HospitalInspections.org

Surveyor: Penniall, Barbara J.
Based on record review (RR) and interviews, the facility did not follow its grievance policy/procedures. The patient should have reasonable expectations of care and services and the facility should address those in a timely reasonable manner. One patient (P)1/representative concerns of a sample size of three were not identified as a grievance. There was lack of documentation the concerns were thoroughly investigated for resolution and response to the complainant was not communicated in a timely manner.

Findings include:

1) Review of the facility policy #H-263 titled "Patient Complaint/Grievance Process" revised date 09/2021 included:
"Purpose: To provide an effective organizational process to identify and address concerns, complaints, and grievances of patients, their families, and visitors in compliance with Center of Medicare and Medicaid Services. ...To establish a method to identify and address patient concerns at the point of care and provide patients, their families and visitors with an identified, organizational liaison to serve as a primary contact for their point of care concerns, complaints and grievances. ..."

Definitions: "Complaint: ...any communicated concern by a patient or patients family member or visitor on behalf of a patient receiving care from any Wahiawa General Hospital (WGH) department. A complaint is a concern that is resolved at the "point of care." ...The complaint is usually resolved at the time of the communication of the concern or within a reasonable short time frame. Resolution of the complaint should occur within twenty-four (24) hours from the time the complaint arose and before discharge. ... A complaint can rise to the level of a grievance if it is not resolved at the point of care or within a reasonably short time frame, or if the patient requests the complaint be addressed as a grievance. ..."
"Grievance: A formal written or verbal complaint that cannot be resolved at the point of care. ...A grievance is directed to the hospital for resolution of the issue by the patient or on the patient's behalf."
"Patient Liaison: ...designated staff member who interacts directly with patients, their families and visitors while on patient care rounds in the facility or through verbal or written communication to address the patient point of care concerns, complaints and grievances and works collaboratively with the Patient Relations Committee and... other departments and staff to resolve complaints and grievances. The Patient Liaison chairs the Patient Relations Committee (PRC) and reports on the patient complaints, point of care matters and grievances to the PRC on a weekly basis and to the WGH Board of Directors (BOD) on a monthly basis..."

"Timelines for Response: Patients will be given estimated resolution time frames and notified if additional time is needed to investigate and respond to the complaint/grievance. WGH will use its best efforts to respond to patient concerns within the following timeframes. ...b Grievances: After a patient has submitted a grievance the Patient Liaison will contact the patient via phone or letter within a reasonable time frame (usually within twenty four (24) hrs., or one (1) business day to: obtain information from the patient concerning the grievance; and to inform the patient of the relevant time frames for investigation and resolution and next steps in the grievance process. In general, and when possible, grievance investigations should be completed within seven (7) days from the initiation of the grievance. The Patient Liaison will send the patient a letter concerning the grievance and outcome of the investigation seven (7) days from the initiation of the grievance. If the investigation cannot be completed within 7 days, the patient will be informed that the investigation is still in progress and that an updated written response will be provided within 7 days."

"A grievance is resolved when the patient is satisfied with the action taken by WGH. Where appropriate and reasonable action has been taken by WGH and the patient remains unsatisfied with the outcome the grievance will be closed unless new action is required."

" The WGH staff, Medical Providers, departments, ...involved, directly or indirectly in the patient care that gave rise to the patient complaint, point of care concern or grievance will participate and collaborate in the investigation, identification of causative or related factors, development and implementation of an appropriate plan of action and resolution of the concern as requested by the Patient Liaison, the PRC, WGH administration or as otherwise required."

2) Review of the complaint/grievance log from March 1, 2022, through April 18th included a "point of care/complaints" for P1, which was documented a follow up communication letter was not applicable. Further investigation revealed the extent of the issues identified by P1's daughter met the criteria for a grievance. There was lack of documentation of a thorough investigation, timely response to the complainant and issues that still had not been resolved.

