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Based on the number and nature of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Governing Body. Specifically, the governing body failed to ensure that appropriate and safe services were available to the patients it admitted into the satellite unit and failed to timely transfer patients to the main hospital or other appropriate care facility when it recognized patients conditions were outside its established scope of care, failed to ensure the hospital satellite provided all its own nursing and admission services and that it did not co-mingle staff and space. The governing body also failed to ensure it kept its own medical record integrated with the main hospital as required, and conducted its own grievance and complaint investigations.

The multiple failures resulted in the hospital not providing the expected care and treatment. The lack of systems to prevent the appropriate acceptance and transfer of patients placed all patients at risk for receiving poor quality care and negative patient outcomes. The co-mingling of space, services and medical records caused confusion among staff and patients for both hospitals and increases the potential for poor patient outcomes.

Cross-reference:

482.12(e) Standard: Governing Body: Contracted Services - the governing body failed to maintain separate hospital space, nursing, surgical and admission services as well as the main telephone contact number in a manner that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services.

482.12(f)(2) Standard: Governing Body: Emergency Services - the governing body failed to ensure the hospital's satellite location had a plan for the provision of emergency services that addressed the needs of all patients and visitors.

482.13 Condition of Participation: Patient's Rights - the facility failed to investigate patient's written or verbal grievance at the Children's Hospital satellite location. The facility relied on Hospital B to conduct complaint and grievance investigations with no oversight.

482.24 Condition of Participation: Medical Record Services - the facility failed to have one unified medical record. The facility relied on Hospital B's electronic medical records system for inpatients at the Children's Hospital satellite location.



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FINDINGS

Based on observations, interviews and document review the Governing Body failed to ensure patients were accepted at the satellite location based on the availability of specialized services and identified admission criteria. Specifically, for 2 of 2 (patients #17, #24), pediatric neuro-trauma patients reviewed and admitted after 10/1/14, the hospital admitted the patients without regard as to whether they had a pediatric neurosurgeon available to provide care and services. In addition, the admissions were contrary to conditions placed on the licensed held by the satellite. Further, the governing body failed to ensure its space within the host hospital was separate and distinct to that of the host.

References

According to http://www.trauma.org/archive/scores/gpcs.html, Glasgow Paediatric Coma Score (GCS), the GCS is scored between 3 and 15, 3 being the worst, and 15 the best. A coma score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

According to a "Conditional license to operate a Hospital Unit", effective 10/01/14, patients who would be eligible for transfer to the facility's satellite location "include those pediatric patients with high risk and critical injuries that may include... Glasgow Coma Scale 13-15 with significant trauma."

Additionally, pediatric patients who shall not be served by the facility's satellite location, as they require a higher and/or specialized level of care, include pediatric patients requiring neurosurgical consult or who may require neurosurgical consult at the discretion of the facility.

1. The Governing Body failed to ensure patients were accepted to the facility's satellite location based on the availability of specialized services and in accordance with their conditional license.

a) Record review for Patient #17 showed s/he was admitted to the Children's satellite location on 01/14/15 at 4:45 p.m. from Hospital B's emergency department.

Review of the H&P (History & Physical), dated 01/14/15, showed the patient was brought to Hospital B's emergency room (ER) by his/her caregiver after being discovered unresponsive at the home. Upon arrival, the pediatric patient had poor spontaneous breathing and appeared unresponsive. The patient was rapidly intubated (a breathing tube was inserted in order to provide life support). According to the H&P, Patient #17's most remarkable findings were lack of responsiveness, dilated pupils, Glascow Coma Scale (GCS) of 3, and multiple bruises over his/her body.

Patient #17 was admitted to the Pediatric Intensive Care Unit (PICU) located in the Children's satellite location. The H&P noted the patient had been evaluated by an adult neurosurgeon in Hospital B's ER with the lack of pupillary response and the GCS of 3, the adult neurosurgeon suggested that optimal therapy would include transport to the main Children's Hospital in Aurora where pediatric neurosurgery services were available.

The H&P stated the pediatric patient may very well benefit from placement of an intracranial pressure monitor and was being transported by the pediatric trauma team at the main Children's hospital for multidisciplinary care.

Review of admission Flowsheet Data showed Patient #17's GCS remained at 3 when s/he was admitted to the Children's satellite PICU on 01/14/15 at 4:45 p.m.

In compliance with the requirements set in the state's Conditional License, the patient should not have been accepted to the Children's satellite location with a severe brain injury, indicated by a GCS of 3, as s/he did not meet the admission criteria for that location and required a pediatric neurosurgical consult. The patient should have been transferred from Hospital B to a facility who could provide the required services.

Review of physician notes on 1/14/15 stated transfer by air could not be accomplished due to fog. At approximately 8:00 p.m., as ground transportation was being arranged, the patient became hemodynamically unstable and required emergent surgery for a decompressive hemicraniectomy and evacuation of subdural hematoma. The procedure was conducted by the adult neurosurgeon in the operating room of the co-located hospital, Hospital B.

There was no documentation as to the 3.25 hour delay in securing ground transportation.

Subsequent to the procedure the pediatric patient was returned to the PICU in the Children's satellite location. Review of the neurosurgery note, dated 01/15/15 at 8:56 a.m., stated the adult neurosurgeon had discussed operative findings with the critical care physician immediately after the surgery (approximately 9 hours earlier) and agreed on the plan for transfer to the main Children's Hospital within the next few hours. S/he was not aware of a decision to hold transfer since "outcome was imminent" until this morning. The neurosurgeon documented, "I have discussed again with our pediatric intensivist who reports the child still has motor response to pain. I have emphasized that ongoing management needs to proceed as per plan," and the patient should be transferred to the main Children's Hospital.

During an interview with the Associate Chief Medical Officer (Employee #1), on 03/02/15 at 11:00 a.m., s/he acknowledged that communication could have been better and there was clearly no "captain of the ship" with regard to the coordination of care for Patient #17.

Staff interviews and record review show the Children's satellite location had significantly delayed the required and clinically appropriate transfer to the main Children's Hospital. The pediatric patient was finally transferred to the main Children's Hospital on 01/15/15 at 10:30 a.m., approximately 17 hours after admission to the satellite location and transfer had first been indicated. On 01/17/15 life support measures were withdrawn and the patient expired.



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b) Record review for Patient #24 showed s/he was admitted from Hospital B's Emergency Department (ED) to the Children's satellite location's pediatric unit on 01/17/15 at 10:18 p.m. where Patient #24 remained at the Children's satellite location until discharge on 02/18/15.

Review of Hospital B's ED notes, dated 01/17/15, revealed the patient was brought to the ED with a chief complaint of head injury. According to the ED notes Hospital B's clinical impression was that of scalp bruising and head injury. The patient's assessment noted s/he had swelling to the head and face and was lethargic.

Review of the satellite facility's History & Physical (H & P), dated 01/18/15 at 12:59 a.m., showed the patient presented with significant sleepiness, bruising, and other skin markings. Patient #24 was brought into Hospital B's ED after s/he had fallen out of bed and later hit his/her forehead on the corner of a table. In the ED, there was concern that the trauma was intentionally inflicted.

Review of the initial nursing flow sheet, conducted on the patient's arrival to the satellite facility at 01/17/15 at 10:19 p.m., showed Patient #24 had a GCS of 12, below the acceptable identified criteria of GCS 13-15 for patients eligible for transfer from Hospital B to the Children's satellite location.

