HospitalInspections.org

Based on interview and record review, the hospital failed to provide information regarding advance directives for 6 of 41 sample patients. Findings:

Review of hospital's policy and procedures regarding "Advance Directives" dated 4/14/10 indicated the hospital "provides to each adult patient written information on Advance Directives...........if the patient is admitted to the hospital in such a condition that it is not practical to provide information regarding Advance Directives at the time of admission, such information will be provided as soon as reasonably feasible after admission.......if patient lacks decision-making capacity at the time of admission........information regarding Advance Directives, and directs questions regarding the existence of an Advance Directive to a relative or person accompanying the patient.......if the patient is unaccompanied...information on Advance Directives and direct inquiry into the existence of an Advance Directive to the patient's surrogate decision-maker, once he or she has been identified."

1. Patient 6 was admitted to the hospital on 12/30/10 for a traumatic brain injury (TBI). On 1/4/11 a review of Patient 6's medical record was conducted. The record had no indication the patient or the patient's representative was informed regarding advance directives.

2. Patient 15 was admitted to the hospital on 11/29/10 from a skilled nursing facility. A review on 1/4/11 of Patient 15's medical record indicated the patient was intubated and was unable to sign forms regarding advance directives on 11/30/10. Hospital's admission assessment dated 11/30/10 indicated the patient's family answered questions on behalf of the patient (see psycho-social section). Further review of the record had no indication the hospital made any attempts to inform the patient's family of advance directives.

3. Patient 16 was admitted to the hospital on 12/28/10 for a syncopal event. On 1/4/11 a review of Patient 16's medical record revealed the patient did not receive information regarding advance directives at the time of admission.

4. Patient 29 was admitted to the hospital on 12/28/10 for altered level of consciousness. A review of Patient 29's medical record on 1/5/11 had no indication the patient or a patient's representative received information regarding advance directives.

5. Patient 30 was admitted to the hospital on 12/22/10 for a subdural hematoma (collection of blood on the surface of brain). A review of Patient 30's medical record on 1/5/11 indicated the patient was under an Laterman, Petris, and Short Act (LPS) conservatorship (legal authority for the patient has been given to the County, which can make medical decisions for the patient). During a review of the chart there was no evidence that information regarding advance directives had been given to the conservator.

6. Patient 41 was admitted to the hospital's psychiatric unit on 12/3/10. The patient was under an LPS conservatorship (legal authority for the patient has been given to the County, which can make medical decisions for the patient). During a review of the chart there was no evidence that information regarding advance directives had been given to the conservator.

Based on observation and interview, the hospital failed to maintain patients' medical records in a secure area to ensure the confidentiality of patient records for six non-sampled patients. Findings:

During an observation of the fourth floor surgical unit on 1/4/11 at 10:15 a.m., a binder containing patient information was left on top of a cart in the hallway unsupervised. The binder contained information for six patients. Information exposed included the patients' names, medical record numbers, date of birth, and admitting diagnoses.

During an interview with the occupational therapist (OT) on the same day and time, the OT stated she was unaware the binder needed to be in a locked unit when left unsupervised.

Based on documentation and interview, the hospital failed to measure and analyze all indicators relevant to staff and patient safety. Findings:

The hospital quality program consisted of departments identifying quality indicators to improve patient care and services. On 1/6/11 the quality program was reviewed with administrative leaders.

During the review and interview it was noted the hospital had a 48 bed locked psychiatric unit consisting of two patient units (BAP 400 and 500). The psychiatric service had a separate quality section within the overall hospital program that provided oversight to quality performance and improvement of the psychiatric service. This quality section reported to the overall hospital quality steering committee that provided oversight to all quality performance studies being done within the organization.

According to documentation, the two psychiatric units had an increase in patient assaults from six assaults in 2009 to 12 assaults (including 1 sexual assault) for 2010. Despite the doubling of patient assaults within a year, the hospital failed to develop a quality plan to study this issue. The issue became relevant when on 10/8/10, a patient in the psychiatric unit attacked a staff nurse. Although nursing staff was close by in proximity to the incident, it took another patient to remove the attacker off the nurse. Another patient to staff assault occurred on 12/21/10 when a patient with psychiatric staff present, attacked a laboratory technician after drawing the patient's blood.

On 1/6/11 administrative staff, responsible for the service (psychiatry) was interviewed regarding the recent increase in patient assaults. Because there was no formal plan to study or analyze these events (which occurred throughout the year) administrative staff did not know the reason for the increase in patient assaults.