HospitalInspections.org

Based on medical record review, document review and staff interview, the hospital failed to assure each patient/or patient's representative is made aware of their patient rights for 9 of 9 medical records reviewed (patients #'s 10, 12, 13, 15, 17, 18, 19, 20, and 21) who were emergency department patients, out-patient and observation patients including patients admitted for observation and later admitted as inpatients. The hospital failed to assure each patient/or patient's representative is made aware of the hospital's grievance policy for 9 of 9 medical records reviewed (patients #'s 10, 12, 13, 15, 17, 18, 19, 20, and 21) who were emergency department patients, out-patient and observation patients including patients admitted for observation and later admitted as inpatients, failed to comply with a patients advanced directive for one of one medical records reviewed requiring Durable Power of Attorney (DPOA) involvement (patient #1), and failed to implement a patients advanced directive for one of one medical records reviewed requiring a Durable Power of Attorney (DPOA) involvement (patient #1).

Findings include:

- The hospital failed to assure each patient/ or patient's representative is made aware of their patient rights. See further evidenced at CFR 482.13(a)(1), A-0117.

- The hospital failed to assure each patient/ or patient's representative is made aware of their patient rights including the hospital's grievance policy as evidenced at CFR 482.13(a)(2), A-0118.

- The hospital failed to comply with a patients advanced directive for one of one medical records reviewed requiring Durable Power of Attorney (DPOA) involvement. See further evidence at CFR 482.13(b)(2), A-0131.

- The hospital failed to implement a patients advanced directive for one of one medical records reviewed requiring a Durable Power of Attorney (DPOA) involvement (patient #1). See further evidence at CFR 482.13(b)(3), A-0132.

Based on document review and staff interview, the hospital failed to assure each patient/or patient's representative is made aware of their patient rights for 9 of 9 medical records reviewed (patient's #'s 10, 12, 13, 15, 17, 18, 19, 20, and 21) who were emergency department patients, out-patient and observation patients including patients admitted for observation and later admitted as inpatients. This deficient practice had the potential to affect all emergency department patients, outpatients, and observation patients.

Findings include:

- Patient #10's medical record revealed an admission date of 5/7/11 as an inpatient on with diagnoses of hypoglycemia (low blood sugar) and respiratory failure. The medical record, reviewed on 5/16/11 at 1:00pm revealed the medical record lacked documentation the patient or patient's representative was aware of their patient's right.

- Patient #11's medical record revealed an admission date of 5/12/11 with diagnosis of fever and pneumoperitoneum (air or gas in the abdominal cavity). The medical record, reviewed on 5/16/11 at 3:30pm revealed the medical record lacked documentation the patient or patient's representative was aware of their patient's right.

- Patient #12's medical record revealed an admission date of 5/14/11 as an observation patient and became inpatient on 5/18/11 with an allergic reaction. The medical record, reviewed on 5/17/11 at 1:15pm revealed the medical record lacked documentation the patient or patient's representative was aware of their patient's rights.

- Staff B, C and D interviewed on 5/17/11 at 9:00am acknowledged the hospital failed to assure emergency department patients, out-patients, and observation patients are informed of their rights.

- Administrative staff E, interviewed on 5/19/11 at 8:30am acknowledged the hospital lacked a policy or procedure identifying who should receive patient rights information and how to educate the patients/representatives.

The deficient practice also affected patient #'s 15, 17, 18, 19, 20 and 21.


25604

Based on document review and staff interview, the hospital failed to assure each patient/or patient's representative is made aware of their patient rights including the hospital's grievance policy for 9 of 9 medical records reviewed (patients #'s 10, 12, 13, 15, 17, 18, 19, 20, and 21) who were emergency department patients, out-patient and observation patients including patients admitted for observation and later admitted as inpatients. This deficient practice had the potential to affect all emergency department patients, outpatients, and observation patients.

Findings include:

- The hospital's Patient's Bill of Rights document reviewed on 5/16/11 at 7:00pm directed " ...The patient has the right to complain. Patients who have a complaint or grievance or feel their rights have been violated may dial 0 and ask for the patient care supervisor. They may also call the Complaint Hotline provided by the Kansas Department of Health and Environment at 1-800-842-0078 ..."

- Patient #10's medical record revealed an admission date of 5/7/11 as an inpatient on with diagnoses of hypoglycemia (low blood sugar) and respiratory failure. The medical record, reviewed on 5/16/11 at 1:00pm revealed the medical recorded lacked documentation the patient or the patient's representative was aware of their patient's right including the hospital's grievance policy.

- Patient #11's medical record revealed an admission date of 5/12/11 with diagnosis of fever and pneumoperitoneum (air or gas in the abdominal cavity). The medical record, reviewed on 5/16/11 at 3:30pm revealed the medical record lacked documentation the patient or the patient ' s representative was aware of their patient's right including the hospital's grievance policy.

- Patient #12's medical record revealed an admission date of 5/14/11 as an observation patient and became inpatient on 5/18/11 with an allergic reaction. The medical record, reviewed on 5/17/11 at 1:15pm revealed the medical record lacked documentation the patient or the patient's representative was aware of their patient's rights including the hospital's grievance policy.