There was no documentation in the medical record that explained why the satellite accepted the transfer patient when s/he did not meet the admission criteria.

Review of the nursing flow sheet, dated 01/18/15 at 8:00 a.m., showed the patient's GCS remained a 12.

There was no documentation to show why the patient had not been transferred to the main Children's Hospital, where the indicated higher level of care could be provided, when it was identified s/he should not have been accepted to the Children's satellite location.



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2. The Children's satellite location co-mingled space with Hospital B in multiple locations throughout the hospital. Examples include:

a) On 03/02/15 at 9:40 a.m., an interview was conducted with the Quality and Patient Safety Director (Employee #3) who stated the Children's satellite location was a "hospital within a hospital." Employee #3 stated the building itself belonged to Hospital B and the Children's satellite location was located in the East Tower of the building.

Observations of the front entrance and main lobby of the hospital, on 03/02/15 at 9:56 a.m., revealed a directory which contained information for the Children's satellite location in addition to Hospital B within the same building. The directory was labeled with signage for Hospital B.

The identification in Hospital B's directory for the satellite location was not clearly marked as belonging to the Children's satellite location. During the observation, Employee #3 stated the directory was confusing because both facilities shared the same building.

b) A second tour of the front entrance, main lobby, and admissions area was conducted with Employee #3 on 03/02/15 at 11:07 a.m. A sign for the Children's satellite location was on the reception desk of Hospital B, under signage on the wall identifying Hospital B. Employee #3 stated the main entrance to the satellite facility was a "common location" shared with Hospital B.

c) On 03/03/15 at 10:16 a.m., further observation of signage and postings for the satellite location was conducted. A large sign above the directory showed the name and logo for Hospital B. Signage overhead to the right of the directory identified Children's Hospital, and had an arrow pointing to the right for Children's Hospital Registration and an arrow pointing to the left for Hospital B registration. Children's Hospital Registration was located in Hospital B.

d) To the right of the main entrance, in the area identified as belonging to the Children's satellite location, was a door with a sign noting, "Welcome to the Birth Center." The Birth Center was a department of Hospital B. Two additional signs were posted to the left of the entrance to the Birth Center. One sign read "Financial Counseling" and the second read "Release of Information." The signs contained the name and logo of Children's Hospital. The same signs were also noted inside the Birth Center at the Financial Counseling desk and at the Release of Information desk.

On 03/03/15 at 11:32 a.m., Employee #3 stated staff members who worked at the financial counseling and release of medical information desks, inside the Birth Center, were employees of the satellite location. The employee stated the Birth Center was a department of Hospital B and that the offices for financial counseling and release of medical records were located inside the Birth Center.

During the tour on 03/03/15 at 11:32 a.m., an interview was conducted with Employee #26, a Financial Counselor. S/he was an employee of the Children's satellite location, and s/he only provided services to patients and families associated with the satellite location. Employee #26 stated families entering the Birth Center, who were not associated with the satellite location, stopped at his/her desk regularly to ask questions, including financial questions, and they "get frustrated because they are being shuttled all over," as the signage was confusing. Employee #26 stated s/he would direct patients or families to Hospital B for admissions or financial questions associated with that separately certified facility.

A second desk was observed with a sign that stated for release of medical records to call a stated phone number. Employee #3 stated the person who worked at the desk was not currently available and medical record requests were being received at the main Children's Hospital by use of the phone number.

e) On 03/03/15 at 11:51 a.m., a tour was conducted with the Regulatory Director (Employee #12) to observe another area of the building and two additional staff offices belonging to the satellite location. The two offices were located on floor #2, down a hallway identified as part of Hospital B. The sign above the hallway stated, "Conscious Sedation." Down the hallway, one office was noted with signage that read, "Patient Access Registration," and a second office was noted with signage that read, "Health Information Management/Managed Care." Each of the signs contained the name and logo for The Children's Hospital.

The Supervisor of Revenue and Financial Counseling (Employee #27), who was housed in one of the offices, stated s/he was an employee of Children's satellite location. The Health Information Analyst (Employee #24), who was housed in the second office, stated s/he was also an employee of the satellite location. Both staff members confirmed their offices were located in Hospital B.

f) On 03/05/15 at 08:56 a.m., observation was conducted of the surgical department of Hospital B with the Regulatory Director (Employee #12). The surgical department housed offices for two Registered Nurses (RNs) who were employees of Children's satellite location (RN #17 and RN #25). The surgical department was located in the North Tower of Hospital B. The office for the Perioperative Pediatrics Service Leader (RN #17) was inside the space of the surgical department.

On 03/05/15 at 11:45 a.m., an interview was conducted with RN #17 who stated s/he was an employee of the satellite location, and maintained an office in the perioperative area of Hospital B's surgical department.

On 03/05/15 at 9:04 a.m., a tour was conducted of the South Tower of Hospital B's Emergency Department. An office was observed for RN #18, who was an employee of the Children's satellite location, and who worked as the Emergency Department Pediatric Coordinator. The Emergency Department was a department of Hospital B.

On 03/05/15 at 9:05 a.m., an interview was conducted with the Regional Vice President of Southern Colorado Care System (Employee #2), who stated there were two RNs (RN #17 and RN #25) who were employed by the satellite location and who worked out of the perioperative area of Hospital B. The Vice President stated the office for RN #17 was "embedded in the OR."

The Vice President further stated the satellite location employed RN #18 as the Emergency Department Pediatric Coordinator and stated this RN worked out of the Emergency Department of Hospital B.

Based on observations, interviews and document reviews, the governing body failed to maintain separate hospital space, nursing, surgical and admission services and the main telephone contact number in a manner that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services. These failures had potential to affect all patients.

The failure resulted in the co-mingling of patient services, physical space, and personnel with a separately certified facility, Hospital B creating confusion for patients and visitors for both the satellite and Hospital B.

POLICY

The Children's satellite location policy, Pediatric Code Blue Activation, stated Children's satellite Registered Nurses (RNs) responded to pediatric code blue calls in all areas of Hospital B. The satellite location would bring the code cart from Pediatrics to all areas of Hospital B Central East Tower (Floors 2-4). The PICU code team only (no cart) would respond to Hospital B Central Tower, Emergency Department, Operating Room, Post-anesthesia Care Unit (PACU), Gastrointestinal Lab (GI Lab) and Sedation Unit. The Pediatric Intensive Care Unit (PICU) Charge RN would bring the code cart, and was responsible for finalizing the code record and posting documentation to the patient's medical record and functioned as team leader until the physician arrived.

The Children's satellite location policy, Neonatal Resuscitation Code Pink, stated the purpose of the policy was to provide guidelines for satellite staff response to all newborn codes, Neonatal Intensive Care Unit (NICU) codes, and all pre-hospital births arriving in the Emergency Department (ED) at Hospital B. The NICU Charge Nurse would function as a team leader, bring transport packs, function as a team member, direct other staff and be responsible for finalizing the code record and posting documentation to the patient's medical record.

FINDINGS

1. The satellite facility's licensed personnel responded to all pediatric and neonate emergencies in Hospital B and provided patient care services in Hospital B during concurrent hours they worked for the satellite facility.

a) A tour of the Children's satellite NICU was conducted on 03/02/15 at 11:39 a.m. with the Quality and Patient Safety Director (Employee #3) and the Clinical Manager of Pediatrics (Registered Nurse, RN #6).

