HospitalInspections.org

Based on review of hospital documents and interviews with patients and hospital staff, the hospital failed to ensure patients knew whom to contact to file a grievance. Two of two current patients (Patients #1 and 2) did not know whom to contact to file a grievance.

Findings:

1. On 09/09/2010, administrative staff told the surveyors that the hospital had patient rights handouts that included whom to contact at the hospital if patients had concerns.

2. During the tour of 4-Tower inpatient unit on the morning of 09/09/2010, the surveyors interviewed two patients. Patients #1 and 2 stated they were unaware whom to contact in the hospital if they had patient care issues and were not comfortable voicing those concerns to the nursing staff.

3. Staff B stated that, in addition to the handout, located on the wall in each room was a sign that identified a number to call if the patient had a problem. Patient #2 stated she was unaware what the number meant and that no one had told her about the number.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. One (# 1 ) of two ( #'s 1 & 2 ) grievances/bedside complaints that were received by the Oklahoma State Department of Health did not have evidence of being entered into the hospital's grievance process, an investigation conducted and a written response sent .

Findings:

1. Grievance #1 did not have evidence of a letter being sent to the complainant.

2. Grievance #1 did not have evidence of an investigation, resolution and a written response.

3. Grievance #1 was not listed on the grievance log and no investigation, resolution, or written response was documented. Staff had been in communication with the complainant.

4. Interviews with staff responsible for the hospital's grievance process verified in the afternoon of 09/09/10 that this grievance did not have evidence of a review, resolution and a written response.

Based on review of hospital documents and interviews with staff, the hospital failed to ensure patients' right to privacy. This occurred in two of three patients reviewed who had video monitoring in their hospital room.

Findings:

1. Hospital administrative staff told the surveyors on the morning of 09/09/2010 that the hospital had a camera patient monitoring system called Care Vue in patient rooms. They stated that recently they had changed the practice from video monitoring each patient unless they specified they did not wish to be video monitored, to only monitoring/videoing the patients that gave permission for the monitoring.

2. Medical records for Patient's #3 and 4 did not contain consents for video monitoring. This was confirmed with medical record Staff J and K on the afternoon of 09/09/2010 at 1425. In correspondence with Patient #3, the patient stated she was unaware the camera was in the room until she was about to be discharged from the hospital and was told by hospital staff that the camera had been monitoring her throughout her stay. On the afternoon of 09/09/2010, Staff E, F and G confirmed the patient had not signed a consent for video monitoring. On 09/09/2010 at 1240, Staff E stated when Patient #3 asked about the camera, he checked and the video feed was active.

3. During the tour of 4-Tower on the morning of 09/09/2010, the surveyors noted two rooms where video feed was active at the nursing station and interviewed the two patients (Patient #1 and 2). Patient #1 stated he knew about the camera, but had not given his permission for the camera to be on and monitoring. Patient #1's medical record reflected the patient had not given permission for the Care Vue camera to be turned on and monitoring his bed. This was reviewed at the time with Staff B and H.

Based on review of policies and procedures, review of medical records and interviews with staff, the facility failed to provide medical records as stipulated by the facility's policies.

Findings:

1. On the morning of 9/9/2010 surveyors were provided copies of medical records policies and procedures. The policy "U(use) & D (disclosure) of (protected health information) PHI for patient care and notification" stipulates the facility "may disclose PHI to a family member other relative, a friend, or any other person identified by the patient to assist with the patient's care. The PHI that may be disclosed for this purpose should be limited to the PHI that is directly relevant to that person's involvement with or payment related to the patient's care. The policy further stipulates "health care professionals will use professional judgment and their experience with common practice to make reasonable inferences of a patient's best interest in determining whether to allow a person to act on behalf of the patient to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of PHI.
A. On 9/9/2010 surveyors reviewed the medical record of Patient #5, the patient mentioned in the complaint, medical record. Patient #5 had a signed release of PHI documented in their chart. Correspondence received by the Department indicated all of the medical records were not received by the facility where patient #5 was transferred.

B. On 9/9/2010 surveyors asked Staff J about procedures for release of medical information. Staff J stated there are regular business hours Monday through Friday but the weekend is not fully staffed. Staff J told surveyors there was no log kept identifying requests for PHI or release of PHI. Staff J also stated there was no way for an individual to receive PHI on the weekends. Staff J stated receiving facilities would be able to receive information on the weekends if they called the facility. Correspondence received by the Department indicated Patient #5 was not able to obtain medical records pertinent to care in a timely fashion and care was delayed due to the lack of this information. Correspondence received by the Department also indicated attempts were made to obtain information on behalf of patient #5 by authorized family members. There was no documentation records had been released or there had been follow up with the family member.

C. On the afternoon of 9/9/2010 these findings were reviewed with administration and no further documentation was presented.