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Based on record review and interview the governing body did not ensure that one of one (ID#1) patient received bereavement counseling after a fetal demise.

Finding Include:

Record review of the facility policy "Care Manager /Social Worker Consult Criteria", dated 12/10/2020, stated nurses at UTMB will consult social services and care management independent of physicians to facilitate care that is beneficial and timely for maternal patients. Bereavement/Hospice Fetal demise-SW to provide support IF inadequate support systems exist, mother of baby is not coping well or family is needing a list of funeral homes.

Interview with on 09/02/2022 at 1700 Social Worker Manager (ID #66), Manager and (ID#67) RN Director of Case Manager at who discussed the consult process. (ID# 66) social worker, stated: "we are a consult-based service, anyone can generate a consult, physicians, or nurses".

Social worker manager (ID#66) entered the medical record and did not find consult generated for patient (ID#1) in the medical record.

She stated a care manager should be consulted for a fetal demise, "we review the chart and meet with the patient. Some patients do not want our services, but we check on them anyway. In any case we are routinely consulted, for most part we are consulted for fetal demise. We assess the patient, assist with making appointments, caregiver support, and provide resources for the burial of the fetus.
We follow up with the patient even if they do not want the service.
We reach out to the pastoral care to assist. I do not know how this patient was missed".

Based on patient chart review, interview and document review the facility failed to ensure nursing followed their current policy in that a nursing re-assessment was not completed with one hour after administration of pain medication in 1 of 10 records reviewed. (Patient #1).

Policy Reviewed:

Review on 9/01/2022 of the facility's current policy titled, "Pain Management", #7-2-101; Revision date 5/20/2019. Audience: All nursing service employees. Outcomes of Interest: Pain is assessed, treated, and reassessed according to individual patient needs and considering the time frames related to interventions: Assessment/Re-Assessment: 3. Pain assessment/re-assessment shall be performed, 3.6. before and after each pain management intervention ....14. Pain is reassessed within one (1) hour after each pharmacological intervention.

Review of Patient ID #1 medical record:

October 5, 2021, nurse notes registered nurse (RN) staff ID #60.
00:00 - Patient complaint of pain, abdominal cramping. Scale used 0-10, rating 3. Blood Pressure (BP) 145/89, Pulse 89, Respiration: 18, Oxygen saturation 98%. FHT (fetal heart tones) 130.
00:05 Patient taken off monitor. Patient states pain improved and declined anything for pain.
00:25 Observations: Physician ID #75 reviewed strip and states patient may remain off monitor and will order Tylenol for pain if needed.
00:56 Acetaminophen (Tylenol), tablet 650 mg given, dose 650 mg oral and Diphenhydramine (Benadryl) 25 mg, dose 25 mg oral
04:00 Patient Observation: Patient resting comfortably with eyes closed at the time. Denies any needs or complaints. Pain Rating: 0

Record review along with Director of Quality, staff ID #53 confirmed records documented no reassessment of patient after pain management intervention.

Interview on 9/01/2022 staff ID #53 confirmed per the facility's policy the nurse should have completed a reassessment of the patient within one hour of the patient receiving pain medication.

The facility failed to ensure prompt retrieval of medical records by its staff as requested within the 15-day time limit specified in the facility's current policy.

Policy Reviewed:

Review on 9/01/2022 of the current facility policy 6.04.27 title, "Receiving and Entering requests for the release of Protected Health Information (PHI)". 05/07/21 - Reviewed with changes. Policy: Enter all requests for the release of PHI into electronic data base completely and accurately in a timely manner.

HIM has fifteen (15) days from the date of receipt to respond to all requests, per state law. IV. Request must be processed within 15 days of receipt.

Documents Reviewed:

Review of Authorization for the release of Protected Health Information forms from for patient ID #1. Form signed by patient ID #1 12/1/2021.

Received date stamp - Dec 06,2021 Request ID #UTMBNE2633340
Description of items Requested:
Emergency Records 8/16/19 - 10/06/2021
Clinic Records 8/6/19 - 10/06/21
Lab Reports 8/16/19 - 10/06/21
Hospital records 8/16/19 to 8/16/2021
Fetal birth strips 0/29/21 - 10-05/21

Invoice # UTMB953836 dated 01/03/2022 for $29.38 was sent out to patient ID #1 along with 1451 pages of medical records.

Phone call notes and emails document a medical records request revision on 01/19/21 by patient ID #1 now request all of 2021 regarding labor/birth.
Email notes several phone calls to patient ID #1 with message "not accepting calls".

Review of Authorization for the release of Protected Health Information forms from the facility for patient ID #1. Form signed by patient ID #1 12/20/2021. Requested information sent by email.

Description of items Requested:

Entire Medical Records
Partial Records: From Feb 14, 2019, to October 6, 2021
Other: baby's monitoring stripes/vitals 9/29/21 - 10/5/2021

Invoice # UTMB1537125 dated 01/03/2022 for $6.50 was sent out to patient ID #1 for electronic Copy Fee-email medical records.

Initial request for records was received by the facility December 6, 2019. Partial documents were received.

Interview on 9/01/22 with medical records staff ID #70 confirmed the process of request for medical records. Staff ID #70 stated the request can be via fax, email, or mail. No verbal request. Staff ID #70 confirmed the facility needs to respond to the request within 15-days. We verify the patient in EPIC and verify signature, enter the request into the release program and upload the records to be sent out however they request to be sent out. If the file is too large and email won't go through, they can sign up for the portal we offer or a CD. In the portal the patient can sign up and get access and download it and save.

Staff ID #70 confirmed the My Chart portal only lets you pull up certain parts of a patient's records, Clinic visits, test, lab, prescriptions, visit notes, patient appointments, imaging, and physician notes. Staff ID stated the My Chart portal does not contain all the patient's inpatient hospitalization records.

Staff ID #70 confirmed the medical records request should have been responded within 15 days and was not.