3) The facilities scope of services does not include surgical services, or obstetrical/gynecological services. In addition, they do not have a cardiac catheter lab or magnetic resonance imaging (MRI). Patients requiring emergency interventions would be transferred to another acute care facility for these services. If the treatment is non emergent, special arrangements would have to be made.

4) P1 was a 92 year old female with a history that included congestive heart failure (CHF), hypertension and dementia. P1 was unable to care for herself or at home with family and resided at a long term care facility (LTC)1 for the past three years. She was hospitalized for acute care from 01/13/2022 to 01/26/2022 for acute hypoxic respiratory failure secondary to COVID-19 and CHF. When she no longer required acute care, P1 was transferred to WGH subacute COVID 19 unit on 01/26/2022 for continued care and isolation which finished on 01/31/2022. P1 was to return back to LTC1, but they refused to take her back. Although P1 no longer meets acute care criteria, she remains at WGH and is on the "wait list" for placement at another LTC facility. At the time of survey, P1 had been at the hospital for 100 days. On 03/08/2022 P1 had vaginal bleeding and subsequently had a transvaginal ultrasound.

RR of P1's Physician, Social Service (SS), Nursing Notes, Radiology report and internal communications included the following:
03/08/22 08:11 AM, Physician (MD)1 (day hospitalist) Progress Note: "Patient with notable vaginal bleeding overnight. ...Has not had a prior history of vaginal bleeding, hematuria (blood in urine) or cancer. Otherwise still awaiting placement... Large mass concerning for endometrial/uterine carcinoma. Does not appear to be simply related to endometrial hyperplasia. Discussed results with patient, who would like her daughter and son informed. Given her advanced age, comorbidities, likely will be just managed at the current time. Otherwise, can follow-up with obstetrical/gynecologist (OB/GYN) as an outpatient and for further imaging. However, menorrhagia (heavy or prolonged bleeding) may continue without surgical intervention or possible a dilation and curettage. We will follow-up CBC (complete blood count). no transfusion currently required."

03/08/22 09:00 AM, pelvic ultrasound (transvaginal) radiology report: "The uterus is enlarged. The uterus measures 10.9 x 9 x 9.7 cm (centimeters) in size. There is a irregular 6.4 x 6.9 x 6.7 cm mass within the central portion of the uterus. it isn't possible to determine the exact location of the mass originating in the endometrium rather than representing merely a fibroid. ...Recommend MRI of the pelvis."

03/09/2022 Date of Service (DOS) MD2 created at 3/10/2022 08:21 AM: "No further menorrhagia, follow up with outpatient OB/GYN, but unlikely to proceed with procedure, surgery. Will discuss plan of care with patient's daughter. ..."

03/13/2022 DOS MD2 at 10:10 PM. "Patient with one episode of vaginal bleeding... This could either be a fibroid or malignancy. Patient will need dilatation with curettage to determine the etiology of this mass...Case was discussed with the daughter via telephone call per her request... She request to proceed with gynecology referral for evaluation of uterine mass. I stated to her that there is no gynecologist available at the facility for evaluation. She is now requesting that the patient be transferred to the gynecologist office for evaluation and then back. I stated to her that does not possibly [sic] because the COVID-19 pandemic and that patient is still currently hospitalized... She was not satisfied with that answer and demanded the patient be transferred for gynecological evaluation she felt that it was emergent condition which I stated it was not. I stated to her the evaluation can be done on an outpatient basis after discharge. We will have her follow-up with the case manager and hospitalist team during the day."

