invalid POA (as we were told from Legal). (Name of family member) was informed that if possible she should get a signed authorization from the patient. (Name of family member) sent us back a patient signed Release of Information. HMRH (Harmon Medical & Rehabilitation Hospital) Med (Medical) Records faxed the "new" ROI to Legal."
6/27/11: Received notice that (name of family member) needed to provide HIPAA completed release.
6/29/11: (Name of family member) came in to pick up first set of copies of medical records.
6/30/11: We told (name of family member) that as soon as we had the MAR's (Medication Administration Records) we would call her.
7/6/11: (Name of family member) was called to let her know the missing MAR's were available for pickup.
7/7/11: (Name of family member) asked for diabetic flow sheets.
7/8/11: (Name of family member) gives HMHR a new phone # - flow sheets were faxed successfully.

Based on interview and document review, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI) Program to monitor and assess patient rights for privacy, dignity, access to medical records, and confidentiality of medical records.

Findings include:

1. The facility failed to incorporate Patient Rights adequately for the QAPI Program to address privacy and dignity of patients. (Cross Reference TAG A 143)

2. The facility failed to incorporate Patient Rights adequately for the QAPI Program to address nurses' treatment toward patients. (Cross Reference TAG A 143)

3. The facility failed to incorporate Patient Rights adequately for the QAPI Program to address patients' rights to access and maintain confidential medical records.

On 8/18/11 at approximately 4:30 PM, it was verified by interview with the Administrator and the Director of Nursing (DON) the medical records for Patient #18 could not be located from 6/20/11 through 7/7/11. The Administrator indicated the following:

-(The Administrator) did see the loss of the medical records of Patient #18 was a problem.
-The issue regarding the medical records going missing was not brought to the attention of administration.
-The Director of Medical Records did attend the QAPI meetings; however, the issue related to the missing records of Patient #18 was not brought up.
-The only items brought up at the QAPI meetings regarding the Medical Records Department since January of 2011 have been about the physicians' timely signatures on telephone orders.
-The Administrator acknowledged there should have been a search at each hall once it was realized that the medical records for Patient #18 from 5/31/11 through 6/13/11 were missing.
-The Administrator further acknowledged there should have been an indepth investigation regarding where the records were for the period of time from 6/22/11 (date requested by Patient #18's family member) through 7/7/11 (date located by facility).
-The Administrator acknowledged there should have been a process in place to notify the patient or the patient's representative after identifying the breach of confidential protected health information to an inappropriate party.