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Based on interview and record review, the facility failed to follow their policy and procedure to ensure a patient's right to access their own medical records for 1 of 1 patient [Patient #20]. Patient #20's second request for the entire medical record on 06/20/11 was not initiated or completed by the medical record staff.

On 09/06/11 at 11:20 AM, Patient #20 was interviewed. Patient #20 told the surveyor that when she requested her medical records from the facility, she was only given 6 pages, which had to do with her neck surgery on 02/05/10. Patient #20 stated that when she again asked for her full record, she was treated rudely by the "large lady at the medical records office" and was told she had to complete the release form herself, and that she would have to pay for her records. Patient #20 stated that she had trouble writing, due to weakness, and had to ask for help from another person in line to fill out the medical record request form for her, and she signed it as best she could. Patient #20 said that she was not given the medical records from her second request on 06/20/11, and had never been contacted and/or received those records from the facility.

Review of Patient #20's medical record reflected she had completed two (2) "Authorization for Release of Information" forms on 06/20/11. These forms did not include a space to document the time of the patient's request, but does require the date of the request.
-Request #1 showed that Patient #20 requested her medical record from "2/5/2010 to 2/5/2010" for neck surgery, and was dated 06/20/11.
-Request #2 showed that Patient #20 requested her medical record from "2/10 to present," and was also dated 06/20/11.

The "Authorization for Release of Medical Information" policy #16000-102, last revised 06/15/11, under "Procedure," noted the following:
-"#18. For walk-in patients, the ROI (release of information) staff should help the patient as needed in determining what parts of the medical record will be most beneficial for their use."
-"#19. Generate an invoice and notify requester of charges, if applicable..."
-"#20. Copy all information requested."
-"#24. Enter the release of copies of the medical information in the Correspondence software program."
-"#25. Place the authorization and any other pertinent requesting information in the patient's chart."

The Associate Director for Health Information Management (Personnel #66) was interviewed at 9:45 AM on 09/07/11. Personnel #66 verified that there were (two) 2 "Authorization for Release of Medical Information" facility request forms in Patient #20's official medical record. When asked if the facility kept records that showed all requests for release of information and the staff who processed the requests, she said "yes." She provided an internal computer printout that documented Personnel #68 had processed Patient #20's first request, starting at 2:33 PM, and that the medical record request had been fulfilled at 3:07 PM. Personnel #66 stated that Patient #20 had signed in 2:30 PM on 06/20/11 at the Release of Information desk sign-in form, but she did not sign in again that day, when she made the 2nd request. Personnel #66 was asked if the facility also had documentation in the computer system that showed the 2nd request had been initiated and completed, and she said "no."

Personnel #68 was interviewed at 1:15 PM on 09/07/11. She verified that she helped Patient #20 fill out the release of information form, based on recognition of her own hand writing on this form. She stated that she "fills in" when the regular staff are on break, and verified her computer documentation for Patient #20's first request on 06/20/11. Personnel #68 also stated she did not process the second request, based on the fact that the writing on the form was not hers.

The Associate Director was interviewed at 1:30 PM on 09/07/11 specifically over the Release of Information process. Personnel #67 verified the facility had "no record of the second request being filled for Patient #20 on 06/20/11."

Based on interview and record review the facility's policy for tracking adverse patient events was not followed for 1 of 1 patient [Patient #20]. Patient #20's surgical complication was not reported through their hospital incident reporting process (patient safety network) as required.

Patient #20 was interviewed on 09/06/11 at 11:20 AM. Patient #20 told the surveyor that she had neck surgery on 02/05/10 and claimed that "they tore a hole in her spinal column," and she woke up with "a tube in her spine with spinal fluid in a bag." Patient #20 further stated "after release she began having problems holding bowel and bladder, right side totally numb, and she cannot write."

The operative report of 02/05/10, located in the medical record noted the following:
- Patient #20 had an Anterior Cervical (C4-5) diskectomy and fusion.
- Also noted under "operation performed," was "patch dural defect with Duraform and Tisseel."
- "Complications: 1) Cerebral spinal fluid leakage, and 2) Decrease of right upper extremity somatosensory evoked potential."
- "Findings: 1) Cerebral spinal fluid encountered when disk material removed...3-4 mm (millimeter) defect noted with transdural disk herniation."
2) "Decrease in somatosensory evoked potentials in the right upper and right lower extremities during diskectomy but good return with less distraction, with complete recovery of the right lower and partial recovery of the right upper."