During the tour, RN #9 stated the NICU Charge RN would respond to all code pink (neonatal resuscitation) calls in the Children's satellite location, as well as all Hospital B locations, pursuant to hospital policy. S/he also stated RNs from Hospital B responded to all adult code blue (adult resuscitation) calls and MET (adult medical emergency team, also known as Rapid Response Team or RRT) calls in the Children's satellite location.

b) A tour of the Children's satellite location's PICU was conducted on 03/02/15 at 12:13 p.m. with Employee #3 and RN #6. RN #6 stated the MET and Code Teams from Hospital B responded to all adult emergencies in the Children's satellite location, and that all calls from the Children's satellite location for the MET and Code Teams went to a main operator shared with Hospital B.

During the tour, RN #10 stated all PICU Charge RNs responded to all pediatric code blue calls in the satellite location and Hospital B, and all pediatric trauma activations in Hospital B's emergency department (ED). S/he also stated Hospital B's ED RNs would come to the satellite location PICU when called for assistance, as often as "a couple of times a month."

c) A review of Hospital B's main operator report, titled January, 2014 METs and Code Blues, revealed Hospital B's MET and Code Team responded to adult emergencies in the Children's satellite location NICU on 01/01/14 at 2:46 p.m. and on 01/01/14 at 2:52 p.m., and to the Pediatric Medical/Surgical Unit on 04/19/14 at 3:23 p.m. and on 10/06/14 at 4:52 p.m.

Further, the report noted Hospital B's MET and Code Team responded to the Children's satellite PICU on 03/10/2014 at 1:26 a.m., 05/06/14 at 4:40 a.m., 05/13/14 at 3:48 p.m., 06/23/14 at 9:03 p.m., 09/13/14 at 3:14 a.m., and 12/10/14 at 8:08 p.m.

d) A review of Hospital B's Pediatric Codes log for September 2014 through February 2015 revealed pediatric code blue calls in Hospital B's emergency department on 09/04/14 at 1:13 p.m.; 09/05/14 at 10:40 a.m.; 09/13/14 at 8:49 p.m.; 10/13/14 at 9:41 p.m.; 10/15/14 at 4:22 p.m.; 12/23/14 at 3:41 p.m.; and 01/20/15 at 3:29 a.m.

e) An interview with the NICU Clinical Manager (Employee #15) on 03/05/15 at 3:53 p.m., revealed NICU charge RNs attended high risk births and cesarean section deliveries in Hospital B's labor and delivery unit. S/he stated this occurred approximately 100 times per month.

2. The Children's satellite location provided licensed staff to work in Hospital B and coordinate emergency department services.

a) On 03/05/15 at 09:04, a tour of Hospital B's emergency services offices revealed the Children's satellite location's Emergency Department Pediatrics Coordinator (RN #18) used an office space there.

A review of RN #18's job description showed it included carrying out direct and indirect patient care responsibilities and demonstrating the ability to provide consistent direction for designated department personnel.

3. The Children's satellite location provided staff to work in Hospital B and coordinate pediatric perioperative services.

a) On 03/05/15 at 8:56 a.m., a tour of Hospital B's surgical services' offices revealed the Children's satellite location's Perioperative Pediatrics Coordinator (RN #17) maintained office space in Hospital B. The Regulatory Director (Employee #12) stated, during the tour, that RN #17 performed clinical duties in Hospital B's operating rooms (ORs) in addition to administrative tasks.

b) Review of a document, provided by RN #17 on 03/04/15, stated his/her duties were 80% clinical and 20% meetings. According to the document, RN #17 worked in Hospital B's OR coordinating the right staff, equipment, instrumentation and supplies for every surgery conducted on Children's Hospital patients in Hospital B's OR. RN #17 stated s/he was the communication liaison with the satellite patient's caregivers. S/he would incorporate the caregivers presence during induction of anesthesia, show them out of the OR, where to wait, and communicate how long the surgery would be.

Additionally, RN #17 stated s/he would participate on the Children's Hospital committees and bring back important information to the OR, make new policy changes as recommended, and incorporate Children's Hospital ideas as seen suited for the Hospital B OR.

c) During an interview, on 03/05/15 at 11:45, RN #17 stated the Children's satellite location sent inpatients over to co-located Hospital B for surgical services without discharging patients from the satellite location and admitting the patients to Hospital B. The inpatients' status in the electronic medical record showed an internal transfer for the purposes of locating the patient. S/he stated that Hospital B personnel also cared for the main Children's Hospital in Aurora pediatric outpatients who received elective and ambulatory surgical services at Hospital B.

d) A second interview was conducted with RN #17 on 03/05/15 at 3:40 p.m. S/he stated the term "transfer" was used in electronic medical records of surgical patients to show when the patients were moved from the Children's satellite location to the Hospital B OR. S/he stated neither facility formally discharged or admitted the Children's satellite location's patients when they received surgical services in Hospital B, and that no discharge or admission documents were completed for those transfers.

e) A review of medical records for Children's satellite location focus Patient's I, J, and K confirmed there were no discharge documents from the Children's satellite location, or admission documents for Hospital B, when the patients were moved from the satellite location to Hospital B for surgery. The medical records contained the term "transfer in" and "transfer out" for patients when they were moved between the co-located facilities.

f) A review of Informed Consent For Operation or Procedure forms for Patient's #13, #14, #18 and #19 showed it contained logos and identifying information for both the Children's satellite location and Hospital B. There was no information on the consent which identified which hospital would conduct the surgery and which hospital the patient was admitted to for the surgical procedure.

g) During an interview on 03/05/15 at 12:30 p.m., the Executive Director of Perioperative Services (Employee #28) stated s/he did not manage the perioperative services employees at the Children's Hospital satellite location, co-located with Hospital B. Employee #28 stated the 2 Children's satellite perioperative employees (RNs #17 and #25) reported directly to Hospital B's OR Manager of Perioperative Services (Employee E). Employee #28 stated s/he met with Hospital B's Employee E initially but there were currently no routinely scheduled meetings.

4. The Children's Hospital satellite location relied on Hospital B's House Supervisor to provide day to day coordination of services.

a) On 03/03/15 at 4:12 p.m., an interview was conducted with the Director of Patient Care Services (Employee #13) who stated s/he was responsible for the direction of nursing, respiratory, patient care technicians, and pharmacy staff at the Children's satellite location. Employee #13 stated House Supervisors, who were employed by Hospital B, were scheduled to be in the building "24/7" and were utilized by both Hospital B and the Children's satellite location as they were part of oversight for the building as a whole.

S/he stated House Supervisors "look out for patients and staff," participated in rounds, assisted with staffing issues, responded to codes, and participated in grievance issues all in the Children's satellite location. Employee #13 stated the schedule for House Supervisors was not shared with nursing staff in the satellite location, however all nurses in the satellite location could either use the direct line on the phones they carried or call the building operator to page a House Supervisor.

b) On 03/04/15 at 9:05 a.m., an interview was conducted with the Regional Vice President, Southern Colorado Care System (Employee #2) who stated House Supervisors were a "purchased service" from Hospital B and listed some of the responsibilities of House Supervisors for the Children's satellite location. S/he stated House Supervisors were responsible for ensuring adequate staffing, were available to patients and families if issues such as complaints should arise, and served as a "communicator with unit leadership" for the Children's satellite location. Employee #2 stated the House Supervisors were involved in ongoing review of "bed capacity" and anticipated the staffing needs for upcoming shifts for the satellite location.

c) On 03/05/15 at 8:59 a.m. House Supervisor (Employee B) was interviewed, and stated s/he was an employee of Hospital B, and covered both Hospital B and the Children's satellite location during his/her 12 hour shifts. Employee B stated, in the role of House Supervisor, s/he responded to "anything out of the ordinary" which would include attending codes, "dealing with patients and families," and staffing issues. Employee B stated s/he carried out these activities in the Children's satellite location. Employee B stated s/he also attended rounds with Children's staff at least once or twice each shift. Employee B stated if there was a code at the satellite location, s/he would speak with family members to keep them informed of the code activities.

