HospitalInspections.org

Based on record review and interview the facility failed to recognize and address patient complaints as a grievance and follow facility policy and procedure in 1 of 1 patient complaint reviewed (Patient (Pt) #1); and failed to ensure that only authorized individuals have access to patient health information in 1 of 10 patient medical records reviewed (Pt #1) in total sample of 10 medical records reviewed.

Findings Include:

Facility staff failed to protect and promote patient rights by failing to address and investigate patient complaints as a grievance in 1 of 10 patient medical records reviewed (Pt #1).
See tag A-0118

Facility staff failed to protect and promote patient rights by failing to ensure that only authorized individuals have access to patient health information in 1 of 10 medical records reviewed (Pt #1).
See tag A-0143

Based on record review and interview the facility failed to recognize and address patient complaints as a grievance and follow facility policy and procedure in 1 of 1 patient complaints reviewed (Patient (Pt) #1), in a total sample of 1 patient complaint reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Complaint/Grievance Process" last approved 03/2022 revealed the following:

Grievance:
-Type of complaint in which at least one of the following measure is met:
1. If a patient care complaint cannot be resolved at the time of the complaint by staff present...
2. Is referred to Department Leadership, patient experience manager, other employees for later resolution.
3. Requires investigation
4. A written complaint is always considered a grievance...including email...
5. When a patient requests a response from the health system.
Procedure:
1. The complaint/grievance is entered into the Healthcare Safety Portal (Clarity) within 24 hours by the person who initially received the complaint/grievance from the patient.
2. The Director/Manager of the department involved will further investigate the issue by contacting the complainant to resolve the issue and then enter the findings and/or actions of the resolution into Clarity within 7 days of receiving the complaint/grievance.
3. Resolution of the grievance should be completed within 7 days...
4. If a grievance cannot be resolved or the investigation not completed within 7 days, the complainant will be notified in writing of the investigation and expected date of resolution. This notification will occur within 7 days.
5. Grievance investigation should be completed and the final response sent within 30 days.

Review of policy and procedure titled, "HIPAA Privacy--Breach Notification of Protected Health Information" last approved 07/2021 revealed the following:
-The HIPAA (Health Insurance Portability and Accountability) Privacy Officer or designee will act as the investigator of the breach.
-To determine if an impermissible use or disclosure of PHI (Protected Health Information) constitutes a breach requires further notification...the organization will need to perform a risk assessment...
-The facility shall document the risk assessment as part of the investigation noting the outcome of the risk assessment process.
-Based on the outcome of the risk assessment, the organization will determine the need to move forward with breach notification.
-The risk assessment and the supporting documentation shall be fact specific and address the following:
1. Consideration of who the information was impermissibly disclosed.
2. The type and amount of PHI involved
3. The potential for significant risk for financial, reputational, or other harm
4. Will be documented in Clarity, in the event reporting tool.

Per email correspondence from Pt #1 to Patient Experience I on 08/06/2022 at 8:04 pm, Pt #1 stated, "...I specifically stated that I wanted (Driver J) to receive NO information about me, other than I was okay and ready to be picked up. I stated this a couple of times when I checked in at the surgery floor..." (Driver J) was just the driver, that's all...He is not providing any care for me. Why was the nurse talking to (Driver J) about stool softeners? Why was the nurse talking to (Driver J) about my pain medication? Why did the nurse show (Driver J) paperwork explaining [sic] I had done (hernia removal)? Why did (Driver J) see, along with that paperwork shown to him by that nurse, a PHOTO of my pre-operation hernia-an intimate part of my body?????" "I gave no permission for any of this, in fact I was very, very, very clear that I wanted no information given to (Driver J) other than what I noted above. As I stated in my third voice mail, I want to file a HIPAA complaint about this nurse..."

Per review of email correspondence from Pt #1 to Patient Experience I dated 08/06/2022 at 8:04 pm, Pt #1 stated, "Also, as I think about it, the nurse never discussed the information on my discharge paperwork with me..."

Per review of email correspondence from Privacy Officer A to Pt #1 dated 08/08/2022 at 10:02 am, Privacy Officer A stated, "...I take patient privacy very seriously and I will be launching my internal investigation on this matter today. I've also spoken to (Patient Experience I) and she will be giving me the details of your voicemail to ensure I have all the facts."

Per review of email correspondence from Pt #1 to Privacy Officer A dated 08/10/2022 at 10:29 am, Pt #1 stated, "I would like to know when your investigation is complete."