The discharge summary by the attending physician, Personnel #71, noted under Procedures Done, "anterior cervical diskectomy and fusion C4-5. The patient had a traumatic durotomy which necessitated placement of a lumbar drain postoperatively."

The attending orthopedic physician on this surgical case, Personnel #71, was interviewed via telephone at 3:15 PM on 09/08/11. Personnel #71 told the surveyor that he was "scrubbed in" and assisted in the surgery, along with the 4th year orthopedic resident physician, Personnel # 109. Personnel #71 stated "the disk had eroded through the dura, which is pretty unusual, and that it had required repair." When asked what their procedure was for reporting complications, he said that "usually the circulating RN [Registered Nurse] asks questions at the end of the case, including if there were any complications, and then they report it." He also said that all complications were reviewed in the monthly Orthopedic department M & M (morbidly & mortality) meetings for physician review at that time.

The "Adverse Events" policy #Admin 5-18, noted that this procedure applies "to All Adverse Events, including adverse events involving potential or actual harm that require medical intervention." This policy also notes under the documentation guidelines, that staff personnel will "ensure that a Patient Safety Net report is completed in a timely manner," and that "consideration of the extent of harm, severity and likelihood of recurrence will determine the extent and degree of an institutional led investigation following an adverse event."

The circulating RN on the surgical case, Personnel #73 was interviewed via telephone at 11:15 AM on 09/12/11. Personnel #73 told the surveyor that he was present during the surgical case. When asked if the usual procedure for the circulating RN to initiate the patient safety net (PSN) report for any complications or adverse events during surgery, he said "yes, if he had witnessed the event." He also said that if the RN had not witnessed the event, it would be decided whether the RN or the physician writes the PSN report. Personnel #73 stated he was not aware of a traumatic durotomy, and therefore, had not initiated the required PSN report for such occurrences.

The Director of Patient Safety and Risk Management (Personnel #70) was interviewed at 3:30 PM on 09/07/11. Personnel #70 was asked if in the Quality Assessment Performance Improvement program, they had received and tracked this adverse event from their PSN reporting system. Personnel #70 said "no."

Based on interviews and record review, the hospital failed to ensure appropriate and safe discharge planning was provided for one psychiatric ED [Emergency Department] patient [Patient #18] as evidenced by the following:

1) The Hospital failed to discharge 1 of 1 patient [Patient #18] in a safe and appropriate manner. Patient #18, a female patient, was discharged from the Psychiatric Emergency Department with a bus pass on the morning of 08/17/11 at 05:36 AM [in the dark] wearing nothing but two hospital nightgowns and paper shoes.

Cross Refer to Tag 0821.

The Hospital failed to reassess the discharge plan for 1 of 1 patient [Patient #18]. Patient #18, a female patient, was discharged from the Psychiatric Emergency Department [ED] with a bus pass on the morning of 08/17/11 at 05:36 AM [in the dark] wearing nothing but two hospital nightgowns and paper shoes.

Findings Included:

The Peace Officer's Application for Emergency Detention dated 08/16/11 timed at 2:00 PM reflected, "Attempted to kill or injure self, jumped out of a second story window naked and dove head first out the second story..."

The physician ED note dated 08/16/11 timed at 14:46 PM reflected, "This is a 24 year old female who comes to...hospital emergency department in for evaluation of a jump...pt [patient] was using drugs and jumped from a second story window, hit her frontal head, positive for loss of consciousness, now only complaint of being embarrassed, denies suicidal ideation...ambulatory at the scene...C-collar [cervical collar] in place...2 x [times] 3 cm [centimeter] superficial laceration to the lateral aspect of the right leg..."

The nursing main ED note dated 08/16/11 timed at 15:56 PM, reflected, "RN [Registered Nurse] remains at bedside for 1:1. Patient's grandmother notified that pt [patient] is here per pt request..."

The nursing ED note dated 08/16/11 timed at 20:26 PM, reflected "Report called to psychiatric ER [emergency room] nurse. Will await police escort..."

The patient valuables form dated 08/16/11 timed at 21:04 PM reflected "robe."

The psychiatric social worker note dated 08/16/11 timed at 21:17 PM reflected, "The pt [patient] reported she smoked K2 and felt like she wanted to fly...social worker will attempt to gain consent to speak with the patient's family once the patient is resting in the day area..."