- Staff B, C and D interviewed on 5/17/11 at 9:00am acknowledged the hospital failed to assure emergency department patients, out-patients, and observation patients are informed of their rights including the hospital's grievance policy.

The deficient practice also affected patient #'s 15, 17, 18, 19, 20 and 21.

25604


Based on medical record review, Patient's Right document review, and staff interview the hospital failed to comply with a patients advanced directive for one of one medical records reviewed requiring Durable Power of Attorney (DPOA) involvement (patient #1).

Findings include:

- The hospital's Patient's Bill of Rights document reviewed on 5/16/11 at 7:00pm directed " ...The patient or his/her representative has the right to make informed decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment of plan of care ..."

Patient #1's medical record reviewed on 5/17/11 at 1:00pm revealed the patient's mental status required the need for the designated DPOA to make medical decisions for them. The medical record evidenced a voluntary application for admission dated 11/29/11 and signed by patient #1 and their DPOA. The medical record evidenced a "Probable Cause" justifying protective custody dated 11/29/11 and signed by the facility staff. The "Probable Cause" document indicated patient #1 required involuntary placement for care and treatment. The medical record lacked evidence patient #1's DPOA received notification of the proposed court notice or made aware of information to make an informed decision.

Administrative staff F interviewed on 5/18/11 at 7:45am acknowledged documentation in the medical record indicated the facility initiated commitment papers when the patient and the patient's DPOA had already signed a voluntary commitment paper. Staff F acknowledged the medical record failed to provide evidence the DPOA had been involved prior to initiation of the court order. Staff F acknowledged based on the patient's medical record the facility failed to up hold the patient's rights to comply with the patient's advanced directive

Staff G interviewed on 5/18/11 at 10:10am reviewed patient #1's medical record and acknowledged the medical record lacked evidence they had provided the DPOA with information so they could make an educated decision prior to proceeding with the court order.

25604


Based on medical record review, Patient's Right document review, and staff interview the hospital failed to implement and comply with a patients advanced directive for one of one medical records reviewed requiring a Durable Power of Attorney (DPOA) involvement (patient #1).

Findings include:

- The hospital's Patient's Bill of Rights document reviewed on 5/16/11 at 7:00pm directed "...The patient has the right to have an advanced directive (such as a living will, heath care proxy of durable power of attorney for health care decisions) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive..."

Patient #1's medical record reviewed on 5/17/11 at 1:00pm revealed the patient's mental status required the need for the designated DPOA to make medical decisions for them. The medical record evidenced a voluntary application for admission dated 11/29/11 and signed by patient #1 and their DPOA. The medical record evidenced a "Probable Cause" justifying protective custody dated 11/29/11 and signed by facility staff. The "Probable Cause" document indicated patient #1 required involuntary placement for care and treatment. The medical record lacked evidence patient #1's DPOA received notification of the proposed court notice or made aware of information to make an informed decision.

Administrative staff F interviewed on 5/18/11 at 7:45am acknowledged documentation in the medical record indicated the facility initiated commitment papers when the patient and the patient's DPOA had already signed a voluntary commitment paper. Staff F acknowledged the medical record failed to provide evidence the DPOA had been involved prior to initiation of the court order. Staff F acknowledged based on the patient's medical record the facility failed to implement and comply with the patient's advanced directive

Staff G interviewed on 5/18/11 at 10:10am reviewed patient #1's medical record and acknowledged the medical record lacked evidence they implemented and compiled with the patient's advanced directive and involve the patient's DPOA prior to proceeding with the court order.

.

Based on record review, Medical Staff By-Laws review, and staff interview the hospital failed to assure all written, verbal, and telephone orders are dated and timed when authenticated (signed) for 5 of 23 medical records reviewed (patient #'s 7, 9, 12, 13 and 15).

Findings include:

- The hospital's "By-Laws of the Medical and Dental Staff", reviewed on 5/17/11 at 3:20pm revealed "...3. It shall be the duty and responsibility of each attending member of the Medical and Dental Staff to complete the medical record...including dating, timing and signing all entries..."

- Patient #7's medical record, reviewed on 5/16/11 at 11:15am, revealed the patient was admitted on 5/11/11 to the hospital's acute care. The medical record contained 14 written,verbal and/or telephone orders which lacked the date and/or time the orders were authenticated.

- Patient #9's medical record, reviewed on 5/16/11 at 12:15pm, revealed the patient was admitted on 5/15/11 to the hospital's acute care. The medical record contained five written, verbal and/or telephone orders which lacked the date and/or time the orders were authenticated.

- Patient #12's medical record, reviewed on 5/17/11 at 3:30pm, revealed the patient was admitted on 5/14/11 to the hospital's acute care. The medical record contained four written, verbal and/or telephone orders which lacked the date and/or time the orders were authenticated.

- Administrative staff D and E, interviewed on 5/17/11 at 4:00pm acknowledged all entries in a patient's medical record are to be dated and timed when signed.

The deficient practice also affected patient #'s 13 and 15.