Additionally, Employee B stated s/he responded to complaints and grievances in the satellite location if there was no Patient Representative available. Employee B stated if s/he was not able to manage a complaint, s/he would refer the patient or patient's family to a Patient Representative from Hospital B. Employee B stated if s/he received a "grievance" from a family, s/he would submit the issue to a Patient Representative from Hospital B.

Employee B reported his/her orientation and training for the House Supervisor role in the Children's satellite location consisted of a tour of that part of the building and knowing who the team leaders were at the satellite location. Otherwise, there was no formal education and training from the satellite location. Employee B stated in his/her job role as House Supervisor, s/he would report to the administrator on-call, who was always an employee of Hospital B.



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5. The Children's satellite location relied on Hospital B to provide non-emergent surgical services for Children's Hospital patients instead of transporting the patients to the main Children's Hospital for services.

a) During an interview, on 03/05/15 at 11:45 a.m., the satellite location's Perioperative Pediatrics Coordinator (RN #17) stated if Children's Hospital pediatric elective ambulatory surgery patients received procedures in Hospital B's Operating Rooms (ORs), they would be Children's Hospital patients throughout the procedure and admission and not patients of Hospital B.

b) A record review of Patient #13 revealed s/he was directly admitted on 01/21/15 at 9:06 p.m. to the Children's satellite location from a separately certified facility in another city. According to the History and Physical (H&P), Patient #13 was diagnosed with Hypertropic Pyloric Stenosis at the separately certified facility. Patient #13 was admitted by the Pediatric Surgery Service of the Children's satellite location for further management. The H&P stated Patient #13 was well nourished, a well developed 36 day old who was not in acute distress and appropriate for his/her age.

The H&P stated the plan for the patient was to go to the OR in the morning for a Laparoscopic Pyloromyotomy. According to the event management page in the medical record, Patient #13 went to Hospital B's OR on 01/22/15 at 8:34 a.m., approximately 10 ½ hours after initial admission to the Children's satellite location. Patient #13 was brought back to the Children's satellite facility on 01/22/15 at 10:38 a.m.

It was not evident why the patient was admitted to the Children's Hospital satellite facility for a procedure the satellite facility was unable to perform.

c) A record review of Patient #14 revealed s/he was directly admitted on 02/03/15 at 7:29 a.m. to the Children's satellite location for a planned Ladd's procedure with an appendectomy. Patient #14 had a history of abdominal pain, and received an abdominal ultrasound on 12/29/14. According to the medical record, the admission type was designated elective. As stated in the operating note: after a discussion with the patient and his/her parents, it was decided that his/her symptoms more closely fit symptomatic malrotation with possible intermittent volvulus and; therefore, s/he was scheduled for an elective Ladd's procedure with appendectomy. The patient received his/her surgical procedure at Hospital B, and was admitted to the Children's satellite pediatric floor from 02/03/15 until 02/08/15, when s/he was discharged home.

As this was not an emergent procedure, it was not evident why the Children's Hospital satellite location directly admitted a patient for which they were unable to provide services. Further, there was no documentation as to the reason the satellite location did not send the patient to the main Children's Hospital for the non-emergent procedure.

d) A record review of Patient #18 revealed s/he was born and admitted on 11/19/14 to the Neonatal Intensive Care Unit at the Children's satellite location. Patient #18 received surgical services from Hospital B on 1/02/15 for a Ventriculosubgaleal Shunt insertion; then on 01/28/15 for Ventriculosubgaleal Shunt removal and External Drain placement; again on 02/13/15 for a second Ventriculosubgaleal shunt insertion; and finally on 03/03/15 for bilateral inguinal hernia repair and circumcision.

According to the H&P completed on 03/02/15 at 8:55 a.m., the plan stated the patient was to have a bilateral inguinal hernia repair on 03/03/15. Per the event tracking system, Patient #18 went to Hospital B's perioperative services on 03/03/15 at 10:35 a.m., and into Hospital B's OR at 11:04 a.m. for bilateral inguinal hernia repair and circumcision. Patient #18 was transferred back to the Children's satellite NICU on 03/03/15 at 12:37 p.m.

The patient received multiple non-emergent procedures that could have been performed at the main Children's campus in Aurora. Patient #18 did not require emergent intervention using Hospital B's surgical services.

e) A record review of Patient #19 revealed s/he was admitted on 02/17/15 at 7:51 p.m. to the Children's satellite location's pediatric floor for dehydration. Patient #19 was brought to Hospital B's perioperative services on 2/18/15 at 7:35 a.m., and then to Hospital B's operating room on 2/18/15 at 8:11 a.m. for a laparoscopic appendectomy. Patient #19 was on the pediatric floor for approximately 11 hours and 16 minutes before receiving surgical services from Hospital B. The patient was brought back to the pediatric floor at the Children's Hospital satellite location post operatively.

There was no documentation as to why the patient received surgical services at Hospital B, more than 11 hours after admission, instead of the main Children's Hospital.

6. Interview and record review showed the Children's satellite location failed to discharge patients as they were sent to Hospital B for surgical services, and failed to readmit the patients as they returned to the Children's satellite location, a separately certified hospital.

a) A review of medical records revealed 7 out of 7 medical records for patients of the Children's satellite location, who received surgical services in Hospital B's OR between 01/02/15 and 01/12/15, did not contain discharge or admission documents for the patients when they were moved between the facilities (Patients #13, #14, #18, #19 and focus sample Patients I, J and K).

b) The Perioperative Pediatric Coordinator (RN #17) was interviewed on 03/05/15 at 11:45 a.m. S/he stated all patients of the Children's Hospital satellite location who received surgical services at Hospital B were scheduled through Hospital B's central OR scheduling department, and the Hospital B OR charge nurses were responsible for scheduling emergency and unplanned pediatric surgery cases.

S/he stated elective pediatric surgery cases were also scheduled through Hospital B's OR central scheduling department, and these patients did not show a "transfer" from the Children's satellite location to Hospital B. Instead, those patients remained patients of Children's Hospital while they received surgical services at Hospital B.



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7. The Children's Hospital satellite facility failed to provide registration and admissions personnel for all admissions and relied on Hospital B to provide those services when satellite personnel were unavailable.

a) On 03/02/15 at 11:12 a.m., a tour of the facility was conducted with the Director of Quality and Patient Safety (Employee #3), who stated that registration services for the satellite facility were not available "24/7" and that after hours and on weekends, staff from Hospital B provided registration services for Children's Hospital satellite facility patients. The Director stated Hospital B was contracted to provide this service.

A sign was posted on the door to the satellite facility's registration office which stated office hours were Monday through Friday, 7:00 a.m. to 5:00 p.m. The sign also stated "for assistance" to see the registration office for Hospital B, located across the hallway or to call a stated phone number.

