HospitalInspections.org

Based on findings from document review and interview, in 3 of 3 complaint investigations performed, the hospital did not provide complainants with a written response that indicated the findings of its investigation. This could lead to unresolved patient grievances.

Findings include:

-- Per review of the hospital policy and procedure (P&P) titled "Patient and/or Patient Representative Complaints and Grievance Process" last revised 9/15, it requires that once the investigation process is complete, the Director of Quality and Risk Management will send a letter of closure to the complainant. The letter will include the steps taken in the investigation, titles of individuals involved in the investigation and when the investigation was completed.

-- Per review of 3 complaint investigations, all lacked a written response to the complainant about the investigation findings.

-- During interview of Staff A (Director of Quality and Risk Management) on 7/7/17 9:30 am, he/she acknowledged that not all complainants are provided a written response of the investigation findings.

Based on findings from medical record (MR) review, document review and interview, in 2 of 2 MRs reviewed the facility did not ensure all patients were provided a Notice of Privacy Practices. This lapse of offering information could place patients at risk for health information being unknowingly shared.

Findings include:

-- Per review of the facility's Notice of Privacy Practices, last reviewed 10/18/16, it described how medical information about the patient may be used and disclosed.

-- Per review of Patient #1's MR, the patient was admitted on 3/20/17 and refused a copy of the Notice of Privacy Practices. Patient #1 was admitted again on 6/27/17 and the MR lacked documentation that the Notice of Privacy Practices was offered.

-- Per review of Patient #2's MR, the patient was admitted on 7/6/17 and the MR lacked documentation that the Notice of Privacy Practices was offered. Patient #2's MR from a previous admission (2/16/15) revealed he refused a copy of notice of Privacy Practices.

-- Per interview of Staff B (Registration Manager) on 7/7/17 at 12:15 pm, all patients being admitted are offered the Notice of Privacy Practices. When a patient accepts the Notice of Privacy Practices this is documented on the facility form titled "Acknowledgement of Receipt of Cortland Regional Medical Center/Rehabilitation and Nursing Center Notice of Privacy Provisions" and placed in the patient's MR. Similarly, if the patient refused to accept the Notice of Privacy Practices, this would be documented on the same form and the notice would not be offered again.

-- Per interview of Staff C (Chief Compliance Officer) on 7/11/17 at 10:20 AM, the Notice of Privacy Practices should be offered during the admission process. If a patient accepts the notice, this is recorded in the MR and the notice is not offered again. If a patient refuses the notice, facility staff would continue to offer the notice at each new admission until it was accepted by the patient.

Based on findings from observation and interview, facility staff did not ensure that patients' clinical information was kept confidential. This lapse in confidentiality practices placed patients' health information at risk for exposure to the public.

Findings include:

--During observation in the Emergency Department (ED) on 7/10/17 between 9:00 am and 10:00 am, a computer tablet displaying a patient's confidential information was left unattended in the hallway. The information was visible to anyone (patients, visitors, staff, etc.) in the area.

-- Per interview of Staff D (ED Physician) on 7/10/17 9:10 am, the tablet had been left unattended because he/she took a phone call, and was not aware that the screen would not time out and/or lock when not in use.

Based on findings from document review and interview, the hospital's Quality Assessment and Performance Improvement (QAPI) program did not track and trend grievance data. This lapse in monitoring could lead to failure in recognizing potential trends in quality of care issues.

Findings include:

-- Review of the facilities complaint/grievance log for the time period covering 7/6/16-6/21/17 revealed that grievances are categorized by date of service, department, the date the complaint was filed, who it was assigned to, the date it was reviewed and the date the acknowledgment letter was sent to the complainant. The log lacked pertinent information related to the type of complaint received (i.e., medical care, nursing care, physical environment, etc.) Therefore, the QAPI meeting minutes (for that time period), didn't identify any possible trends in quality of care issues.

-- Per interview of Staff A on 7/10/17 at 12:00 pm, he/she acknowledged the QAPI program did not keep tracking or trending data on complaints/grievances, but that they are reviewed on a case by case basis at QAPI meetings.