On 03/16/2022 the Patient Liaison (PL) received a phone call from P1's daughter and spoke over an hour regarding concerns. The PL summarized her concerns in an email to the Chief Nursing Officer (CNO). Nursing Unit Manager (UM), and Utilization Review/Case Management Supervisor (URS) that day. The concerns included, but not limited to:
Daughter called the Social Worker (SW) and was told that they would provide her with a list of places (LTC facilities) that she could call to arrange placement for her mother. The SW said she would also call and see if there were any beds available. Within 24 hours the daughter received a call back that there were no beds available.
Daughter was given two choices, to take her mother home or "they will send her to the streets in her wheelchair (WC)."
Daughter said "someone" called her and said she needed to either pick up your mom or we can put her on the streets. A comment was made "This would not be the first time we have done this. ..."
Daughter "felt threatened by what was stated to her."
Daughter said she was face timing with her mother when she was told that her mother was bleeding. The nurse was in the room and asked if the Doctor had spoken to her, but he had not. The Nurse said the Doctor would be calling her.
Daughter spoke with MD2 who said her mother was bleeding vaginally, but "did not need a transfusion."
Daughter said the comment about not needing a blood transfusion made her think that her mother was bleeding profusely. MD2 told her they would be running some tests that would take a few days, but he would let her know the results. She waited for several days, longer than three days and no one called her back, so she called and spoke to MD1, who said since MD2 was her mother's doctor, he would call her back.
MD2 told her mother has a large tumor inside her uterus the size of an orange but does not know if it is a fibroid or cancer. "This would need to be followed up on."
Daughter asked if they could send her (P1) to another hospital to have more tests done, and MD2 told her that he could not, "it was out of his hands that he can't send her because of COVID and if he did he could get fired from his job. MD2 told her she that was up to the Board of Directors (BOD) to decide whether they wanted to change the policy. She said she wanted to talk to someone on the BOD.
About an hour later, she received a call from a woman who did not want to mention her name. The woman stated to her: You wanted to me to call you, you wanted to talk to me about your mom? ...She asked if the caller was part of the BOD, and she did not answer. She was confused who the woman was.
Daughter spoke to her mother on 03/16/2022 and her mother was upset that someone told her that they were going to move her to the streets. She is very concerned that someone said this to her mother.
Daughter would like answers on why they can't send her to another hospital for treatment, and if the plan was to send her mother to the streets.

03/18/2022 DOS MD2 at 05:48 PM: "Had discussion with patient's daughter over the phone during Interdisciplinary (IDT) meeting. Discussed the patient's clinical situation again and lack of placement currently available. Patient is clinically stable, does not require hospital level of care, but does require full assistance of activities of daily living. In regard to the vaginal bleeding, there is no reoccurrence so far, but patient does have uterine mass and workup is indicated in the outpatient setting if the patient is desiring, of which she is. Daughter had many questions regarding why it is so difficult to find placement for patient even though she has state insurance, why the patient cannot go to see outpatient specialists, and other logistical questions. The questions (which I could not adequately answer) were routed to case management and also hospital administration who will discuss directly with the family. ..."

03/22/2022 SS note: MD1 called daughter (she). She said SW is threatening to send pt. to the street. Clarified it was UM vs. SW.
03/25 2022 SS note: "Exhausted all island facilities and now referring to LTC facilities on Big Island."
03/25/2022 DOS MD2 at 12:55 PM: "... Will need to be placed in a facility to pursue outpatient gynecology and further imaging. ..."
04/01/2022 DOS MD2 at 12:06 PM: "... No accepting facilities on island, looking at outer island options. ..."
04/06/2022 DOS MD2 at 06:02 PM: " ... Daughter did not call back the DON (CNO) even though she has the number. ..."
04/10/2022 DOS MD2 at 03:58 PM: "... Discussed her eye situation and how she still wants to get her cataract surgery."
04/15/2022 DOS MD3 at 08:13 AM: "Intermediate Care Facility (ICF) status. Still awaiting long-term placement..."