During the tour, on 03/02/15 at 11:12 a.m., an interview was conducted with registration staff, Employee #8, who stated the office was open Monday through Friday, from 7:00 a.m. until 5:00 p.m. Employee #8 stated at times s/he would be required to go to the patient units to register patients directly on the floor. If the second scheduled registrar was not in the office, the door would be closed and locked and patients would use the process noted on the door to go across the hallway to be assisted by registration staff at Hospital B.

Employee #8 stated patients were registered by Hospital B staff after hours and on weekends and at other times because "patients don't know we are here." Employee #8 stated there were typically 2 registrars scheduled Monday through Friday, and typically 1 registered patients directly on the units during office hours.

b) On 03/03/15 at 10:16 a.m., the door to the registration office for the satellite facility was noted to be closed and locked with the posting on the door to contact Hospital B's admissions office for assistance. At 10:28 a.m., the door remained closed and locked.

On 03/04/15 at 7:25 a.m., the door to the registration office for the Children's Hospital satellite facility was noted to be closed and locked with the posting on the door to contact Hospital B's admissions office for assistance.

c) On 03/04/15 at 11:15 a.m., an interview was conducted with Employee #8 who described his/her workday so far. The registrar stated s/he arrived at work and logged into the electronic registration system at 7:00 a.m., then went to Hospital B to get registration packets to give to patients and to retrieve demographic sheets and information from registrations conducted by Hospital B since the close of business the day before (03/03/15). When s/he was out of the office at this time of morning, the door to the office was closed and locked, and patients would use the process noted on the door to go across the hallway to be assisted by registration staff at Hospital B.

Employee #8 stated on the morning of 03/04/15, s/he retrieved demographic sheets for 5 patients that Hospital B registered since 03/03/15 at 5:00 p.m. The employee stated on Monday mornings there could be as many as 25 demographic sheets to retrieve from Hospital B as staff from Hospital B registered patients throughout the weekend who were admitted to the Children's satellite location.

d) On 03/05/15 at 3:22 p.m., the registration desk at the North Entrance to the building was observed. The North Entrance was located in Hospital B and was adjacent to the parking deck for patients, visitors, and staff. A Hospital B registrar, Employee A, was at the desk and stated s/he was an employee of Hospital B but conducted patient registration for both Hospital B and for the Children's Hospital satellite location at his/her registration desk. Employee A stated during the day, if a patient came through this entrance needing to be registered for the Children's satellite facility, s/he would register the patient at his/her desk instead of sending the patient to the satellite facility's registration office because it was "so far."

8. The Children's Hospital satellite location shared phone services and a public telephone number with the public. The hospital operator failed to identify the Children's Hospital satellite location when s/he fielded calls on the satellite location's published number.

a) On 03/04/15 at 1:07 p.m., a surveyor called the phone number posted on the Children's Hospital public website for the Children's Hospital satellite location. This phone number was posted on the website as the main phone number for the satellite location. The operator answered and stated the name of Hospital B, and did not state the name of the Children's satellite hospital. The surveyor stated, "I thought I was calling Children's Hospital," to which the operator stated, "We answer for both." Review of the public website for Hospital B revealed the main phone number for Hospital B was the same phone number posted for the Children's satellite location.

On 03/04/15 at 1:35 p.m., a second surveyor called the main phone number posted on the websites for the two separately certified hospitals. The operator answered and stated the name of Hospital B, and did not state the name of the Children's satellite location. The surveyor asked the operator to repeat the greeting and s/he did by stating only the name of Hospital B.

The surveyor called the number again at 1:36 p.m., and the operator answered by stating the name of Hospital B only. The surveyor stated s/he was trying to reach the Children's Hospital, to which the operator replied, "What do you need?" The surveyor stated s/he needed some information from the Children's Hospital. The operator than asked if the caller needed a patient room and which Children's site was needed. The operator stated there were two Children's Hospital sites in the community and stated one was on the north side of town and the other was in the central part of town (the satellite location).

Based on interviews and document reviews, the governing body failed to ensure the hospital's satellite location had a plan for the provision of emergency services that addressed the needs of all patients and visitors. The Children's satellite location relied on a separately certified hospital (Hospital B) to respond and provide emergent services for adult medical emergencies which occurred in the hospital.

This failure potentially contributed to delays in the provision of emergency medical treatment and poor patient outcomes.

FINDINGS

1. The satellite facility relied on Hospital B's licensed personnel to respond to all adult medical emergencies that occurred in the Children's satellite location.

a) A tour of the Children's satellite NICU was conducted on 03/02/15 at 11:39 a.m. with the Quality and Patient Safety Director (Employee #3) and the Clinical Manager of Pediatrics (Registered Nurse, RN #6).

During the tour, RN #9 stated the NICU Charge RN would respond to all code pink (neonatal resuscitation) calls in the Children's satellite location, as well as all Hospital B locations, pursuant to hospital policy. S/he also stated RNs from Hospital B responded to all adult code blue (adult resuscitation) calls and MET (adult medical emergency team, also known as Rapid Response Team or RRT) calls in the Children's satellite location. RN #9 stated if a parent or adult visitor experienced a code blue or medical emergency the ICU (Intensive Care Unit) team and emergency department physician from Hospital B would respond.

b) A tour of the Children's satellite location's PICU was conducted on 03/02/15 at 12:13 p.m. with Employee #3 and RN #6. RN #6 stated the MET and Code Teams from Hospital B responded to all adult emergencies in the Children's satellite location, and that all calls from the Children's satellite location for the MET and Code Teams went to a main operator shared with Hospital B.

During the tour, RN #10 stated Hospital B's ED RNs would come to the satellite location PICU when called for assistance, as often as "a couple of times a month."

c) During an interview, on 03/05/15 at 8:55 a.m., Hospital B's House Supervisor (Employee B) stated s/he would respond to all code and MET calls in both Hospital B and the Children's satellite location. Employee B stated if there was an adult code blue at the Children's satellite location s/he would respond, in addition to Hospital B's code team (from the ICU). S/he stated the adult patient would then be transported to Hospital B's emergency department.

d) A review of Hospital B's main operator report, titled January, 2014 METs and Code Blues, revealed Hospital B's MET and Code Team responded to adult emergencies in the Children's satellite location NICU on 01/01/14 at 2:46 p.m. and on 01/01/14 at 2:52 p.m., and to the Pediatric Medical/Surgical Unit on 04/19/14 at 3:23 p.m. and on 10/06/14 at 4:52 p.m.

Further, the report noted Hospital B's MET and Code Team responded to the Children's satellite PICU on 03/10/2014 at 1:26 a.m., 05/06/14 at 4:40 a.m., 05/13/14 at 3:48 p.m., 06/23/14 at 9:03 p.m., 09/13/14 at 3:14 a.m., and 12/10/14 at 8:08 p.m.

Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance. The hospital failed to protect and promote patient rights by not directly attending to patient complaints and grievances. The failures had the potential to affect all patients.

Cross-reference:

482.13(a)(2) - Standard: Review of Grievances - the governing body failed to ensure a standard approach was maintained for the main Children's hospital location and the satellite location regarding the grievance process. The Children's Hospital satellite location used Hospital B's policies and procedures, the content of which were unknown to Children's Hospital staff and which had not been approved by the governing body.

