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Based on documentation and interviews and review of the medical record for patient #1, it was determined that the hospital failed to promote and protect the rights of patient #1 and inform the patient about pertinent information related to patient #1's health status.

Findings include: The hospital failed to develop an effective system for protecting the rights of all patients and providing patient #1 (refer to A131) with pertinent information related to patient #1's health status at the time of patient #1's discharge from the emergency department.

Based on documentation and interviews, the hospital failed to inform and provide all patients within a timely manner all pertinent medical information pertaining to their health status in one (patient #1) of ten patients reviewed. Findings include:

Documentation in patient #1's 4/19/11 Emergency Department (ED) record revealed that patient #1 was admitted to the ED at 10:08 a.m. for abdominal pain. Physician (L), who provided care to patient #1 in the ED, ordered a CT scan of the patient's pelvic and abdominal areas. The CT scan was conducted at 2: 28 p.m. on 4/19/11. The CT (Imagecast) results were available electronically at 3:18 p.m. on 4/19/11. The ED report written by physician (L) states patient #1's CT scan of the abdomen and pelvis are unremarkable. The ED report did not identify any other areas of concern related to the CT scan, and a copy of the ED report was forwarded to patient #1's primary physician (K). Patient #1 was provided discharge instructions at 3:43 p.m. which stated the patient had non-specific abdominal pain. The discharge instructions advised patient #1 to drink fluids, rest, take Tylenol for pain or Oxycodone for severe pain, follow up with patient #1's clinic and return to the ED for worsening pain, fever and vomiting. Patient #1 was discharged from the ED at 4:10 p.m.

The report/findings of patient #1's 4/19/11 CT scan of the abdominal and pelvic areas was reviewed. The official report states the following: 1) No cause of acute abdominal pain is identified; 2) Colonic diverticulosis without evidence of diverticulitis; 3) A 2.2 indeterminate nodule in the left lower lobe. Neoplasm is possible. Recommend comparison with prior imaging studies, if available. If not available, a PET scan could be considered for further evaluation. Alternatively, a follow-up CT scan could be performed in three months.

Medical record documentation indicated that patient #1 again presented to the ED on 6/15/12 after a fall. Documentation in patient #1's 6/15/12 Emergency Department (ED) record and interviews revealed that patient #1 was admitted to the ED at 6:12 a.m. for contusions and abrasions that resulted from a fall. Patient #1 had a chest x-ray and x-rays of her left elbow and left humerus. The x-rays were negative for fracture but a "suspicious" enlarged mass was noted in patient #1's left lung. A CT scan of patient #1's chest was also performed, and it was compared with the 4/19/11 CT scan of patient #1's abdomen and pelvis. The chest CT scan revealed that the nodule in patient #1's left lower lobe measured 2.6 x 2.2 cm. and had increased in size since 4/19/11 (fourteen months prior) and was "concerning for malignancy." At the time of this ED visit, physician (M) informed patient #1 about the 6/15/12 CT scan results and the enlarged and suspicious nodule in the left lung. Physician (M) also informed patient #1 about the nodule being present on the prior (4/19/11) CT scan. Physician (M) advised patient #1 to follow up with primary physician (K) and referred the patient to an oncologist for further care related to the lung nodule.

Radiologist (I) was interviewed in person on 10/2/12 and by phone on 10/9/12. Radiologist (I) reviewed the 4/19/11 CT results and completed a report that referred to patient #1's abdominal symptoms and included the findings and recommendations for further care related to the patient's lung nodule. The report was entered into the hospital's electronic system. Radiologist (I) dictated the report on 4/19/11 and made it available for timely review by physician (L) prior to patient #1 being discharged from the ED. Radiologist (I) did not speak to ED physician (L) or primary physician (K) about the 4/19/11 CT report and the lung nodule being noted. He stated the standard of practice in the ED is for the ED physician to independently review CT reports in the electronic system prior to a patient being discharged from the ED. If a report is not available for review, the ED physicians notify the Radiology Department.

Physician (L) was interviewed by phone on 10/8/12 and stated patient #1 had abdominal pain at the time of the patient's 4/19/11 ED admission. Physician (L) ordered a CT scan of patient #1's abdomen and pelvis related to the pain. Physician (L) stated the CT scan report did not reveal any findings or cause for patient #1's abdominal pain. Physician (L) did not speak with radiologist (I) related to the patient #1's CT scan and lung nodule. Physician (L) was unable to recall which reports he reviewed prior to discharging patient #1 from the ED on 4/19/11. Physician (L) did not tell patient #1 about the nodule in patient #1's lung and did not know why this was not done. Physician (L) stated the lung nodule finding "slipped between the cracks." Physician (L) stated the results pertaining to the lung nodule were available and should have been provided to patient #1 prior to patient #1's discharge from the ED on 4/19/11.

Patient #1 was interviewed by phone on 10/8/12, and stated physician (L) did not inform her about the nodule in her lung that was noted on the CT scan at the time of the 4/19/11 ED visit. Physician (M) informed her about the nodule during a 6/15/12 ED visit and indicated the nodule was also present on the 4/19/11 CT scan and was getting larger. Patient #1 saw primary physician (K) on 6/21/12 per physician (M's) recommendation and told primary physician (K) about the 4/19/11 and 6/15/12 ED visits and the lung nodule that was noted on the two CT scans. Primary physician (K) viewed the 4/19/11 CT report and recommendations at the time of patient #1's 6/21/12 office visit. Patient #1 consulted a thoracic oncology surgeon and had surgery on 7/3/12. The left lower lobe of patient #1's lung was removed as a result of the nodule being identified as cancerous.

The hospital's July 2011 Patients' Bill of Rights policy was reviewed. The policy states the following: Patients shall have the right to appropriate medical care; patients shall be given by their physicians complete and current information concerning their diagnosis and treatment; the patient has the right to be informed of his or her health status and be involved in care planning and treatment, and the patient has the right to access information contained in his or her clinical record within a reasonable time frame.