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Based on record review, interview with clinical and administrative staff, and review of policy and procedure, the hospital failed to ensure the protection and promotion of patient rights for patients related to discharge option, alternative physicians, or a second opinion, grievances being responded to timely, and the right privacy of personal data. These failures demonstrates systemic noncompliance with the condition of patient's rights.

1. The hospital failed to ensure patient rights for discharge options for 1 patient. Patient #2 was being discharged despite the daughter's request for a different physician. This resulted in a delay of services. (Refer to A117 for details.)

2. The hospital failed to ensure grievances were referred and processed in a timely manner for 3 patients. Patient #2's grievance had no letter of resolution. Patient #15's grievance had a letter of resolution sent 29 days after initiation. Patient #16's complaint had a letter of resolution sent 26 days after initiation. (Refer to A120 for details.)

3. The hospital failed to ensure a rapid response was responded to timely for 1 patient. The hospital also failed to provide a new doctor in a timely manner in response to the request from Patient #2's representative. (Refer to A131 for details.)

4. The hospital failed to protect patients' rights for personal privacy on 3 (2nd, 3rd, 4th) of 4 floors of the hospital. Potentially individually identifiable health information was posted to computer boards on multiple units. (Refer to A143 for details.)

Based on a record review and staff interview, the hospital failed to ensure patient rights for discharge options for 1 (Patient #2) of 11 patient records reviewed. Patient #2 was being discharged despite the daughter's request for a different physician. This resulted in a delay of services.

The findings included:

1. Review of clinical records revealed Patient #2 had been hospitalized 3 times within a short period of time. The first admission was 4/29/18 through 4/30/18. The patient was readmitted 5/3/18 through 5/11/18. She was readmitted 5/12/18 complaining of chest pain and stomach pains. The patient was placed on observation status. The original plan was for the patient to return to the skilled nursing facility where she had been prior to the hospital admission. On 5/14/18 a pending discharge was written by the hospital. The patient's daughter did not want the patient discharged as she felt the patient needed additional workup. No physician visited the patient on 5/14/18.

2. In an interview on 7/2/18 at 1:56 p.m., the Patient Safety Officer and Vice President of Nursing both agreed the daughter was requesting a different doctor, but the order was already written for discharge. They explained Patient #2 initially made no objection to the discharge, but when transport arrived in the late afternoon to take the patient, she refused. The Chief Nursing Officer (CNO) told the staff to keep the patient in the hospital. On 5/13/18 at 8 p.m. orders were written to keep the patient. The new doctor did not see the patient until on 5/15/18 at approximately 1:30 p.m.

3. In an interview on 7/3/18 at 10:11 a.m., Case Manager (CM) HH and the Director of Case Management indicated the patient was admitted to the hospital under observation status. They said the patient had no rights about appealing the discharge as the patient was under observation status. When questioned, both case managers admitted the patients are given the same rights statements whether they are under observation status or admitted to the hospital. CM HH indicated they were waiting for a physical therapy evaluation to enable the patient's insurance to pre-certify the patient for nursing home placement.

Based on a grievance record review and staff interview, the hospital failed to ensure grievances were referred and processed in a timely manner for 3 (Patient #2, #15, and #16) of 3 grievances reviewed. Patient #2's grievance had no letter of resolution. Patient #15's grievance had a letter of resolution sent 29 days after initiation. Patient #16's complaint had a letter of resolution sent 26 days after initiation.

The findings included:

1. The hospital policy Patient Grievance & Complaint Management P-10-003-RI (reviewed 1/17) differentiates between complaints and grievances. A complaint is an issue that can be resolved promptly by staff members who are present at the time of the complaint. A patient grievance was defined as a written or verbal complaint that cannot be resolved immediately. All written complaints are identified as grievances. This type of grievance requires investigation and/or "if it requires further actions.

Under the grievance resolution process:
"2. Upon receipt of a grievance staff will confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance..."
"5. In resolution of a grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

2. Review of Patient #2's grievance dated 5/16/18 revealed it was documented on a Follow Up Form. No letter of resolution had been sent.

3. Review of Patient #15's grievance dated 5/24/18 revealed the Chief Nursing officer contacted the complainant on 5/30/18. The resolution letter to the complainant was dated 6/22/18, 29 days after initiation.

4. Review of Patient #16's complaint dated 5/18/18 revealed a note on the grievance dated 5/21/18 asking staff to reach out to the patient. On 5/21/18, a physician was asked to contact the patient. The resolution letter to the complainant was dated 6/13/18, 26 days after initiation.

5. In an interview on 7/3/18 at 11:00 a.m., the Patient Safety Officer confirmed the missing and late dates of the resolution letters.

Based on a grievance record review and staff interview, the hospital failed to ensure grievances were resolved and resolution communicated in a timely manner for 1 (Patient #2) of 3 grievances reviewed. Patient #2's grievance had no letter of resolution.
The findings included:

1. The hospital policy Patient Grievance & Complaint Management P-10-003-RI (reviewed 1/17)differentiates between complaints and grievances. A complaint is an issue that can be resolved promptly by staff members who are present at the time of the complaint. A patient grievance was defined as a written or verbal complaint that cannot be resolved immediately. All written complaints are identified as grievances. This type of grievance requires investigation and/or "if it requires further actions.

Under the grievance resolution process:
"2. Upon receipt of a grievance staff will confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance..."
"5. In resolution of a grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

2. Review of Patient #2's grievance follow-up form dated 5/16/18 revealed no letter of resolution had been sent.

3. In an interview on 7/3/18 at 11:00 a.m., the Patient Safety Officer confirmed the missing resolution letter.

Based record review and staff interview, the hospital failed to ensure a rapid response was responded to timely for 1 (Patient #2) of 3 patients identified as having had rapid response teams. The hospital failed to provide a new doctor in a timely manner in response to the request from Patient #2's representative.