5) On 04/19/22 at approximately 11:00 AM, during an interview with the PL, she explained the complaint/grievance process. PL verbalized the definitions as in the policy. She said when she gets a complaint or concern, she will email it to the appropriate leadership for follow up. When inquired why P1's daughters concerns were considered a complaint rather than a grievance, PL said she received a reply that it was "a difficult discharge," so she knew they were actively working on the discharge placement, and she figured it would be resolved. Inquired if she had received any other feedback about the other issues regarding the OB/GYN evaluation or the perception P1's daughter had that her mother would be discharged to the streets. PL said she had not.

PL said she did not have any other contact with P1's daughter until just recently and just got off the phone with her. She went on to say she contacted the daughter because there was some mail that came to her mother she needed to pick up. When they spoke, the daughter shared several concerns, some of which had been verbalized on the call 03/16/2022. The daughter was still concerned about "discharge to the streets." PL said she gave her reassurance that would not happen. She said the daughter and mother wanted her cataracts to be taken care of, which had been scheduled in December 2021 and canceled. She also said she had been working to get an appointment with ophthalmologist, and explained in the past, Quest paid for the transportation to and from appointments (apt). The daughter verbalized she did want to pursue the OB/GYN apt. after the eyes.

PL said she told the daughter she would bring it up to the discharge planning team and ask the CNO to help with coordination, as her mother's current situation (on an acute floor, but not an acute pt. and not in a LTC facility) would require coordination and approval for the outpatient appointments. She said the daughter was told in the past if her mother leaves the facility, she would be considered discharged and would not be able to return. The PL said she explained when an acute care pt. is in the hospital, they don't leave for outpatient apt., but that her mother was in a different predicament that would require permission for her to leave for appointments. This would be coordinated by our Case Management/discharge planning team.

On 04/20/2022 during an interview with the CNO, she said they do send patients out for procedures not available at the facility if an MD writes an order. She confirmed the MRI could have been done if the MD wrote an order for it. She went on to say the SW had just arranged an appointment for an OB/GYN evaluation on May 11th. The CNO said she had spoken to the UM about the conversation she had with the daughter, about discharge and that the UM felt it was resolved at the end of the conversation and what she said had been misinterpreted. The CNO confirmed she has not personally spoken with the daughter. She said she tried to reach her after the IDT meeting when she requested to speak with someone from administration, but did not get a return call.

6) On 04/20/20222 the PL contacted P1's daughter to inform her about the OB/GYN apt. At that time, she informed her there would be a designated "point of contact" person at WGH to help facilitate communication.

7) Review of policy H-272 titled "Discharge Planning" last reviewed 12/202 included the following:
Specific responsibilities for disciplines: "2. Nurse h. Plan for interdisciplinary continuity of care meetings or care conferences for the more complex patients to determine what is to be done, by whom, when and how. ...4. Utilization Review/Case Management. individual assignment of case manager to assist in coordination of discharge planning if substantial needs are identified. ...d. Develop an individualized care plan in collaboration with family and interdisciplinary team to ensure continuity of care in collaboration with family and interdisciplinary team to ensure continuity of care after discharge.

8) When the facility became aware P1 had several barriers for placement in a new LTC facility and there was no confirmed discharge date within a reasonable amount of time, P1's treatment goals and care planning should have been reevaluated and plans developed based on medical needs and patient /family request to ensure continuum of care. It would not be acceptable to continue to wait for a discharge from the facility. The recommendation that P1 have an MRI was first made on 03/08/2022.



Surveyor: Penniall, Barbara J.
Based on record review (RR) and interviews, the facility did not follow its grievance policy/procedures. The patient should have reasonable expectations of care and services and the facility should address those in a timely reasonable manner. One patient (P)1/representative concerns of a sample size of three were not identified as a grievance. There was lack of documentation the concerns were thoroughly investigated for resolution and response to the complainant was not communicated in a timely manner.

Findings include:

1) Review of the facility policy #H-263 titled "Patient Complaint/Grievance Process" revised date 09/2021 included:
"Purpose: To provide an effective organizational process to identify and address concerns, complaints, and grievances of patients, their families, and visitors in compliance with Center of Medicare and Medicaid Services. ...To establish a method to identify and address patient concerns at the point of care and provide patients, their families and visitors with an identified, organizational liaison to serve as a primary contact for their point of care concerns, complaints and grievances. ..."