The psychiatric social worker note dated 08/16/11 timed at 22:59 PM reflected, "With the pt's [patients] permission, the SW [social worker] spoke with her grandmother...she stated she is willing to pick up the pt [patient] from the ER once she is ready for discharge...information shared with the treatment team..."

The psychiatric social worker note dated 08/17/11 timed at 00:22 AM, reflected "Social Work Discharge Note, mode of transportation: car, alone or accompanied: Grandmother, final disposition: After meeting with patient, the interdisciplinary team has determined the patient does not meet criteria for inpatient hospitalization...the patient will be discharged home with family members...she denies any intent to harm herself and collateral from her grandmother supports this..." It was noted the patient was not discharged as described above with her grandmother.

The physician note dated 08/17/11 timed at 03:24 AM reflected, "Patient complaining of back pain from fall...will give one dose of Norco-5/325...will continue to monitor...anticipate discharging patient in the morning with bus pass, as her grandmother unable to come pick her up tonight..."

The nursing discharge note dated 08/17/11 timed at 05:36 AM reflected, "Condition at discharge: stable...to home self...transported with bus pass via bus...condition at the time of discharge the patient is not considered to be an imminent danger to self or others, is dressed in seasonally appropriate attire, and feels safe with discharge plan..."

On 08/29/11 at 3:30 PM Staff #51 was asked what she knew regarding Patient #18's discharge. Staff #51 stated that the psychiatric ED staff did not follow the discharge process. Staff #51 stated the patient should not have been discharged on the bus stop wearing only nightgowns and paper shoes.

On 08/30/11 at 12:15 PM Staff #56 was interviewed. Staff #56 verified by video documentation that Patient #18 was discharged on 08/17/11 at 05:32 AM wearing two hospital nightgowns.

On 08/31/11 at 2:55 PM Staff #54 was interviewed. Staff #54 was asked to review Patient #18's medical record and the social worker notes. Staff #54 stated she did document adequately and Patient #18 was not discharged in a safe manner. Staff #54 stated she wrote her discharge note after midnight but did not update it to reflect the changes in the discharge plans. Staff #54 stated the patient was discharged wearing two nightgowns and given a bus pass. Staff #54 stated the patient was not discharged with grandmother via car as previously documented.

On 08/31/11 at 1:25 PM, Staff #53 was asked what she knew regarding Patient #18's discharge. Staff #53 stated Patient #18's grandmother called her about 08:00 AM on 08/17/11 after Patient #18 was discharged. Patient #18's grandmother informed her the hospital was supposed to call her to pick the patient up. Patient #18's grandmother called back 2 to 3 hours later and said Patient #18 arrived home with two hospital nightgowns on, and wearing nothing underneath. Staff #53 stated the grandmother informed her the local police called her indicating Patient #18 was on the rail and could not walk. Staff #53 stated the concern was reported to hospital management.

On 09/06/11 at 2:30 PM Staff #52 was asked what she knew regarding Patient #18's discharge on 08/17/11. Staff #52 was asked if she discharged Patient #18 in the early morning hours [dark] on the bus stop with two hospital gowns and paper shoes. Staff #52 stated she did. Staff #52 stated the patient would not wait to put her clothes on. Staff #52 was asked to provide the surveyor the documentation which indicated the patient refused to wear her clothes and/or what clothes were documented on her valuables list. Staff #52 stated she did not document the details. The surveyor asked Staff #52 if Patient #18's discharge was safe and appropriate. Staff #52 stated, "Yes."

The discharge documentation education training records dated and signed 08/16/11 by Staff #52 and #54 reflected, "I have been educated in the new mandatory discharge documentation that is being implemented immediately. I understand that I must use either the Nursing Discharge Note or Social Work Discharge Note that is in the Smart Phrases in Epic for every patient that is being discharged. I understand that certain elements must be documented on every patient: Final disposition, condition at discharge, mode of transportation, alone or accompanied, medications administered, seclusion or restrain, most recent vital signs, education and understanding of discharge instructions, prescriptions identified and provided, outpatient appointments/resources/referrals and seasonally appropriate clothing. I understand that charts will be audited for the required documentation, starting immediately, with the expectation of 100 percent compliance with these new processes."

The policy entitled, "Patient Discharge process and instruction with revision date of 01/09 reflected, "To discharge the patient in a safe and efficient manner...to provide the patient with verbal and written instructions for care upon discharge...the nurse shall document a discharge summary note in the nurse's notes that includes the assessment of the patient's ability to manage his/her care after discharge...when the patient is ready to leave, appropriate accommodations(s) will be provided...the discharge is entered in EPIC within 30 minutes after the patient has physically left the nursing unit..." It was noted the discharge policy did not include reassessment of the discharge plan.