482.13(a)(2)(i) - Standard: Grievance Procedures - the main Children's Hospital in Aurora failed to ensure a consistent process for the submission of a patient's or a patient representative's written or verbal grievance to the Children's Hospital satellite location, instead the hospital utilized the staff and procedures of Hospital B.

482.13(d)(1) - Standard: Confidentiality of Records - the facility failed to ensure patient electronic medical records and patient identifiers were safeguarded from unauthorized use. Specifically, the hospital failed to ensure compliance with their policy that all computer laptops displaying medical record information must be closed when not in use.

Based on interviews and document reviews, the governing body failed to ensure a standard approach was maintained for the main Children's hospital location and the satellite location regarding the grievance process. The Children's Hospital satellite location used Hospital B policy and procedure, the content of which were unknown to Children's Hospital staff and which had not been approved by the governing body. The failure had the potential to affect all patients served in the satellite facility.

The failure caused patient complaints and grievances to go unaddressed by Children's Hospital staff and allowed for potential deviation from the process approved by the governing body for complaint and grievance investigation and resolution.

FINDINGS:

POLICY

According to the Children's Hospital policy, Grievance Mechanism, Patient/Family/Legally Authorized Representative, the Board of Directors has delegated the responsibility for responding to complaints and grievances to the Patient Relations Department and the Patient Relations Department will coordinate the grievance process. The Patient Relations will collect information/statistics on complaints and grievances, keep any related documentation, and present a summary report to the Grievance Committee. The policy stated the facility would provide the complainant with a written notice of its decision regarding resolution of the grievance, including contact information for further review if desired.

The procedure portion of the policy stated the facility's patients (excluding the facility's satellite location) may also contact the Patient Relations department directly at a stated phone number during business hours. At the Children's Hospital satellite location, patients may contact the Patient Relations department directly at a different stated phone number during business hours.

According to the facility policy, Patient Representative, Role of, at the facility (excluding the facility satellite location), the patient/family/legal authorized representative may also contact the Patient Relations Department directly, at a stated phone number, during business hours. At the facility's satellite location, the patient/family/legally authorized representative may contact the Patient Relations Representative directly at a different stated phone number.

1. In contrast to the policies above, the Children's Hospital satellite location lacked the same grievance mechanism as the main Children's Hospital. Interviews showed the satellite used policies and staff of Hospital B to investigate complaints. Further, employees of Children's hospital lacked an understanding of the policies used at the satellite location, thereby preventing patients from receiving consistent instructions regarding how to submit a complaint or a grievance.

There was no documented evidence the governing body was aware the Patient Relations Department delegated responsibility for complaint and grievance investigation to Hospital B or that the governing body aware that the Patient Relations Department had not approved the investigative process used by Hospital B.

a) Review of the Grievance Mechanism and Patient Relations policies, noted above, revealed two different phone numbers were identified for the "patient/family/legally authorized representative" to contact to file a complaint or grievance. The phone number identified for all Children's Hospital locations, except for the Children's Hospital satellite location, was for the main Children's Hospital in Aurora. The phone number identified for the Children's Hospital satellite location was the phone number to Hospital B's Patient Relations Department.

b) On 03/05/15 at 2:15 p.m., an interview was conducted with the Manager of Patient Relations (Employee #7). Employee #7 stated the Children's Hospital main facility had 4 patient representatives, including his/herself. Employee #7 stated the Children's Hospital satellite location was different from the main facility because Patient Representatives employed by Hospital B, responded to complaints at the Children's satellite facility. Employee #7 stated the Children's Hospital main campus' compliant and grievance algorithm did not apply to the satellite location because Hospital B Patient Representatives investigated complaints received at the satellite location. Hospital B staff used the grievance process for Hospital B to determine if the inpatient issues at the satellite location were complaints or grievances. Further, Employee #7 stated s/he was not familiar with the grievance policy used by Hospital B. S/he could not state how Hospital B defined a complaint or a grievance. Employee #7 stated any issue brought forward by an inpatient or family member from the satellite facility was considered a complaint and was addressed by the Patient Representatives employed by Hospital B as such.

Employee #7 stated s/he had no involvement in the training of or methods used by Hospital B's Patient Representative staff to conduct complaint or grievance activities at the satellite location. Employee #7 stated if Patient Representatives felt a documented complaint was a grievance, then Hospital B sent that case to the main Children's Hospital location. Employee #7 stated that s/he reviewed all the files s/he received and made sure the families were "taken care of." S/he stated grievances received after a patient was discharged from the Children's Hospital satellite location were forwarded from Hospital B to the Children's Hospital Main Campus, using the judgment of the staff at Hospital B. Employee #7 stated three times during the interview that any issue brought forward by an inpatient or family member at the Children's Hospital satellite location was considered a complaint, not a grievance.

Employee #7 stated s/he had not reviewed complaints received from the Children's Hospital satellite facility to ensure that the issues received were actually complaints and were not instead, grievances. S/he stated, "If it's not my team, I have no authority," referring to the Patient Representatives from Hospital B who were not his/her employees, but who were carrying out the grievance process at the satellite facility, using the grievance policy and process for Hospital B.

Employee #7 stated s/he did not have control from "beginning to end" of the process with the Patient Representative staff at Hospital B because they were not his/her employees. S/he stated the "leadership team" would have some control over the Patient Representatives from Hospital B, but as a manager, s/he did not. Employee #7 stated s/he was, however, the responsible party for reporting complaints and grievances to leadership each quarter for the "entire system," which included the Children's Hospital satellite facility. (Cross-reference A0121)

Based on observations, interviews, and document review, the main Children's Hospital in Aurora failed to ensure a consistent process for the submission of a patient's or a patient representative's written or verbal grievance with that of the Children's Hospital satellite location. The Children's Hospital satellite location used Hospital B policy and procedure, the content of which were unknown by Children's Hospital staff. The failure had the potential to affect all patients served in the satellite facility.

The failure caused patient complaints and grievances to go unaddressed by Children's Hospital staff thereby current issues are unknown and unaddressed by the hospital. The complaint and grievance policy and process used could not be explained by Children's Hospital staff creating the potential for confusion by patients and their representatives.

FINDINGS:

POLICY

According to the Children's Hospital policy, Grievance Mechanism, Patient/Family/Legally Authorized Representative, the Patient Relations Department will coordinate the grievance process. The Patient Relations will collect information/statistics on complaints and grievances, keep any related documentation, and present a summary report to the Grievance Committee. The policy stated the facility would provide the complainant with a written notice of its decision regarding resolution of the grievance, including contact information for further review if desired.

The procedure portion of the policy stated the facility's patients (excluding the facility's satellite location) may also contact the Patient Relations department directly at a stated phone number during business hours. At the Children's Hospital satellite location, patients may contact the Patient Relations department directly at a different stated phone number during business hours.

According to the facility policy, Patient Representative, Role of, at the facility (excluding the facility satellite location), the patient/family/legal authorized representative may also contact the Patient Relations Department directly, at a stated phone number, during business hours. At the facility's satellite location, the patient/family/legally authorized representative may contact the Patient Relations Representative directly at a different stated phone number.

