HospitalInspections.org

Based on document review and interview it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for patient rights, the hospital failed to inform patient of patient's rights and obtain consent for treatment during hospital admission, as required.

Findings include:

1. On 05/11/2022 at 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was directly admitted to the Hospital's Medical-Surgical/Telemetry Unit on 3/31/2022 at 4:16 PM, with a diagnosis of right upper quadrant abdominal pain. The clinical record of Pt. #1 included the following:

-The history and physical note dated 3/31/2022 included, " ...direct admission from clinic...AOX4 [alert, oriented, to person, place, time, and surrounding] ...past medical history HIV [human immunodeficiency virous] infection ...history of ascites [fluid filled in the abdominal wall] ..."

-The physician order dated 03/31/2022 included, " ...admit the patient to general medical floor ...for abdominal pain and ascites ..."

-The clinical record lacked evidence in collecting consent for treatment, advance directives, and patient rights being provided to the patient upon admission to the unit.

3. On 05/11/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" (revised on 01/2019) was reviewed and included, " ...The process to inform each patient ...of the patient's rights in advance ...The right to be fully informed in advance of care or treatment ...to participate in the development and implementation of his/her plan of care ...right to formulate and exercise Advance Directives ..."

4. On 05/12/2022 at 10:00 AM, the Executive Director of Quality (E #1) was interviewed. E #1 stated that the patient rights for treatment was not given to the patient upon admission. E #1 stated that the staff did not collect any information from the patient regarding the advance directives. E #1 stated that the registration staff did not collect the consent for treatment during admission from the patient.

5. On 05/12/2022 at 2:30 PM, the Patient Access Market Manager (E #9) was interviewed. E #9 stated that patient (Pt. #1) was admitted directly to the unit from the physician's clinic. E #9 stated that usually the registration staff goes to the unit and collects all the consents and provide patients with patient rights information. E #9 stated that the registration department closes at 6:00 PM, since this patient was admitted to the unit at 9:00 PM, the registration did not follow-up on the patient the next day. E #9 stated that it is not okay to not provide the patient rights to the patient, every patient that gets admitted to the unit must be provided with patient rights.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #9) complaints or grievance reviewed, the Hospital failed to ensure that a written response was provided to the patient regarding steps taken to investigate the grievance, results of the grievance process, and the date of completion.

Findings include:

1. On 5/11/2022, the Hospital's policy and procedure titled, "Patient's Complaints and Grievances" (effective 4/2022) was reviewed and included, "I... This policy applies to (Name of the Hospital)... V. Procedure... B. Grievance Process... 7. Upon completion of the research and investigation, Patient Advocate or designee and the responsible leader will develop a written response. Said written response shall be made within 30 days or communication shall be had with the patient and/or representative to advise them of status and the anticipated resolution date. 8. All written response, whether 7 or 30 days, whichever is appropriate, will indicate what was done to minimize recurrence of the issue..."

2. On 5/12/2022, the Hospital's grievance log from 3/1/2022 through 5/11/2022 was reviewed. From the log, Pt. #9's grievance dated, 3/14/2022 was reviewed. Pt. #9's grievance lacked a written response regarding steps taken to investigate the grievance, results of the grievance process, and the date of completion.

3. On 5/12/2022 at approximately 1:00 PM, findings were discussed with E #1 (Executive Director of Quality). E #1 could not provide documentation that a written response was provided to Pt. #9. E #1 stated that a letter should have been sent to Pt. #9.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #11) patients' records for restraints, the Hospital failed to ensure that the care plan was updated or modified regarding use of restraints.

Findings include:

1. On 5/12/2022, the clinical record of Pt. #11 was reviewed with E #13 (Nurse Manager 4 South). The clinical record indicated that Pt. #11 was placed in restraints on 2/2/2022 due to violent behavior. Pt. #11's care plan was not modified regarding use of restraints.

2. On 5/12/2022, the Hospital's policy titled, "Restraint and Seclusion" (revised on 2/2022) was reviewed and included, "... C. Documentation. 1. Each episode of restraint use shall be documented... d. Use of restraints must be addressed in the patient's modified plan of care..."

3. On 5/12/2022 at approximately 1:30 PM, findings were discussed with E #13. E #13 stated that Pt. #11's care plan was not modified or updated regarding use of restraints. E #13 stated that the care plan should have been updated.