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Tag No.: A0441
Based on record review, document review, and staff interview it was determined the facility failed to ensure the confidentiality of patient records in one (1) out of twenty (20) patients reviewed, patient #8. This failure has the potential to negatively impact any patients receiving care at the facility.
Findings include:
A medical record review was conducted for patient #2. The patient presented to the Emergency Department (ED) on 04/11/22 at 5:22 p.m. via ambulance with a chief complaint of altered level of consciousness. The patient was noted as discharged from the ED at 6:20 p.m.
Review of documentation in patient #2's electronic medical record revealed under 'consents' there were two (2) pages of a "Patient Agreement" with patient #8's information, including the patient's name, date of birth, address, phone number, and patient #8 was "unable to sign" due to "dementia/ams [altered mental status]."
Review of the complaint intake documents provided to the surveyor revealed it also included patient #8's consent documentation which was sent home with patient #2 upon discharge.
Review of policy, titled "Breach of Protected Health Information (PHI) Notification", last reviewed 11/2020, revealed it states in part: "Definitions: ... Protected Health Information- Individually Identifiable health information including Democratic information That relates to the past present or future physical or mental health or condition including genetic information of an individual the provision of healthcare to an individual or the past present or future payment for the provision of healthcare to an individual. Includes information to which there is a reasonable basis to believe the information can be used to identify the individual."
An interview was conducted on 04/26/22 at 4:29 p.m. with the Corporate Compliance and Privacy Officer. Regarding patient #2 receiving patient #8's consent with the discharge paperwork, they stated, "The individual who hands the packet to the patient, and has the patient sign off on that, should be checking to make sure that there's no incorrect information in the packet. This appears to be an honest error. If this patient went home with the other patient's information then I have to report it and proceed per policy."
Tag No.: A1104
Based on record review, video review, and staff interview, it was determined the facility failed to notify the physician in a change of patient condition in the Emergency Department (ED) in one (1) out of twenty (20) patients, patient #2. This failure has the potential to cause great harm to all patients presenting to the facility's ED for treatment.
Findings include:
A medical record review was conducted for patient #2. The patient presented to the ED on 04/11/22 at 5:22 p.m. via ambulance with a chief complaint of altered level of consciousness. The initial physical findings documented by EMS (Emergency Medical Services) state: "Assessment, Mental status: agitation, altered mental status, unspecified, combative, confused, disorientation, unspecified, hallucinations, strange and explicable behavior, stupor, uncooperative."
Review of an assessment note documented by Registered Nurse (RN) #2, dated 04/11/22 at 6:10 p.m., states in part: "Category Note: Pt [patient] is alert, oriented, requesting to leave facility and refusing any further tx [treatment] at this time. Wants to sign out AMA [Against Medical Advice]. Agreed to sign AMA paper and voiced that [patient #2] understands risks associated. Family voiced understanding that pt has the right to refuse since [patient #2] is a/o [alert and oriented]."
Review of a discharge assessment note documented by RN #2, dated 04/11/22 at 6:13 p.m., states in part: "The AMA paperwork was signed by [patient #2] at 6:20 p.m. and documented witnessed by [RN #2]." The discharge paperwork was signed by patient #2, no time listed. The patient was noted as discharged from the ED at 6:20 p.m., for a total elapsed time in the ED of fifty-eight (58) minutes.
A video review was conducted on 4/26/22 at approximately 12:00 p.m. of the video footage from 4/11/22 of the outside at the ambulance entrance of the ED, starting at 6:24:04 p.m:
6:24:04 p.m.: A dark colored Sport utility vehicle (SUV) pulls up in front of the ambulance entrance.
6:25:25 p.m.: Patient #2 was brought to the outside of the ED in a wheelchair (WC) at the ambulance entrance; two (2) staff members (Licensed Practical Nurse (LPN) #1 and ED Technician (Tech) #1) accompanied the patient. The SUV pulls back up to the ambulance entrance doorway, and patient #2 is brought to the front door, passenger side of the SUV. LPN #1 and ED Tech #1 were beside the WC.
6:26:33 p.m.: LPN #1 and ED Tech #1 appeared to be talking to patient #2 who remained in the WC.
6:26:52 p.m.: LPN #1 and ED Tech #1 appeared to have patient #2 around the arms and trying to lift them up. Patient #2 was unable to get up.
6:27:12 p.m.: Patient #2 grabbed the SUV door for assistance and was unable to get out of the WC to a standing position.
6:28:07 p.m.: LPN #1 and ED Tech #1 appeared to be trying to help patient #2 up.
6:28:24 p.m.: Patient #2 stands with help. Patient #2 has ahold of the front window and door of the SUV. LPN #1 and ED Tech #1 appeared to be talking to patient #2.
6:29:04 p.m.: Patient #2 sits in the SUV with legs remaining on the outside of the SUV.
6:29:47 p.m.: Patient #2 appeared to try to shut the door of the SUV, while legs were on the outside of the SUV. ED Tech #1 appeared to stop the door from closing.
6:30:28 p.m.: ED Tech #1 appeared to put the legs of patient #2 in the SUV.
6:31:08 p.m.: LPN #1 and ED Tech #1 appeared to be talking to patient #2.
6:31:39 p.m.: LPN #1 and ED Tech #1 appeared to be lifting patient #2 up in the seat of the SUV.
6:32:48 p.m.: LPN #1 and ED Tech #1 appeared to still be assisting patient #2 while sitting in the SUV seat.
6:33:20 p.m.: Staff closed the SUV Door.
6:33:31 p.m.: The SUV pulls away from the ambulance entrance of the ED.