Definitions: "Complaint: ...any communicated concern by a patient or patients family member or visitor on behalf of a patient receiving care from any Wahiawa General Hospital (WGH) department. A complaint is a concern that is resolved at the "point of care." ...The complaint is usually resolved at the time of the communication of the concern or within a reasonable short time frame. Resolution of the complaint should occur within twenty-four (24) hours from the time the complaint arose and before discharge. ... A complaint can rise to the level of a grievance if it is not resolved at the point of care or within a reasonably short time frame, or if the patient requests the complaint be addressed as a grievance. ..."
"Grievance: A formal written or verbal complaint that cannot be resolved at the point of care. ...A grievance is directed to the hospital for resolution of the issue by the patient or on the patient's behalf."
"Patient Liaison: ...designated staff member who interacts directly with patients, their families and visitors while on patient care rounds in the facility or through verbal or written communication to address the patient point of care concerns, complaints and grievances and works collaboratively with the Patient Relations Committee and... other departments and staff to resolve complaints and grievances. The Patient Liaison chairs the Patient Relations Committee (PRC) and reports on the patient complaints, point of care matters and grievances to the PRC on a weekly basis and to the WGH Board of Directors (BOD) on a monthly basis..."

"Timelines for Response: Patients will be given estimated resolution time frames and notified if additional time is needed to investigate and respond to the complaint/grievance. WGH will use its best efforts to respond to patient concerns within the following timeframes. ...b Grievances: After a patient has submitted a grievance the Patient Liaison will contact the patient via phone or letter within a reasonable time frame (usually within twenty four (24) hrs., or one (1) business day to: obtain information from the patient concerning the grievance; and to inform the patient of the relevant time frames for investigation and resolution and next steps in the grievance process. In general, and when possible, grievance investigations should be completed within seven (7) days from the initiation of the grievance. The Patient Liaison will send the patient a letter concerning the grievance and outcome of the investigation seven (7) days from the initiation of the grievance. If the investigation cannot be completed within 7 days, the patient will be informed that the investigation is still in progress and that an updated written response will be provided within 7 days."

"A grievance is resolved when the patient is satisfied with the action taken by WGH. Where appropriate and reasonable action has been taken by WGH and the patient remains unsatisfied with the outcome the grievance will be closed unless new action is required."

" The WGH staff, Medical Providers, departments, ...involved, directly or indirectly in the patient care that gave rise to the patient complaint, point of care concern or grievance will participate and collaborate in the investigation, identification of causative or related factors, development and implementation of an appropriate plan of action and resolution of the concern as requested by the Patient Liaison, the PRC, WGH administration or as otherwise required."

2) Review of the complaint/grievance log from March 1, 2022, through April 18th included a "point of care/complaints" for P1, which was documented a follow up communication letter was not applicable. Further investigation revealed the extent of the issues identified by P1's daughter met the criteria for a grievance. There was lack of documentation of a thorough investigation, timely response to the complainant and issues that still had not been resolved.

3) The facilities scope of services does not include surgical services, or obstetrical/gynecological services. In addition, they do not have a cardiac catheter lab or magnetic resonance imaging (MRI). Patients requiring emergency interventions would be transferred to another acute care facility for these services. If the treatment is non emergent, special arrangements would have to be made.

4) P1 was a 92 year old female with a history that included congestive heart failure (CHF), hypertension and dementia. P1 was unable to care for herself or at home with family and resided at a long term care facility (LTC)1 for the past three years. She was hospitalized for acute care from 01/13/2022 to 01/26/2022 for acute hypoxic respiratory failure secondary to COVID-19 and CHF. When she no longer required acute care, P1 was transferred to WGH subacute COVID 19 unit on 01/26/2022 for continued care and isolation which finished on 01/31/2022. P1 was to return back to LTC1, but they refused to take her back. Although P1 no longer meets acute care criteria, she remains at WGH and is on the "wait list" for placement at another LTC facility. At the time of survey, P1 had been at the hospital for 100 days. On 03/08/2022 P1 had vaginal bleeding and subsequently had a transvaginal ultrasound.