Based on interview and record review, the Outpatient Clinic for Jail Services failed to meet the medical needs for 1 of 1 patient [Patient #13] in a timely manner as evidenced by the following:

1. The LVN [Licensed Vocational Nurse], Staff #83, and 2 of 2 NP's [Nurse Practitioner's], Staff #82 and Staff #85, failed to provide timely assessment/reassessment, and documentation for 1 of 1 patient [Patient #13]. Patient #13 complained of severe abdominal pain on 06/27/11 at 20:45 PM. Patient #13 was not sent to the Hospital ED [Emergency Department] until 06/28/11 at 10:44 AM. Patient #13 required emergency surgery for the removal of the appendix 06/28/11.

Cross refer to Tag 1077

Based on interviews and records review, the Outpatient Clinic services were not organized and integrated into the hospital inpatient services in that, the Jail Health Clinic failed to supervise and ensure 1 of 2 LVN's [Licensed Vocational Nurses], Staff #83, and 2 of 2 NP's [Nurse Practitioner's], Staff #82 and #85, provided timely assessment/documentation and intervention for 1 of 1 patient [Patient #13]. Patient #13 complained of severe abdominal pain on 06/27/11 at 20:45 PM. Patient #13 was not sent to the hospital ED [Emergency Department] until 06/28/11 at 10:44 AM. Patient #13 required emergency surgery for the removal of his appendix on 06/28/11.

Findings Included:

The Emergency/Walk-in nursing note at the Jail dated 06/27/11 timed at 20:45 PM showed "Patient complains of pain in the lower abdomen that is radiating to the right, back and his groin area, states it hurts when he urinates. Patient rates pain at 10/10...blood pressure 153/108, pulse 77, respirations 18, temperature 97.8...patient is alert and oriented denies any issues with breathing, patient seemed in pain kept squeezing his lower abdomen ...map provider contacted...and a VO [verbal order] for UA [Urinalysis] was received, also order for Clonidine 0.2 mg [milligram], Tylenol 650 mg, and Zantac 150 mg po [by mouth] now was received. The provider requested that patient bring a specimen of his stool when he had a bowel movement. UA results within normal range; patient was giving [sic] a specimen container to collect the stool in. All ordered medication administered...back to tank..." No further documentation and/or reassessment was done until the 6 PM to 6 AM shift by Staff #83 and/or Staff #85.

The Emergency/Walk-in nursing note at the Jail dated 06/28/11 timed at 06:24 AM showed, "POD officer called this nurse stating the patient has stool ready. Patient alert, has bowel movement, sample in hand appears to be in a lot of pain, related to his left Abd [abdomen] area ...blood pressure 153/108, pulse 77, respirations 18, Temperature 97.8 ...pain scale 10/10 hemoccult results negative...results reported to...nurse practitioner. Nurse Practitioner seen [sic] at this time. Please see medical notes...still in clinic at this time ...give Norco 5/325 now..." No nurse practitioner assessment note was found for the above date for Staff #82.

The referral to Parkland Emergency Department or out-patient clinic for [Patient #13] dated 06/28/11 timed at 10:44 AM reflected, "Acute abdominal pain since earlier this AM. Left lower quadrant with guarding, positive for nausea, negative emesis rule out cholecystitis..." No assessment notes from the Nurse Practitioner Staff #82 were found in the medical record.

The Hospital's "Discharge Summary Notes" electronically signed on 08/14/11 at 12:13 PM included that Patient #13, age 29, "...presented to the ED on 06/28/11 with a classic appendicitis exam as well as CT evidence...taken to the OR [operating room] on 06/28/11..."

The operative report dated 06/28/11 reflected, "Emergency General Surgery...specimen appendix...findings...early acute appendicitis..."

Staff #80 was interviewed on 09/06/11 at 1:45 PM . Staff #80 was asked to review Patient #13's medical record. Staff #80 verified the patient should have been seen right away on 06/27/11 by the physician or nurse practitioner. Staff #80 stated he could find no reassessment or nurse practitioner notes.

