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Based on interviews and the review of documents, it was determined the facility staff failed to timely complete a provider ordered urine laboratory test for one (1) of six (6) sampled patients (Patient #1).

The findings include:

The facility staff failed to ensure that a urinary laboratory test ordered for Patient #1 was completed in a timely manner.

A urine drug screen (UDS) 11 was signed and released by a provider (Staff Member (SM) #14) on 5/15/19 at 10:10 p.m. This order was acknowledged by a registered nurse (RN) (SM #16) at 10:14 p.m. When Patient #1 was transferred to ICU, this order was documented as being continued at transfer by a nurse practitioner (NP) (SM #24) on 5/16/19 at 12:21 a.m.; ICU RN (SM #19) acknowledged this order at 2:38 a.m.

Audio recordings of the call center communication between the sending provider (SM #14) and the receiving provider (RP) were reviewed. During a call on 5/16/19 at 2:29 a.m., the RP asked about the potential of drug use for Patient #1. The SM #14 reported the UDS had not been completed; the SM #14 reported he/she was "not sure why" because the urine sample was in the laboratory.

On 10/1/19 at 9:00 p.m., a nurse practitioner (NP) (SM #24) was interviewed about the aforementioned laboratory urine test. SM #24 reported the physician (SM #14) was questioning why the urine test had not been completed. SM #24 reported he/she called the laboratory staff to ask about the test results.

On 10/1/19 at 10:00 p.m., SM #38 (an employee of the laboratory with which the facility contracted) was interviewed about the aforementioned laboratory urine test. SM #38 reported he/she was asked about the results of the test in question by SM #24. SM #38 stated that when he/she looked at the laboratory orders that he/she could not see that the test had been ordered. SM #38 reported he/she telephoned a staff member on the unit who reported the test was showing as being ordered. SM #38 stated he/she then entered the order into the laboratory system and performed the provider requested test. Documentation indicated the order was entered by laboratory staff as received on 5/16/19 at 4:07 a.m. with the results reported at 4:21 a.m.

On 9/27/19 at 9:08 a.m., SM #9 (a lead technician in the laboratory) and SM #15 (the regional laboratory manager) were interviewed about Patient #1's laboratory urine test results. SM #15 reported the urine test that was initially ordered on 5/15/19 at 10:10 p.m. was a test that is completed at another facility in the hospital's system but not completed at the facility where the patient was being treated.

On 10/1/19 at 9:45 a.m., the Laboratory Manager (an employee of the laboratory with which the facility contracted) (SM #21) was interviewed about the delay in obtaining the aforementioned laboratory urine test. SM #21 reported he/she had been made aware of the issue with Patient #1's urine laboratory test delay "last week". (The survey team had started asking questions about this delay during the prior week.) SM #21 reported the laboratory staff did not know the urine test had been ordered until individuals providing care for the patient in ICU stated asking for the results. SM #21 reported this issue had not been entered into the laboratory event reporting system. The facility's Director of Nursing (DoN) reported that this event had not been entered into the facility's event reporting system.

On 10/1/19 at 1:30 p.m., the facility's DoN, Senior Director of Quality, and Director of Quality were interviewed about the timing of the completion of Patient #1's aforementioned urine laboratory test. It was reported during this interview that an event report related to this event had not been completed. The survey team was informed that facility staff members were reviewing the information related to the completion of the urine laboratory test in question.

The following information was found in a facility policy/procedure titled "Management of Event Reports and Serious Safety Events" (with an origin date of 1/2017 and a last updated date of 6/2019): "(Facility's corporate name omitted) is committed to improving safety, quality of care, and reducing patient harm by identifying conditions that are conducive to error and designing processes that protect patients and employees. All staff are trained in the event reporting process and are expected to report all near misses, adverse events, and serious safety events ... The individual who is involved, observes, or first becomes aware of the event should submit a report. Events can be reported in the SafeWatch online event reporting portal, or by calling (phone number omitted) ..."

On 10/3/19 at 3:15 p.m., the delay in obtaining the aforementioned urinary laboratory test was discussed for a final time during a survey team meeting with the facility's Director of Quality, Administrator, Director of Nursing, and Senior Director of Quality.

This is a complaint deficiency.

Based on interviews and the review of documents, it was determined the facility staff failed to provide copies of all clinical documentation as requested by a patient's family member for one (1) of six (6) sampled patients (Patient #1).

The findings include:

The facility staff failed to provide Patient #1's family members with the requested copy of the patient's clinical record. On 6/5/19, Patient #1's adult child completed a form requesting all records from May 2019 visits for the specific dates of service of May 15, 2019 and May 16, 2019.

The facility's HIM (health information management) Site Supervisor (Staff Member (SM) #18) was interviewed on 9/30/19 at 2:05 p.m. SM #18 reported that on 6/18/19, Patient #1's adult child presented at another facility in this hospital's system requesting a copy of Patient #1's medical record. SM #18 reported Patient #1's family member was provided nineteen (19) pages of the clinical record on 6/18/19 and another 107 pages of the clinical record on 6/28/19. SM #18 acknowledged Patient #1's family member was not provided all the requested clinical documentation; SM #18 stated requested clinical documentation which was not provided included nursing notes and flowsheets.

The following information was found in a facility policy titled "Release of Protected Health Information" (with an origin date of 1/1997 and last updated date of 11/2014):
- "Within fifteen (15) days of the receipt of an authorized request for PHI, the copies of the medical record must be provided ..." and
- "A covered entity may disclose a decedent's information to family members and others who were involved in the care or payment for care of the decedent prior to death."
(PHI = Protected Health Information)

On 10/3/19 at 3:15 p.m., the failure of the facility staff to provide Patient #1's family member with the requested clinical documentation copies was discussed for a final time during a survey team meeting with the facility's Director of Quality, Administrator, Director of Nursing, and Senior Director of Quality.

This is a complaint deficiency.