Review of policy, titled "Against Medical Advice (AMA), Patient Leaving", last reviewed 05/01/20, states in part: "Policy: ... The Registered Nurse and/or physician shall discuss, with the patient and/or family, the potential complications that may occur if the patient leaves prior to the physician discharging the patient."
A telephone interview was conducted with RN #1 on 04/25/22 at 4:07 p.m. RN #1 remembered patient #2. RN #1 states, "I saw [patient #2] the second time [patient #2] came to the ER [Emergency Room]. I did [patient #2's] triage and a brief assessment. [Patient #2's] primary nurse was [RN #2]. I remember [patient #2] came by squad [ambulance]. [Patient #2] was confused talking out of [patient #2's] head. [Patient #2] knew where [patient #2] was and [patient #2's] name but [patient #2] was disoriented to time. [Patient #2] was tachycardic."
An interview was conducted on 04/26/22 at 8:41 a.m. with RN #2. Regarding patient #2, RN #2 states, "When [patient #2] got to the ED, I didn't do the original assessment. I got the run down from the nurse that did. I went and talked to [patient #2]. I asked [patient #2] 'do you know why you are here?' [Patient #2] was able to answer everything appropriately, all the standard questions. At that point, I explained to [patient #2] that [patient #2] would have to sign the AMA form. So we proceeded with the form. The patient said [patient #2] understood." Regarding the AMA paperwork, RN #2 states, "The standard is the physician goes in and speaks with the patient about it, but I didn't witness that. When I took the AMA paperwork in, I explained the risk, explained [patient #2] refused treatment, and had another nurse have [patient #2] to sign the paper. [LPN #1] had the patient sign the paperwork. The discharge paperwork was given and [LPN #1] did the discharge. I had no interaction with the patient after I explained the AMA paperwork to [patient #2]. We were all very busy that day. I went back the next day to document the AMA paperwork. When I was in the room with the patient, [patient #2] was alert and oriented."
A telephone interview was conducted on 04/26/22 at 10:00 a.m. with LPN #1. LPN #1 remembered patient #2. LPN #1 states, "The patient was delusional and [patient #2] didn't have any words that formed any coherent sentences. I was in there for about ten (10) to fifteen (15) minutes. [Patient #2] became more lucid towards the end. I drew blood out of the IV. When I was getting the blood ready [Physician #1] said not to worry about it, [patient #2] was going to sign out AMA, so I disposed of the blood tubes in the sharps container. I overheard the [sibling] and the [parent] saying they wanted the patient to stay. The patient kept saying [patient #2] wanted to go. The patient was more with it, but [patient #2] did not fully understand the implications of [patient #2] leaving in my opinion. I did have [patient #2] sign the AMA. I was told I have to follow the doctor's orders. Me and one (1) of the techs [ED Technician] got [patient #2] into the wheelchair. [Patient #2] was unsteady. We had to lift [patient #2] into the chair. We got [patient #2] out to the car. It was fifteen (15) to twenty (20) minutes of trying to get [patient #2] into the car. [Patient #2] kept on saying [patient #2] wanted to know how to do this. We got [patient #2] halfway into the car, and [patient #2] was halfway out of the car with the legs hanging out and tried to shut the door. [Patient #2] was picking at the EKG (electrocardiogram) stickers that were on [their] shoulders. At one (1) point, [patient #2] told the family to drive off anyway as [patient #2] was halfway out of the car still. There was nothing else I could do at this time. The patient was not really alert and oriented in my opinion. I talked to one (1) of the RNs after [patient #2] left about this and I was told we have to go with it when a doctor orders the AMA, if the patient was lucid when [patient #2] signed the papers. I didn't personally feel okay with this. I was told again if a doctor orders an AMA there is nothing that we could do even if the patient got confused after [patient #2] signed the paper."
An interview was conducted with the ED Tech on 04/27/22 at 9:56 a.m. Regarding patient #2, the ED Tech states, "We were arguing with [patient #2] to get into the car, and [patient #2] just didn't want to get into the car. [Patient #2] kept saying that [patient #2] couldn't. During this time, [patient #2] had an EKG sticker in [patient #2's] mouth chewing on it. [Patient #2] said it was [Opioid Antagonist]. I had [patient #2] to spit it out. I don't know if the LPN with me knew [patient #2] was chewing on the sticker. I didn't tell anybody afterwards."
An interview was conducted with the Chief Nursing Officer (CNO) on 04/27/22 at 10:18 am. Regarding patient #2, the CNO states, "You shouldn't have the patient sign the consent unless you were the one discussing. You would need to get reassurance the patient understands the risk if you were the one having the patient sign the paperwork. Any nurse would need to bring it to the Physician's attention or go to the charge nurse or next in command, if the physician was busy, and they felt that the patient did not understand. The nurse is the patient's primary advocate. I don't think any nurse here would fear that." When asked if once a doctor orders the AMA and says a person is alert and oriented, there is nothing they can do about it, the CNO states, "No, that's not how it is. If they don't feel comfortable talking with a physician, they can always call the administrator on call. The LPN can be collaborative in this decision, but the LPN can and should be assessing the patient themself before having the patient to sign."
An interview was conducted with Physician #1 on 04/26/22 at 1:51 p.m. Regarding patient #2, Physician #1 stated in part, "If [patient #2] would have had any altered mental status changes, or had been confused after [patient #2] signed the AMA paperwork, we would have brought them back. I have gone out into the parking lot and got patients that have gotten confused after leaving. No one told me anything about any difficulty getting the patient into the car, or the patient being confused."
An interview was conducted with the Director of the ED, and the senior Charge Nurse of the ED, on 04/26/22 at 3:49 pm. Regarding patient #2, the Director stated, "If a patient was confused and disoriented after signing the AMA paperwork, the staff would be expected to bring them back into the emergency department and a nurse do another evaluation or assessment."