Staff #81 was interviewed on 09/07/11 at 11:00 AM. Staff #81 was asked to review Patient #13's medical record entries for 06/27/11 and 06/28/11. Staff #81 stated the patient should have been seen by a physician or nurse practitioner. Staff #81 stated the documentation and assessment should have been better. Staff #81 provided a copy of the jail health orientation manual dated 08/11/09 at 1:30 PM. Staff #81 stated the nursing staff receive a copy and are expected to follow it. Staff #81 stated the manual covers everything the nurse needs to know including documentation expectations. Staff #81 stated that the jail either sends the inmate to the Hospital ED or calls 911 in an emergency.

Staff #82 was interviewed on 09/07/11 at 11:45 AM . Staff #82 was asked to review Patient #13's medical record. Staff #82 stated she saw the patient on 06/28/11 about 06:10 AM for complaint of abdominal pain. Staff #82 stated she gave the patient pain medication, reassessed him and then sent him to the hospital. Staff #82 stated she wrote a note. The surveyor asked her to provide the note. Staff #82 stated she could not find the note in the computer and could not provide requested assessment documentation she had completed for Patient #13.

Staff #84 was interviewed on 09/08/11 at 9:30 AM . Staff #84 stated when she arrived on duty the morning of 06/28/11 at 06:00 AM, the night nurse was speaking with the nurse practitioner and reported Patient #13 was in pain and needed to be seen. Staff #84 stated the Nurse Practitioner saw the patient and gave him some pain medication and monitored him for several more hours. Staff #84 stated she monitored the patient but did not make any further entries in the medical record.

Staff #83 was interviewed on 09/08/11 at 10:05 AM . Staff #83 was asked to review Patient #13's nursing note entries. Staff #83 stated Patient #13 was complaining of abdominal pain. Staff #83 stated he reported it to the Nurse Practitioner. Staff #83 stated the Nurse Practitioner gave orders but did not see the patient. Staff #83 stated he reassessed the patient later in the night but did not document his reassessment.

Staff #85 was interviewed on 09/08/11 at 12:40 PM. Staff #85 was asked to review Patient #13's medical record. Staff #85 stated the nurse notified her according to the nursing documentation and she gave orders which were listed on the nursing documentation. Staff #85 stated she did not remember the patient and did not see the patient. Staff #85 acknowledged no medical notes were initiated by her.

The hospital Jail Health Orientation manual dated 08/11/09 showed, "Document location and reason for assessment...document problems identified, document procedure, treatment and medications administered, document accurate and timely reporting...symptoms, characteristic and course, history of symptoms, onset, location, aggravating factors and relieving factors..."

The policy entitled, "Pain Management " with a revision date of 03/08 reflected, "If patient's pain score is not at an acceptable level or greater than 4, the nurse should assess and intervene to improve pain control. A reassessment should be carried out in a timely manner. All assessments, reassessments, and interventions must be documented... "

The policy entitled, "Hospital and Specialty Care...Jail Health" with a revision date of 09/11 reflected, "...County Jail Health does provide limited specialty services on site at the Jail, including but not limited to: Dialysis, OB/GYN including screening ultrasound, Dental, Nephrology Clinic, and HIV services...County Jail Health patients in need of specialty care or hospitalization will receive care at...hospital... "

The Nurse Practitioner Job description with a revision date of 09/02/10 reflected, "Collaborates with other members of the healthcare team including physician's, nurses...social services and community providers with regard to educating patients...maintains accurate and timely records of patient information to ensure coordinated service delivery and continuity of care..."

The Licensed Vocational Nurse [LVN] Job Description with a revision date of 06/02/10 reflected, "Responsible for providing total nursing care for assigned patients, under the guidance of a Registered Nurse, in order to ensure quality care...screens and prioritizes patients with regard to medical problems, ensuring that appropriate treatment is delivered in a timely manner per physician orders and established policies and procedures...completes appropriate written and computer documentation according to established procedures and guidelines..."

The Medical Director Jail Health Services Job Description with a revision date of 02/12/10 reflected, "Provides medical expertise, administrative, medical and nursing support as well as professional liaison functions which enhance quality, timely and safe patient centered, patient values services, best practice and compliance...responsible for the direction and coordination of all medical and clinical services for Jail Physical Health Services...acts as a consultant for mid-level practitioners and nurses. Provides and evaluates medical education and training for residents, students, and mid-level staff..."

The Director of Nursing Job Description with a revision date of 04/12/11 reflected, "Responsible for the overall direction and daily operational activities of designated department...coordinating clinical services...to ensure high quality, patient-centered services...evaluates patient care and monitors all aspects of service delivery..."