HospitalInspections.org

Based on record review and interview, the facility failed to ensure the patient or patient's legal guardian had the right to be informed about the patient's health status in order to have involvement with treatment and care planning decisions, in 1 of a total sample of 10 patients (Patient #1).

Findings

Facility policy "Disclosure of Unanticipated Outcomes" a System Administrative Policy of SSM Health last review date of 10/31/2017 was reviewed on 8/13/2019. The policy, in part states under Process III Notification , "A. The entity Risk Manager/Coordinator and System Risk Services must be notified within 24 hours of the event, so they can provide support and guidance to the care-giving team during this difficult time." B. Members of the care-giving team should jointly meet as soon as possible to discuss the known facts of the event; prepare to advise the patient and when appropriate the family, in a timely manner." Review of the facility Grievance file on Patient #1's incident revealed that Patient #1 received the wrong x-ray on 4/3/2019. The facility Grievance investigation file reveals that this incident was not reported to the facility Risk Manager until 4/8/2019 at which time they initiated their investigation. Interview with Risk Manager A on 8/13/2019 confirmed this timeline.

Interview with Risk Manager A on 8/13/2019 at 11:30AM confirmed that this event met the requirements for reporting and should have been entered into the event reporting system by Rad Tech (Radiation Technician) D at the time it occurred. Review of Rad Tech D's personnel file on 8/13/2019 revealed that the facility policy entitled "Corrective Action" was followed and a written warning and action plan was present in Rad Tech D's file. Risk Manager A stated. "as soon as I was made aware of the incident I set up a meeting with the complainant." This meeting was documented in the Grievance file as taken place on 4/10/2019.