RR of P1's Physician, Social Service (SS), Nursing Notes, Radiology report and internal communications included the following:
03/08/22 08:11 AM, Physician (MD)1 (day hospitalist) Progress Note: "Patient with notable vaginal bleeding overnight. ...Has not had a prior history of vaginal bleeding, hematuria (blood in urine) or cancer. Otherwise still awaiting placement... Large mass concerning for endometrial/uterine carcinoma. Does not appear to be simply related to endometrial hyperplasia. Discussed results with patient, who would like her daughter and son informed. Given her advanced age, comorbidities, likely will be just managed at the current time. Otherwise, can follow-up with obstetrical/gynecologist (OB/GYN) as an outpatient and for further imaging. However, menorrhagia (heavy or prolonged bleeding) may continue without surgical intervention or possible a dilation and curettage. We will follow-up CBC (complete blood count). no transfusion currently required."

03/08/22 09:00 AM, pelvic ultrasound (transvaginal) radiology report: "The uterus is enlarged. The uterus measures 10.9 x 9 x 9.7 cm (centimeters) in size. There is a irregular 6.4 x 6.9 x 6.7 cm mass within the central portion of the uterus. it isn't possible to determine the exact location of the mass originating in the endometrium rather than representing merely a fibroid. ...Recommend MRI of the pelvis."

03/09/2022 Date of Service (DOS) MD2 created at 3/10/2022 08:21 AM: "No further menorrhagia, follow up with outpatient OB/GYN, but unlikely to proceed with procedure, surgery. Will discuss plan of care with patient's daughter. ..."

03/13/2022 DOS MD2 at 10:10 PM. "Patient with one episode of vaginal bleeding... This could either be a fibroid or malignancy. Patient will need dilatation with curettage to determine the etiology of this mass...Case was discussed with the daughter via telephone call per her request... She request to proceed with gynecology referral for evaluation of uterine mass. I stated to her that there is no gynecologist available at the facility for evaluation. She is now requesting that the patient be transferred to the gynecologist office for evaluation and then back. I stated to her that does not possibly [sic] because the COVID-19 pandemic and that patient is still currently hospitalized... She was not satisfied with that answer and demanded the patient be transferred for gynecological evaluation she felt that it was emergent condition which I stated it was not. I stated to her the evaluation can be done on an outpatient basis after discharge. We will have her follow-up with the case manager and hospitalist team during the day."

