HospitalInspections.org

Based on interview and document review, the hospital failed to implement their policy that patients spiritual beliefs are honored for 1 of 4 patients (Patient #1).

Failure to implement the policy of honoring a patient's spiritual beliefs puts patients at risk from passing away without receiving the spritual ceremony that was important to them.

Findings included:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities Procedure," reviewed 07/17 showed that patient's spiritual beliefs were to be honored.

Review of the hospital policy for security titled " Contraband and Patient Search", reviewed 08/17, showed that security was to notify the department manager, House manager or Risk managment anytime their were concerns contraband may be
being brought to the hospital.

2. Review of the hospitals security log showed that on 08/22/19 at 6:30 PM, the security officer asked a guest to leave with their ceremonial medicine ashes, sea shell and feather. The guest agreed to take the items back to their vehicle.

Review of Patient #1's medical record showed the patient was admitted on 08/21/19 for chest pain. The patient suffered cardiac arrest in the emergency department (ED). The patient passed away on 08/23/19. The patient did not receive the native end of life ceremony before they passed. The hospital chaplain service was documented as having contact with the patient and family.

2. On 01/20/20 at 3:30 PM, the investigator interviewed a contact (Contact #1) for Patient #1. The contact stated that Patient #1 was dying and the family had arranged for a Native end of life ceremony. The person arrived to the hospital and was told by security that they could not bring the feathers and ashes to the patient's room. The family was upset by this and a nurse overheard their conversation and alerted security that it was ok for the person to bring the feathers and ashes. The patient did not end up having the Native end of life ceremony as the person that was to perform the ceremony had left the hospital and was not able to return before the patient passed away.

3. On 01/23/20 at 11:55 AM, the investigator interviewed a licensed nurse (Staff #13). Staff #13 stated they were working when they overheard family being upset that security had turned away the patient's uncle from performing an end of life ceremony. The nurse called security and informed security that the uncle could be allowed to bring the ashes and feathers up for the ceremony. The nurse talked to the family and assumed the matter had been taken care of.

4. On 01/21/20 at 11:30 AM, the investigator interviewed the Security Department supervisor (Staff #2). Staff #2 stated that security was to call the nursing house supervisor (responds to urgent calls to resolve patient care issues) whenever their were concerns about patients being brought items that may be contraband so that patient rights could be honored.

5. On 01/21/20 at 3:30 PM, the investigator interviewed a licensed nurse that worked as a house supervisor (Staff #1). Staff #1 verified the above information.

Based on interview and document review the hospital failed to provide a written discharge plan for 1 of 4 patient records reviewed (Patient #1).

Failure to provide a written discharge plan puts patients at risk for unmet care needs.

Findings included:

1. The hospital policy titled "Discharge Planning and Transitions of Care Procedure", last reviewed 05/18, showed that patients were to receive written discharge instructions at the time of discharge in the form of an after visit summary of their hospital stay that included a list of medications the patient was to be taking.

2. On 01/20/20 at 3:30 PM, the investigator interviewed a contact for Patient #1. Patient #1 was discharged from the hospital on 08/20/19. The patient arrived home on 08/20/19 with no discharge paperwork regarding their hospital stay and what medication regimen they needed to follow. The contact had to call Patient #1's primary care physician to get guidance on the medications the patient should be taking.

3. Review of Patient #1's medical record showed that:

a) Patient #1 was discharged on 08/20/19 to home. There was no documentation that the patient received written discharge instructions.

4. On 01/21/20 at 3:30 PM, the investigator interviewed a licensed nurse (Staff #4). Staff #4 stated that all patients were to receive printed discharge instructions that the hospital called the after visit summary at the time of discharge.

5. On 01/22/20 at 9:30 AM, the investigator interviewed the Chief Medical Officer (Staff #10). Staff #10 verified the above information.