HospitalInspections.org

Based on review of hospital policy, record review and interview, the hospital failed to protect and promote all the patient rights by not following their confidentiality policy for 1 (Patient #2) of 3 patients reviewed.

The finding include:

1. Review of the hospital policy reviewed 10/10/17 "Confidential Patients" revealed, "...WTH will neither deny, nor confirm the presence of confidential patients in our facilities. Patients choosing a confidential status by opting out of being listed in the patient directory will not receive any telephone calls, mail, flowers or visitors...In situations where the patient is not able to make decisions for themselves, and a personal representative wishes to make the patient confidential, follow procedures for "restricted visitation"...The Consent for Treatment and Financial Responsibility form is signed by all patients upon registration or admission and allows the patient the opportunity to object to inclusion in the patient directory and/or object to clergy visits...As soon as the patient completes the form, notify someone in Admission/Registration so that the change can be made in the Named computer system...Note the person in Registration/Admissions spoken with, sign and date, and enter the current time on the form...Fax the completed from to that person in Registration/Admissions...File the form in the patient's medical record behind the Consent for Treatment and Financial Responsibility form...Registration/Admissions will also scan/file the faxed from as documentation of why the status was changed...Staff that need to find if a patient is listed as "Confidential" may refer to the "Patient List" in Powerchart when a star in the "VIP Code" column to the right of the patient name will indicate confidential status. If searching for patient names in Powerchart the "VIP" column will state "Yes" beside the patient name for confidential patients...Restricted Visitation...In Situations where the patient is not able to make decisions for themselves, we must rely on that patient's personal representative, agent, or surrogate (as defined in MGB [Management Guidebook]) If a Rep asks for a patient to be listed as "confidential" the Rep will be asked to complete the "Restrictive Visitation" form...A maximum of two visitors will be allowed and must be clearly noted on the "Restricted Visitation" form...Admitting or nursing personnel will add the forms to the patient's chart and Admitting will enter the Rep as a "Confidential Patient" in the registration system. The Rep will be required to take a copy of the "Restricted Visitation" form to the facility's front desk/check-in area. Only the two listed restricted restricted visitors will be allowed to visit and must provide proof of identification upon each entry into the facility..."

2. Medical record review revealed Patient #2 was admitted to the hospital on 5/15/2021 with a diagnosis of Hyperglycemia, Dementia and Alzheimer's.

Review of Patient #2's face sheet for admission provided by the hospital for the current admission listed as the emergency contact #1 was the name of Patient #1's friend, emergency contact #2 was listed as the patient's step-daughter and the next of kin was listed as the patient's step-son. The patient's Power of Attorney (POA) was listed as the patient's biological son who was unavailable and indisposed.

Review of the nursing progress notes on 5/16/2021 revealed, "...Patients step-son and step-daughter called stating that they are wanting to keep her as a private patient due to non family member calling to try and demand patient care..."

Review of Patient #2's electronic medical record revealed no documentation the patient was to be listed as a confidential patient. There was no evidence of a "star" checked by the VIP Code per the hospital's policy.

During an interview on 9/27/2021 beginning at 10:03 AM with the Quality Outcomes Director (QOD) in the conference room, the QOD was asked if there was a hospital policy concerning VIP codes and confidentiality of patients and the QOD stated, "...Not to my knowledge..." The QOD was asked if the "Restricted Visitation" form was completed by Patient #2's representatives due to Patient #2 not being able to make decisions for herself and the QOD stated, "...No, I'm not aware of this form".

During a telephone interview on 10/5/2021 beginning at 12:44 PM, the friend listed as the emergency contact for Patient #2 was asked if she was the emergency contact for Patient #2 and she stated, "...Yes."
Emergency contact #1 was asked what relationship was she to Patient #2 and emergency contact #1 stated, "...No relationship just a friend..."
Emergency Contact #1 was asked who was Patient #2's next of kin #1 and emergency contact #1 stated, "...Patient #2's stepson, her son that is her Power of Attorney is in jail so [step-son] has been staying at Patient #2 house taking care of her because the patient is bedridden..."
Emergency contact #1 was asked if she had been aware of the request for Patient #2 to be a confidential patient and emergency contact #1 stated, "...Yes [step-son] made her [Patient #2] confidential, due to the fact that someone called and claimed to be the [patient's] daughter and she [Patient #2] doesn't have a daughter... This complaint I know has to be her [Patient #2's] Granddaughter who lives in [name of another city] that has never had anything to do with [Patient #2]... [Patient #2] was at home by her self lying in feces on the floor because she had no one to take care of her because her son was in jail and when he was at home he was smoking that crack and did not take care of her... That is why [stepson] was there".
Emergency contact #1 was asked is she was aware of any visitors attempting to visit with Patient #2 without being listed on the visitor list and emergency contact #1 stated Visitor #1 had called and attempted to make arrangements to visit with Patient #2 and, "...[Visitor #1] was not related to Patient #2...lives in [different State] and comes here and stays with [Patient #2]...[Visitor #1] is friends with [Patient #2's]granddaughter..."

During an interview on 9/27/2021 beginning at 11:36 AM the QOD was asked is she had been made aware that Visitor #1 had called the hospital and attempted to make arrangements to visit Patient #2 and the QOD stated, "...You cannot call to make arrangements for visitation...Also if the visitors have already had their two visitors for the day and no one is in the patient's room. They still cannot have anymore visitors while we are using the COVID visitation policy..."

During an interview on 9/27/2021 beginning at 1:00 PM, in the conference room the Chief Nursing Officer (CNO) was asked what procedure was used to ensure only listed representatives and listed family members received patient information by telephone and the CNO stated, "...I personally don't think we have a written policy about giving a code out to the patient's families...We have always asked for the patient's date of birth and the relationship [to the patient]... If we have multiple family members or family dynamics we give a code [to use when calling to check on patients]... Anybody that presents this code can get [patient] information... If there are no family dynamics we will ask for the date of birth and the relationship".
The CNO was asked how can they ensure that the person who is on the telephone who has the patients' date of birth is a legitimate family representative listed to receive patient confidential information and the CNO stated, "If I have met and talked with you before and we accept that you know the date of birth for that person and we see if your name is listed in the medical record and if you are next of kin then we give out the patient information".