Per review of email correspondence from Pt #1 to Privacy Officer A on 08/10/2022 at 4:09 am, Pt #1 stated, "As I wrote in my original email, she (nurse) did not even go over the discharge paperwork with me. Shouldn't this paperwork be discussed with every patient before discharge?...I want to make it clear that (Driver) has never provided any medical care to me."

Review of email correspondence from Privacy Officer A on 08/10/2022 at 7:53 am revealed Privacy Officer A stated, "In regards to discharging paperwork, yes the discharging paperwork should be discussed with the patient prior to leaving. I will discuss this with nursing leadership as well. In regards to disclosing patient information, we must have consent from the patient to be able to talk to another individual about their medical care. I will be providing education to the nursing staff regarding this matter."

Review of email correspondence from Privacy Officer on 08/11/2022 at 8:56 am revealed Privacy Officer A stated, "...In hindsight the nursing leadership understands your frustrations and concerns regarding this matter and are adding additional questions to their admission process regarding visitor restrictions and consent to share information."

Per review of the complaint/grievance log from August 2022, there was no evidence of Pt #1's written complaint being logged into the Healthcare Safety Portal (Clarity) system (event reporting system) and investigated as a grievance, and no documented evidence of findings and/or actions of the resolution into Clarity within 7 days of receiving the complaint/grievance as per policy. This was confirmed with Privacy Officer A and Director of Quality B on 09/28/2022 at approximately 11:25 am.

Per review of the email correspondence with Pt #1 and Privacy Officer A from 08/06/2022 through 08/17/2022, there was no documented evidence of Pt #1 being notified in writing of the investigation and expected date of resolution.

Review of Pt #1's medical records revealed a Discharge Nursing Summary was documented by Registered Nurse (RN) F on 08/04/2022 at 5:16 pm.

Per interview with Privacy Officer A on 09/28/2022 at 11:20 am, Privacy Officer A stated that Pt #1's emailed written complaint/grievance concerning discharge and patient privacy was not entered into the event reporting tool (Clarity), per "A" all patient Complaints/Grievances should be documented in this system. Per Privacy Officer A, he/she interviewed RN E in regards to Pt #1's complaint of a breach of privacy, but he/she did not interview RN F who completed the discharge nursing summary (no other staff were interviewed). Per interview with Privacy Officer A, there was no Risk Assessment (as per policy) completed to investigate the patient's complaint/grievance related to Pt #1's privacy concerns. Per interview with Privacy Officer A, there was no investigation completed in regards to Pt #1's written emailed complaint of the nurse not discussing discharge instructions with Pt #1 after outpatient surgery. Privacy Officer A stated that no process changes or education was completed in response to Pt #1's privacy complaint; including adding additional questions to the admissions process regarding visitor restrictions and consent to share information as per documented in Privacy Officer A's email correspondence to Pt #1.

Per interview with Director of Surgery D on 09/28/2022 at 11:45 am, Director of Surgery D discussed Pt #1's complaint with Privacy Officer A, but Director of Surgery D did not investigate Pt #1's written complaint as a Grievance. Per Director of Surgery D, she/he started this position on 06/27/2022 and had not received training on the complaint/grievance process.

Based on record review and interview the facility failed to ensure that only authorized individuals have access to patient health information in 1 of 10 patient medical records reviewed (Patient (Pt) #1) in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Rights & Responsibilities" last approved 05/2020 revealed the following:
-A patient has the right to have all records pertaining to his or her medical care treated as confidential...
-Patient have the right to personal privacy. A patient has the right to every consideration of his or her privacy and security concerning his or her own medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly...

Review of policy and procedure titled, "HIPAA Privacy--Breach Notification of Protected Health Information" last approved 07/2021 revealed the following:
-Disclosure is the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
-Protected Health Information (PHI) is oral or recorded in any form that relates to the past, present, or future physical or mental health condition of the individual,and the provision of health care to an individual, including, but is not limited to, diagnosis, treatment, and appointment information.