On 03/16/2022 the Patient Liaison (PL) received a phone call from P1's daughter and spoke over an hour regarding concerns. The PL summarized her concerns in an email to the Chief Nursing Officer (CNO). Nursing Unit Manager (UM), and Utilization Review/Case Management Supervisor (URS) that day. The concerns included, but not limited to:
Daughter called the Social Worker (SW) and was told that they would provide her with a list of places (LTC facilities) that she could call to arrange placement for her mother. The SW said she would also call and see if there were any beds available. Within 24 hours the daughter received a call back that there were no beds available.
Daughter was given two choices, to take her mother home or "they will send her to the streets in her wheelchair (WC)."
Daughter said "someone" called her and said she needed to either pick up your mom or we can put her on the streets. A comment was made "This would not be the first time we have done this. ..."
Daughter "felt threatened by what was stated to her."
Daughter said she was face timing with her mother when she was told that her mother was bleeding. The nurse was in the room and asked if the Doctor had spoken to her, but he had not. The Nurse said the Doctor would be calling her.
Daughter spoke with MD2 who said her mother was bleeding vaginally, but "did not need a transfusion."
Daughter said the comment about not needing a blood transfusion made her think that her mother was bleeding profusely. MD2 told her they would be running some tests that would take a few days, but he would let her know the results. She waited for several days, longer than three days and no one called her back, so she called and spoke to MD1, who said since MD2 was her mother's doctor, he would call her back.
MD2 told her mother has a large tumor inside her uterus the size of an orange but does not know if it is a fibroid or cancer. "This would need to be followed up on."
Daughter asked if they could send her (P1) to another hospital to have more tests done, and MD2 told her that he could not, "it was out of his hands that he can't send her because of COVID and if he did he could get fired from his job. MD2 told her she that was up to the Board of Directors (BOD) to decide whether they wanted to change the policy. She said she wanted to talk to someone on the BOD.
About an hour later, she received a call from a woman who did not want to mention her name. The woman stated to her: You wanted to me to call you, you wanted to talk to me about your mom? ...She asked if the caller was part of the BOD, and she did not answer. She was confused who the woman was.
Daughter spoke to her mother on 03/16/2022 and her mother was upset that someone told her that they were going to move her to the streets. She is very concerned that someone said this to her mother.
Daughter would like answers on why they can't send her to another hospital for treatment, and if the plan was to send her mother to the streets.

Based on record review (RR) and interviews, the facility did not honor one patient (P)1's right to involve her family in proactive ongoing care planning. Specifically, P1 verbalized her wishes for specific treatment (MRI) and requested notification of her daughter and son. In addition, the facility made referrals to long term care (LTC) facilities on other islands prior to discussing with the patient and family. The facility lacked documentation of timely, ongoing active involvement in P1's care planning.

Findings include:

1) P1 was a 92 year old female with a medical history that included congestive heart failure (CHF), hypertension and dementia, recently hospitalized from 01/13/2022 to 01/26/2022 for acute hypoxic respiratory failure secondary to COVID-19 and CHF admitted to WGH subacute COVID-19 unit on 01/26/2022 and finishing isolation 01/31/2022. P1 was supposed to return to the long term care facility (LTC)1 where she resided for over the past three years prior to being hospitalized, but LTC1 would not accept her back. Although P1 no longer met acute care criteria, she remained at WGH and was on the "wait list" for placement at another facility. P1 can make her own decisions, was a full code and her daughter is the designated Power of Attorney. On 03/08/2022 P1 had vaginal bleeding and a transvaginal ultrasound was performed.

2) P1's daughter was not notified of her mother's vaginal bleeding or that she was going to have an intravaginal ultrasound that was performed the morning of 03/08/2022. The daughter became aware of the bleeding and ultrasound that revealed a uterine mass when her mother called her inquiring if the doctor had contacted her. The documentation in the medical record revealed the daughter spoke with the physician at her request five days after it was determined P1 had a mass.

RR of P1's Physician (MD) note, and reports revealed the following:
03/08/22 08:11 AM, MD1 (day hospitalist) Progress Note: "Patient (P)1 with notable vaginal bleeding overnight. ...Has not had a prior history of vaginal bleeding, hematuria (blood in urine) or cancer. Otherwise still awaiting placement... Large mass concerning for endometrial/uterine carcinoma. Does not appear to be simply related to endometrial hyperplasia. Discussed results with patient, who would like her daughter and son informed. Given her advanced age, comorbidities, likely will be just managed at the current time. Otherwise, can follow-up with obstetrical/gynecologist (OB/GYN) as an outpatient and for further imaging. However, menorrhagia (heavy or prolonged bleeding) may continue without surgical intervention or possible a dilation and curettage. We will follow-up CBC (complete blood count), no transfusion currently required.
03/08/22 09:00 AM, pelvic ultrasound (transvaginal) radiology report: "The uterus is enlarged. The uterus measures 10.9 x 9 x 9.7 cm (centimeters) in size. There is a irregular 6.4 x 6.9 x 6.7 cm mass within the central portion of the uterus. it isn't possible to determine the exact location of the mass originating in the endometrium rather than representing merely a fibroid. ...Recommend MRI of the pelvis."