1. In contrast to the policies above, the Children's Hospital satellite location lacked the same grievance mechanism as the main Children's Hospital. Interviews showed the satellite used policies and staff of Hospital B. Further, employees of Children's hospital lacked an understanding of the policies used at the satellite location, thereby preventing patients from receiving consistent instructions regarding how to submit a complaint or a grievance.

a) Review of the Grievance Mechanism and Patient Relations policies, noted above, revealed two different phone numbers were identified for the "patient/family/legally authorized representative" to contact to file a complaint or grievance. The phone number identified for all Children's Hospital locations, except for the Children's Hospital satellite location, was for the main Children's Hospital in Aurora. The phone number identified for the Children's Hospital satellite location was the phone number to Hospital B's Patient Relations Department.

b) On 03/05/15 at 2:15 p.m., an interview was conducted with the Manager of Patient Relations (Employee #7). Employee #7 stated the Children's Hospital main facility had 4 patient representatives, including his/herself. Employee #7 stated the Children's Hospital satellite location was different from the main facility because Patient Representatives employed by Hospital B, responded to complaints at the Children's satellite facility. Employee #7 stated the Children's Hospital main campus' compliant and grievance algorithm did not apply to the satellite location because Hospital B Patient Representatives investigated complaints received at the satellite location. Hospital B staff used the grievance process for Hospital B to determine if the inpatient issues at the satellite location were complaints or grievances. Employee #7 stated s/he was not familiar with the grievance policy used by Hospital B. S/he could not state how Hospital B defined a complaint or a grievance. Employee #7 stated any issue brought forward by an inpatient or family member from the satellite facility was considered a complaint and was addressed by the Patient Representatives employed by Hospital B as such.

Employee #7 stated s/he had no involvement in the training of or methods used by Hospital B's Patient Representative staff to conduct complaint or grievance activities at the satellite location. Employee #7 stated if Patient Representatives felt a documented complaint was a grievance, then Hospital B sent that case to the main Children's Hospital location. Employee #7 stated that s/he reviewed all the files s/he received and made sure the families were "taken care of." S/he stated grievances received after a patient was discharged from the Children's Hospital satellite location were forwarded from Hospital B to the Children's Hospital Main Campus, using the judgment of the staff at Hospital B. Employee #7 stated three times during this interview that any issue brought forward by an inpatient or family member at the Children's Hospital satellite location was considered a complaint, not a grievance.

Employee #7 stated s/he had not reviewed complaints received from the Children's Hospital satellite facility to ensure that the issues received were actually complaints and were not instead, grievances. S/he stated, "If it's not my team, I have no authority," referring to the Patient Representatives from Hospital B who were not his/her employees, but who were carrying out the grievance process at the satellite facility, using the grievance policy and process for Hospital B.

Employee #7 stated s/he did not have control from "beginning to end" of the process with the Patient Representative staff at Hospital B because they were not his/her employees. S/he stated the "leadership team" would have some control over the Patient Representatives from Hospital B, but as a manager, s/he did not. Employee #7 stated s/he was, however, the responsible party for reporting complaints and grievances to leadership each quarter for the "entire system," which included the Children's Hospital satellite facility.

c) On 03/04/15 at 7:30 a.m., a list of complaints and grievances from patients and families at the Children's Hospital satellite location, from 01/01/14 to 03/04/15, was requested of the Director of Quality and Patient Safety (Employee #3). The list was received on 03/04/15 at 9:30 a.m., and contained 16 complaints and 1 grievance. Upon medical record review for Patient #11, and discussion of this patient's hospitalization course, the surveyor asked staff if the family of this patient had voiced concerns or issues during hospitalization that would have been considered a complaint or a grievance. Patient #11 was not listed on the complaint and grievance document received on 03/04/15.

On 03/05/15 at 10:00 a.m., Employee #3 presented a second list of complaints and grievances, which contained a complaint from the family of Patient #11. The list was otherwise identical to the list received on 03/04/15. Employee #3 stated s/he could not explain why the complaint was not documented on the first list received and stated Employee #7 could explain this lapse.

On 03/05/15 at 2:15 p.m., during the interview with the Manager of Patient Relations (Employee #7), the Manager stated s/he did not realize Patient #11 was not on the list of complaints and grievances for the satellite facility. Employee #7 stated because of "filters" on the electronic complaint and grievance system, the issues brought forward by the family of Patient #11, which went through a Hospital B Patient Representative, were labeled an "FYI" meaning the family might contact the main Children's Hospital campus and staff there should be aware. S/he stated some examples of "FYI" categories were, "family needs help," and, "service recovery," and stated there were usually no interventions by his/her staff for FYI issues.

Review of the issue for Patient #11, documented on the complaint and grievance list received on 03/05/15, showed the issue was labeled a complaint, not an FYI, and the issue itself was, "Quality of Care," which was not one of the "FYI" examples given by the Manager.

On 03/02/15 at 10:30 a.m., a document review of the Children's Hospital was conducted. A phone number, stated in the Children's Hospital Grievance Policy, for the Children's Hospital satellite location, was stated as the grievance contact information number for patients, family members, and others to use to submit a grievance by phone. This phone number was the same number listed on the grievance process website page for Hospital B. The Children's Hospital satellite location and Hospital B shared one phone number for the phone submission of grievances for both, separately certified, facilities.

On 03/05/15 at 8:55 a.m., an interview with a House Supervisor (Employee B) was conducted. Employee B stated s/he was employed by Hospital B and served in the role of House Supervisor in both Hospital B and the Children's satellite location. Employee B stated, during his/her shifts, s/he responded to all inpatient issues, including complaints, as s/he was responsible for any unusual issues from patients and their families, and this would include complaints. Employee B stated if s/he was not able to manage a complaint, s/he would refer the patient or patient's family to a Patient Representative from Hospital B. Employee B stated when s/he received a complaint from a patient or family member, s/he would listen to the issues, talk with the patient and or family, and if s/he could "deal with" the compliant immediately, s/he would do so. If s/he could not "deal with" the complaint immediately, s/he would inform the family that a Patient Representative would "be in to see them." Employee B stated if s/he received a "grievance" from a family, s/he would submit the issue to a Patient Representative from Hospital B. Employee B stated inpatients from the Children's Hospital satellite location could submit issues that could be complaints or could be grievances. Employee B did not state that all patient and family concerns were considered to be complaints, as previously stated by the Manager of Patient Relations (Employee #7).

On 03/05/15 at 12:10 p.m., an interview was conducted with Hospital B's Patient Representative, Employee C, who stated s/he responded to complaints at Hospital B and at the Children's Hospital satellite location and was employed by Hospital B. S/he stated that if a complaint was regarding an inpatient at the Children's satellite location, the Patient Representatives dealt with the issue at the time and later sent case files to the Children's Hospital main location. Employee C stated s/he was not familiar with the grievance mechanism used at the main Children's Hospital location and used the grievance policy and process from Hospital B when responding to complaints at the satellite location. Employee C stated most of the calls s/he received from the satellite location were complaints and s/he had "never been involved with a grievance on the Children's side."

Based on observations, interviews, and document review, the facility failed to ensure patient electronic medical records and patient identifiers were safeguarded and sensitive information held confidential. Specifically, electronic medical records contained on laptops were left available for any person passing by to view in areas where there was access to the public. This failure had the potential to affect all patients served in the satellite facility.

The failure created the potential for unauthorized individuals to gain access to patient electronic medical records including patient identifiers, demographics, diagnoses and other information that could be misused..