The findings included:

1. The hospital policy Patient Rights and Responsibilities P-10-008-RI (revised 5/8) was reviewed. Additional patient rights include "to get the opinion of another physician, including specialists, at the request and expense of the patient".

Record review revealed Patient #2 was readmitted to the hospital on 5/12/18. The patient had been complaining of chest pain and stomach pain. The hospitalist had discharged the patient on 5/14/18, but the patient's daughter was requesting an different doctor. On 7/2/18 at 1:56 p.m., the Patient Safety Officer and Vice President of Nursing agreed the daughter was requesting a different doctor, but the order was already written for discharge. The patient had initially made no objection to the discharge, but when transport arrived in the late afternoon, she refused the transport. The Chief Nursing Officer (CNO) told the staff to keep the patient in the hospital. At 8 p.m. on 5/14/18 an order was written to keep the patient. The new doctor did not see the patient until on 5/15/18 at approximately 1:30 p.m.

2. On 7/2/18 at about 2:00 p.m., the CNO explained on 5/15/18, the daughter arrived at the hospital and spoke with the CNO. The daughter expressed to the CNO that her mother (Patient #2) was declining. The CNO went to the patient's room at 12:30 or 1 p.m. The staff nurse indicated to the CNO that the daughter was requesting a rapid response call. The CNO told the nurse to call the rapid response team (rapid response is a means to get additional help to the patient's bedside to "improve patient outcomes").

The record showed on 5/15/18 at 2:14 p.m., the rapid response was called when staff were unable to get the patient's blood pressure. Shortly thereafter, a code was called for cardiac arrest; the patient was transferred to intensive care.

3. In the Hospital policy for Rapid Response Team (dated 10/16), under procedure, a staff member, patient family, or visitors may initiate the Rapid Response Team.

On 7/3/18 at 2:35 p.m., Staff Nurse F said has been here 8 months, had called it once. She said if the family requested she would assess the patient. If she did not think it necessary she would get the charge nurse for the 2nd opinion and they would determine if rapid response should be called.

On 7/3/18 at 2:48 p.m., Staff Nurse G confirmed the same information and would get the charge nurse to determine the need for a rapid response call.

4. On 7/5/18 at about 3:00 p.m., the Patient Safety Officer said in reviewing this case, she thought things could have done been better. The doctor who discharged Patient #2 from his care on the morning of the 14th did not see her and she was not seen by another doctor until the 15th in the afternoon when she was seen by the new doctor.

Based on observation, staff and family interview, the hospital failed to protect patients' rights for personal privacy on 3 (2nd, 3rd, 4th) of 4 floors of the hospital. Potentially individually identifiable health information was posted to computer boards on multiple units. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) offers guidance on privacy of health information.

The findings included:

"Summary of the HIPAA Privacy Rule" defines individually identifiable health information as "information, including demographic data, that relates to:
* the individual's past, present or future physical or mental health or condition,
* the provision of health care to the individual, or
* the past, present, or future payment for the provision of health care to the individual,
and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number)." (downloaded from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html)

On 7/2/18 at 10:00 a.m., observations during a tour included on the 2nd, 3rd and 4th floors, computer boards were located across from nursing stations and in patient hallways. The computer boards posted confidential information including, the first 3 letters of patient last names and their first initial, the room and bed number, date of birth, if the patient was on isolation precautions, and if the patient was a full code or had a Do Not Resuscitate (DNR) order.

On 7/5/18 at 1:25 p.m., the Patient Safety Officer said, the computer board tells you who is on fall precautions, and each symbol means something. It shows information so the staff can see; if you were a CNA (certified nursing assistant) you could look at that before you run in to the room if it was not your patient.

On 7/3/18 at 3:24 p.m., Registered Nurse (RN) Staff A acknowledged that anyone walking by here could see the computer board. It has a lot of information on it. The RN stated, "There is an icon for the camera; I think one is for respiratory medications; and the triangle is a fall risk."

In an interview on 7/3/18 at 3:30 p.m., the sister of Patient #13 stated, "I can see on the computer board who everybody's physician is, which nurse is assigned, who is the aide, what kind of diet they are on, if they are a full code or DNR." She said she could not imagine how someone might feel if they are looking at this and found something upsetting, like their family member is a DNR. She stated, "That really should not be on there."

(Photos on file)

Based on observation, policy review, and staff interview, the facility failed to develop a plan of care for 5 (Patients #3, #7, #8, #9 and #10) of 6 patients reviewed for restraint use. The care plan is a source of information for those responsible for the patient. A restrained patient's responsible nurse may not know which interventions to implement in an effort to have restraints removed.

The findings included:

On 7/2/18 at 10:00 a.m., during a tour of the facility, observed Patients #3, #7, #8, and #10 in soft, bilateral wrist restraints. Patient #9 was in a "net bed" (canopy netting restricts the patient from leaving the bed).

On 7/5/18 at 10:15 a.m., Registered Nurse Staff G said she has given training to the staff for the new computer program they are using. She said when a patient is placed in restraints and the nurse does her assessment, nursing should generate a plan of care for restraints. She attempted to retrieve restraint care plans for Patients #3, #7, #8, #9 and #10 and stated, "The care plan isn't there. I do not know why they are not initiating it. I guess I have more training to do."

Review of the hospital Patient Restraints and Seclusion policy and procedure revealed use of restraints should clearly reflect a loop of assessment, intervention and evaluation for restraint and seclusion and medications. Patients and families should be involved in care planning to the extent possible and made aware of changes to the plan of care.