03/09/2022 Date of Service (DOS) MD2 (night hospitalist) created at 3/10/2022 08:21 AM: "No further menorrhagia, follow up with outpatient OB/GYN, but unlikely to proceed with procedure, surgery. Will discuss plan of care with patient's daughter. ..."

03/13/2022 DOS MD2 at 10:10 PM. "Patient with one episode of vaginal bleeding... This could either be a fibroid or malignancy. Patient will need dilatation with curettage to determine the etiology of this mass...Case was discussed with the daughter via telephone call per her request... She requests to proceed with gynecology referral for evaluation of uterine mass. I stated to her that there is no gynecologist available at the facility for evaluation. She is now requesting that the patient be transferred to the gynecologist office for evaluation and then back. I stated to her that does not possibly [sic] because the COVID-19 pandemic and that patient is still currently hospitalized... She was not satisfied with that answer and demanded the patient be transferred for gynecological evaluation s she felt that it was emergent condition which I stated it was not. I stated to her the evaluation can be done on an outpatient basis after discharge. We will have her follow-up with the case manager and hospitalist team during the day. ..."

3) P1 was waiting for acceptance to a LTC facility and considered to be on the "wait list." There was documented ongoing efforts to place her in a LTC facility, but all facilities on island of Oahu would not accept her.

RR of Physician and Social Services (SS) notes revealed the following:
03/25/2022 SS note: "Exhausted all island facilities and now referring to LTC facilities on Big Island."
04/01/2022 DOS MD4 at 12:06 PM: "...has been noncompliant with care. ...No accepting facilities on island, looking at outer island options. ..."

On 04/20/2022 at approximately 11:00 AM, during an interview with the Utilization Review/Case Manager (CM), she said she was fairly new to the position and had been told to first refer to all facilities on Oahu, so they sent referrals to all the LTC facilities on Oahu, and when no one accepted, they "took the next step and tried other islands." The CM said "I can understand her frustration since then there hasn't been a lot of updates and understand some improvements in communication are needed."

On 04/20/2022 at 11:45 AM, during an interview with the Case Management Utilization Review Supervisor (URS), she said she received "a call from P1's daughter who was mad she got called from Hilo." The URS went on to say when she was on the mainland, the policy was to look at all resources in the state and then go outside the state. The URS agreed the patient and family should have ongoing communication and proactive involvement and agreed if referral is made outside the geographic area, the patient and family must agree. Inquired if the facility have care conferences, and the URS said "not really for acute (patients at hospital acute status). We discuss the status in rounds and make sure physical and occupational therapy follow up with the family.

Discharge planning is considered part of care planning and it is the patients/representatives right to be involved in proactive ongoing planning. Neither P1 nor her daughter were aware referrals were being made to outer island facilities for LTC placement. P1's daughter became aware when she started to receive phone calls from outer island LTC facilities.

4) Review of the facility policy titled "Patient Rights and Responsibilities" review date 11/2021 purpose statement read: "The Hospital and Medical Staff of Wahiawa General Hospital consider patients as partners in their hospital care. When they are informed, participate in treatment decisions, and communicate openly with their doctor and other health professional, they help make their care as effective as possible.

The policy included" Right to Treatment: You have the right to access care as long as it is within the hospitals capacity. You have the right to know if the hospital is not able to provide care for you in the appropriate setting, and for other options of care."

"Information about Treatment: ...You have the right to include or exclude any or all your family members from participating in your care."

"Participation in Care Planning: You have the right to make informed decisions regarding your care and health status. You have the right to be involved in care planning and treatment. You have the right to discuss risks, benefits, and alternatives in terms you can understand, except in emergency situations. ...You have the right to be involved with post discharge decisions."