Review of Pt #1's Nursing Discharge Summary dated 08/04/2022 at 5:16 pm revealed the following:
-Home Caregiver Present for Session: "Yes"
-Barriers to Learning: Cognitive Deficits
-Teaching Method: Explanation, Printed Materials
-Additional Learner Present: "Friend"

Per interview with Registered Nurse (RN) E on 09/28/2022 beginning at 12:10 pm, RN E stated that she/he took over the care of Pt #1 (from RN F) briefly to discharge Pt #1 home. Per interview, RN E stated that Driver J (Pt #1's designated driver) was present in the room upon preparing to discharge Pt #1, and due to RN E's concerns with Pt #1 potentially not remembering the information provided (due to anesthesia), RN E stated that he/she went over Pt #1's discharge medications list with Driver J. RN E stated that she/he was informed that the Driver J would be taking Pt #1 to pick up her medication prescriptions from the pharmacy. RN E stated that she/he felt it was ok to go over Pt #1's discharge medication information because Driver J was listed as Pt #1's Emergency Contact. Per interview with RN E, there was no documented evidence in Pt #1's medical record that Driver J was authorized by Pt #1 to receive medical information. Per RN E, staff do not specifically document in a patient's medical record who is authorized to receive medical updates, it's assumed if an individual is listed as an Emergency Contact that they can receive medical updates.

Per interview with Director of Surgery D on 09/28/2022 at 11:55 am, Director D stated, "An Emergency Contact in my mind is someone who can receive medical updates, otherwise why would they be listed as an Emergency Contact." Per Director D, when a patient is checked in there is no current process to identify who is authorized to receive medical updates, per Director D, "we have talked about it" but there is currently no process for this.

Per review of email correspondence from Pt #1 to Privacy Officer A dated 08/08/2022 at 10:07 pm, Pt #1 stated, "I have (Driver J) on my record as my emergency contact. I told (Driver J) this was only because, in case something happened to me, that (Driver J) could get the police to open my door and bring my cat to the shelter, so that she wouldn't starve to death. I never gave (Driver J) any other info..."

Per telephone interview with Surgeon K on 09/29/2022 beginning at 12:15 pm, Surgeon K stated that prior to the surgery and anesthesia, Pt #1 asked Surgeon K to call Driver J after the surgery and not to tell Driver J too much, just if Pt #1 was ok or not. When asked if the nurses were aware that Pt #1 did not want Driver J to be given medical updates/information, Surgeon K responded that he/she was "not sure" if the nurses were aware or not. Per interview, Surgeon K stated that he/she called Driver J and let him/her know that Pt #1 was ok and ready to be discharged and that Driver J could pick up Pt #1. When Surgeon K was asked if there was any place in the medical record where staff document who can receive medical updates, Surgeon K stated that staff typically ask the patient verbally if it's ok to provide medical updates to an individual, but that this is not typically documented in the medical record.

Based on record review and interview the facility failed to ensure that the Registered Nurse provided discharge teaching that met the needs of the patient in 1 of 10 medical records reviewed (Patient (Pt) #1) in a total sample of 10 records reviewed.

Findings Include:

Review of policy and procedure titled, "Discharge Procedure from Surgery Center" last approved 06/2020 revealed the following:
-Give appropriate discharge instructions
1. Review each instruction sheet and medication reconciliation form with patient and/or responsible adult and obtain signature of above.
2. Give original to patient or family.
3. Place signed instruction sheet on chart.

Review of Pt #1's Surgery/Perioperative Record dated 08/04/2022 at 1:49 pm revealed Pt #1 had a outpatient Laparscopic Ventral Hernia Repair and an abdominal binder was placed on Pt #1 post surgery.

Per review of Pt #1's discharge instruction sheets, there were no instructions documented on Pt #1's discharge paperwork instructing Pt #1 about the use of the abdominal binder after discharge. Review of Pt #1's discharge instruction sheets and medication reconciliation forms, revealed that there was no signature documented by Pt #1, acknowledging receipt and an understanding of the discharge instructions provided (as per policy).

Per interview with Director of Surgery D on 09/28/2022 beginning at 11:00 am, Director D stated that nursing staff should document education and teaching on the Nursing Discharge Summary and should print out the discharge instructions and have the patient sign that they have received the instructions; Director D acknowledged that staff are not following the policy.

Per interview with RN Educator H on 09/28/2022 at 4:05 pm, nursing staff should be educating patients on the use of the abdominal binder and this should be documented in the discharge instructions.

Per interview with Surgeon K on 09/29/2022 at 12:15 pm, Surgeon K stated that he/she would expect that nurses are instructing patients on the use of abdominal binders on discharge.

Per interview with RN E on 09/28/2022 at 12:45 pm, RN E stated that she/he did not provide instructions to Pt #1 on the use of the abdominal binder. Per RN E, the abdominal binder is only used for "comfort" so it didn't require a lot of instruction.

Per telephone interview with Pt #1 on 09/30/2022 at 9:00 am, Pt #1 stated that she/he did not receive instructions from nurse or in the discharge paperwork on the use of the abdominal binder, so Pt #1 was unsure of the frequency and duration of use for the abdominal binder.