FINDINGS:
POLICY

According to the policy, Information Security, all sensitive information must be effectively protected again unauthorized modification, disclosure, use, destruction, or disruption, whether intentional or unintentional. Users must log off after using a work station. Shared workstations in public areas that are not subject to constant supervision will be locked (or screen saver protected) for application access after a maximum of 30 minutes.

According to the Patients' Rights and Responsibilities document, patients and parents can expect the only people allowed to see their records are: the patient and the patient's parents; the people who have the patient's and/or patient's parents' permission in writing; and those who are allowed by law to see the records, for example the child's doctors and nurses.

1. The facility staff did not close screens on patient electronic medical records in patient care units to prevent unauthorized use and protect patient privacy.

a) On 03/02/15 at 10:40 a.m., a tour of the Neonatal Intensive Care Unit (NICU) was conducted with the Accreditation and Regulatory Manager (Employee #19). The electronic medical record of Patient A was open and visible on the hallway on a computer located between rooms 4150 and 4152, unattended by any staff member. Patient A's information and identifiers were visible to the surveyors.

b) On 03/02/15 at 11:04 a.m., a continued tour of the NICU revealed an unattended, open electronic medical record of Patient B at a hallway computer station near room 4112. Patient B's information and identifiers were visible to the surveyors.

c) On 03/02/15 at 11:11 a.m., a tour of the Pediatric Intensive Care Unit (PICU) was conducted with Employee #19. The electronic medical record of Patient C was left open and visible at the hallway computer station near room 3107. The Registered Nurse (RN) for Patient C was in the patient's room, and left the hallway computer screen open and unattended. Patient C's information and identifiers were visible to the surveyors.

d) On 03/02/15 at 2:59 p.m., an interview was conducted with RN #4 who stated the expectation of staff was to minimize the computer screen or to lock the computer if left unattended, to ensure patients' electronic medical records were not visible to families or visitors on the unit.

e) On 03/02/15 at 3:13 p.m., a tour of the NICU revealed an open electronic medical record of Patient D was left unattended at a hallway computer station between rooms 4154 and 4156. Patient D's information, identifiers, and hourly assessments were visible to the surveyors.

f) On 03/03/15 at 3:09 p.m., a tour of the NICU revealed an open electronic medical record for Patient E was left unattended at a hallway computer station next to room 4170. RN #5 was present in the patient's room, and left the computer screen open and unattended. Patient E's information, identifiers, and hourly assessments were visible to the surveyors.

g) On 03/03/15 at 3:12 p.m., an interview with RN #5 was conducted. RN #5 stated s/he was expected to close the electronic medical record when leaving the computer, and reopen the record when s/he was back at the computer. RN #5 stated electronic medical records should not be left open and visible on an unattended computer. RN #5 stated s/he received training every year on this topic as it was part of patient privacy.

Based on the nature of deficiencies referenced to the Condition, it was determined the Condition of Participation, 482.24 MEDICAL RECORD SERVICES was out of compliance.

Based on interviews and document review, the facility failed to have one unified medical record for all Children's Hospital locations. Instead, the Children's satellite utilized the electronic medical record of Hospital B. This failure affected all patients of the satellite facility.

This failure created the potential for negative patient outcomes due to lack of coordination of medical care and miscommunication among health care providers within the hospital system..

FINDINGS:

1. The facility failed to have a unified medical records system which encompassed all locations. Specifically, the Children's Hospital satellite location, which was co-located with an unrelated hospital (Hospital B), did not use the same medical records system as the main Children's Hospital in Aurora.

a) On 03/02/15 at 2:00 p.m., an interview was conducted with the Accreditation and Regulatory Manager (Employee # 19) who stated the Children's satellite location's Electronic Medical Record (EMR) system was part of Hospital B's EMR platform. Employee #19 stated if the surveyors wanted to review medical records from the satellite location while physically at the main Children's Hospital in Aurora, s/he would have to find someone who had access to Hospital B's EMR as it was a separate medical records system from the system used at Children's main location.

b) On 03/04/15 at 1:07 p.m., an interview was conducted with the main Children's Hospital Neonatal Intensive Care Unit (NICU) Registered Nurse (RN #22), who stated s/he was able to view current admission information for any patient in the Children's Hospital system except patients at the satellite location, co-located with Hospital B. RN #22 stated when a patient was being transferred to the NICU s/he would review the patient's current admission information in the medical record. RN #22 stated they were unable to obtain this information for NICU patients transferred from the satellite location, co-located with Hospital B, as the EMR was part of a different electronic system. RN #22 stated the satellite location's medical record would have to go through the transfer service center and the patient would have to be identified in a bed space prior to him/her having access to the entire Children's Hospital EMR for the current admission.

c) On 03/03/15 at 11:51 a.m., an interview was conducted with Employee #24 (Health Information Management Analyst, HIM), at the Children's satellite location, who stated medical records from the satellite location, co-located with Hospital B, would have to be printed and sent with any patient who was transferred to the main Children's Hospital in Aurora, to ensure the entire medical record for the current admission was available at the time of the patient's arrival. S/he stated some parts of the medical record for the current admission could not be viewed at the main Children's Hospital until the satellite location's EMR was completed. Employee #24 stated the EMR at the satellite location was part of Hospital B's medical record system, which was a different system than the main Children's Hospital.

d) On 03/03/15 at 12:26 p.m., an interview was conducted with the Manager of Release of Information and Scanning (Employee #20) who stated the EMR for the Children's satellite location was part of Hospital B's EMR system. S/he further stated some items interfaced with the main Children's Hospital's EMR system but it could be up to 30 days after a patient's discharge before a single integrated record was available.

2. Medical record review confirmed the hospital failed to have one unified records system.

a) Review of Patient F's medical record showed s/he was admitted to the Children's satellite location, co-located with Hospital B, on 02/23/15 and remained a current patient. The Children's satellite location EMR included: vital sign flow sheets, a medication list with administration times, an intake and output flow sheet, and a list of orders.

However, the EMR at the main Children's Hospital in Aurora did not include vital sign flow sheets, a medication list with administration times, an intake and output flow sheet, and orders.

b) Review of Patient G's medical record revealed s/he was admitted to the Neonatal Intensive Care Unit (NICU) on 02/27/15 and remained a current patient. The Children's satellite location instance of the EMR included: vital sign flow sheets, a medication list with administration times, intake and output flow sheet, a list of invasive lines, and detailed lab results and radiology reports.

In contrast, the main Children's Hospital's instance of the EMR did not include vital sign flow sheets, a medication list with administration times, intake and output flow sheet, a list of invasive lines, and detailed lab results and radiology reports.

Additionally Patient G's EMR showed different information for encounters at the 2 locations. On the main Children's Hospital's EMR, only an admission and registration encounter was listed. On the Children's satellite location instance of the EMR, multiple encounters were listed for admissions and radiology appointments.

c) Review of Patient H's EMR showed s/he was admitted to the satellite location on 02/19/15 and remained a current patient. The Children's satellite location EMR included: vital sign flow sheets, medication list with administration times, an intake and output flow sheet, detailed lab results, and orders.

The main Children's Hospital's EMR did not include vital sign flow sheets, a medication list with administration times, an intake and output flow sheet, detailed lab results, and orders.

Further, Patient H had different encounter information on the two different EMRs. On the main Children's Hospital's instance of the EMR, an admission encounter for 02/19/15 and previous encounter dates for August 2014 were listed. On the Children's satellite location instance of the EMR, additional encounters for laboratory tests and radiology were noted.