HospitalInspections.org

Based on complaint investigation Acts intake PR00000627, the review of policies and procedures with the Information Management Officer (employee #3), it was determined that the facility failed to ensure that patient's rights are promoted regarding complete disclosure in the admission packet, related to the right to be informed of the procedures regarding the complete grievance process related to the phone number and address for filing a grievance with the Medicare Hot Line and State Agency for 21 out of 21 record review (RR)

Finding include:

During the review of facility admission packet provided to the patient on 8/13/19 at 10:00 am it was found that the information brochure given to the patient related to the grievance process do not include update Medicare Hot Line and the State Agency phone numbers.

Based on complaint investigation Acts intake PR00000627 review of twenty one clinical records with the Information Management Director (employee #2), it was determined that the facility failed to maintain complete and accurate information necessary to identify whether or not the individual has executed an advance directive. This deficient practice was identified on 2 out of 21 records reviewed (R.R #6, and # 21).

Findings include

1. A mechanism to ensure that the facility maintain complete, pertinent and up dated information of its advance directives, was not performed, nor followed according with the following findings as reviewed on 10/16/19 through 10/17/19 from 9:35 am through 3:00 pm:

a. R.R #6 is a 57 years old male admitted to the outpatient clinic on 5/23/17 with a diagnosis of Secondary Cataract on Right Eye. During admission process before Cataract extraction surgery facility inform the patient or, as appropriate, and the patient's representative of the patient's rights to make informed decisions regarding the patient's care. Medical record include information to identify whether or not the individual has executed an advance directive. On 8/5/19 patient visit outpatient clinic with a diagnosis of Carpal Tunnel on Right Hand. For the visit of patient on 8/5/19 facility did not provide information to the patient and patient's representative of the rights to make informed decisions regarding the patient's care. Medical record did not include information to identify whether or not the individual has executed an advance directive. Facility begun to offer services on the outpatient clinic without renew patient advance directives.

b. R.R #21 is an 88 years old female admitted to the outpatient clinic on 12/10/10 with a diagnosis of Cancer Mass on Face. Patient was admitted for an ambulatory surgery for face mass excision procedure. During admission process before face mass excision facility inform the patient as appropriate, and the patient's representative of the patient's rights to make informed decisions regarding the patient's care. Medical record include information to identify whether or not the individual has executed an advance directive. On 5/7/19 patient visit outpatient clinic with a diagnosis of Unspecified Malignant Neoplasm of Skin on Face. Facility begun to coordinate ambulatory surgery to perform a cancer face wide excision. However for the visit of patient on 5/7/19 facility did not provide information to the patient and patient's representative of the rights to make informed decisions regarding the patient's care. Medical record did not include information to identify whether or not the individual has executed an advance directive. Facility begun to offer services on the outpatient clinic without renew patient advance directives.

During interview on 10/17/19 at 10:20 am Ambulatory Services Administrator (Employee #11) stated that in the outpatient clinics personnel provide information related with advance directives and promote the right of each patient to determine whether or not has executed an advance directive when patient is admitted to receive services.

c. However facility did not have establish provisions on their policies and procedures to renew those patient's advance directives information in subsequent insists to the outpatient clinics. She also explained that they had patients who came to an ambulatory clinic (orthopedic, dermatologist, surgery, or cardiology) and some years go between one and the other visit. She stated that they had many recurrent patients who visits the clinics and other did not make frequent visits to their outpatient clinics.

Based on the complaint investigation PR00000627 and clinical records reviewed (R.R), it was determined that the facility failed to provide the abuse, neglect and exploitation education document to the patient or patient representative for 21 out of 21 records reviewed from (R.R#1 through RR#21).

Findings include:

During the record review from 10/16/19 through 10/17/19 from 9:35 am through 3:00 pm it was found that 21 out of 21 medical record did not have evidence of the abuse, neglect and exploitation education to the patient or patient representative

Based on complaint investigation Acts intake PR00000627 review of twenty one clinical records with the Information Management Director (employee #2), it was determined that the facility failed to assure the integration of outpatient services, including with the corresponding ancillary services and administrative services of the hospital. This deficient practice was identified on 1 out of 21 records reviewed (R.R #21) .


15884

Findings include

1. A mechanism to ensure facility coordinate the care, treatment and services provided to a patient in the outpatient clinics in order to provide continuity of care, was not performed, nor followed according with the following findings as reviewed on 10/16/19 through 10/17/19 from 9:35 am through 3:00 pm:

a. R.R #21 is an 88 years old female who visit the outpatient clinic on 5/7/19 with a diagnosis Unspecified Malignant Neoplasm of Skin on Face. Patient was evaluated at the dermatology clinic and begun to receive services and treatment. Patient visit outpatient clinic again on 8/21/19 and facility begun a process to coordinate process for the excision of left face cheek malignant tumor.

Accordingly with medical record review with Information Management Director (employee #2), on 10/17/19 at 9:35 am facility is coordinating patient tumor excision as evidence by physician orders for laboratory work-up dated 8/21/19 and instructions before procedure.

While coordination of ambulatory surgery they notice that patient only had Medicare Part A health insurance and that this health insurance did not have coverage for ambulatory procedures.

The Billing department proceed to orient the patient and inform her the cost of the procedure. This department provide explicit written information to the patient that it is necessary that she pay surgery services, anesthesia services, operating room services and she must pay the entire quantity billed before the procedure.

The patient in conjunction with facility social worker begun to identify resources to get the money for the procedure.

Between September 27, 2019 and October 1st 2019 the total quantity for the procedure was deposit (paid) to the billing services. Procedure supposed to be performed on October 3, 2019, however it was cancel.

The billing department is in the process to refund money back to patient and to one municipality organization that donate $ 500.00 dollars to the patient for the procedure.

It was informed by the billing services management officer ( employee #7) on 10/17/19 at 1:55 pm that the billing department receive verbal information by the patient physician that she need head and neck specialist services and the facility could not perform the procedure.

The Billing services management officer (employee # 7) interviewed on 10/17/19 at 1:55 pm did not provide accurate information related with date, hour and details informed by the patient physician on the decision to cancel the procedure.

Written information related with physician referral to the patient to the head and neck specialist services are not evidenced on the patients' medical record.

b.The facility failed to maintain a complete documentation of communications between outpatient services coordination of services (referrals, surgery procedures cancellation) and hospital administrative (billing department) services.