HospitalInspections.org

Based on review of grievance documentation, staff and family interviews, and review of policies and procedures, the facility failed to ensure the grievance process was implemented in accordance with the written policy for 1 of 6 grievances reviewed (#7). The findings were:

Interview with a family member of patient #7 on 4/7/22 at 9:20 AM revealed s/he requested a meeting with the Chief Executive Officer (CEO) in late December 2021, after the patient expired in the facility, to discuss concerns with one of the providers who treated his/her family member as an inpatient. The family member stated s/he expressed some concerns related to palliative care and how the provider talked to him/her and to the patient. The family member stated s/he didn't feel the CEO handled the grievance appropriately. S/he stated the CEO said the provider would call him/her, but s/he never received a phone call.

During an interview on 4/6/22 at 2:01 PM the CEO confirmed the family member of patient #7 made an appointment on 12/28/21 to discuss concerns with her. She stated the family member had some concerns about one of the providers and how he spoke to the patient. She stated she asked the family member what s/he wanted, and the family member stated s/he wanted the provider to call and apologize. She stated she spoke to the physician and he said he would call. She stated she never followed up with the provider to ensure he called.

Review of the facility's policy "Patient Complaints/Grievances" (dated 2/2022) showed "...If the patient/resident is discharged and not on campus and the complaint is related to a provider, the complaint will be managed by the Quality/Risk Director and will be directed through the Peer Review Process..." The following concerns were identified:
a. Review of the facility's complaint and grievance logs showed no documentation related to the grievance for patient #7.
b. Review of the facility's peer review log showed the grievance for patient #7 was not forwarded to peer review.
c. During an interview on 4/5/22 at 4:05 PM the director of quality and risk management stated she was on vacation when the family member of patient #7 met with the CEO to discuss concerns. She confirmed the grievance was not on the grievance log and was not forwarded to peer review. She stated it was "informally looked into."
d. On 4/6/22 at 2:14 PM the director of quality and risk management said she spoke to the provider to see if he ever called the family member and was told "he made an attempt, but was not able to hook up."

Based on review of policies and procedures and staff interview, the facility failed to ensure written policies and procedures for visitation rights addressed both inpatient and outpatient settings, and failed to include reasons for restrictions or limitations to visitation. The findings were:

1. Review of the facility's policy "Visiting Guidelines" (dated 8/2020) showed it did not address outpatient settings. In addition, the policy stated "...PVHC [Powell Valley Healthcare] retains the right to restrict visitors" and "...ICU Visitation. Visitors are only permitted between the hours of 0800 and 2000. Visitors are requested to limit their stay to no more than 15 minutes." The policy did not explain the clinical rationale for the restrictions.

2. During an interview on 4/6/22 at 1:19 PM the director of quality improvement and risk management confirmed the facility's visitation policy did not address all of the components required in the regulations.

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to inform each patient of his/her visitation rights for 22 of 24 sample patients (#1, #2, #3, #4, and #7 through #24). In addition, the facility failed to develop written policies to ensure patients were informed of their visitation rights. The findings were:

1. Review of the medical records for patients #1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, and #24 showed no evidence the patient received information on their visitation rights.

2. Review of the facility's policy "Visiting Guidelines" (dated 8/2020) showed the policy did not include procedures to ensure each patient was informed of his/her visitation rights, including the right to receive visitors whom s/he designates, including a spouse, a domestic partner, another family member, or a friend, and his/her right to withdraw such consent at any time.

3. During an interview on 4/6/22 at 1:19 PM the director of quality improvement and risk management stated there was no documentation to show patients received information on visitation rights. In addition, she confirmed the facility's visitation policy did not address notifying patients of their visitation rights.

Based on review of policies and procedures and staff interview, the facility failed to develop written policies to ensure visitation privileges were not restricted based on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. The findings were:

1. Review of the facility's policy "Visiting Guidelines" (dated 8/2020) showed the policy did not not address that visitation privileges were not restricted based on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

2. During an interview on 4/6/22 at 1:19 PM the director of quality improvement and risk management confirmed the facility's visitation policy did not address all of the components required in the regulations.

Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure access to stored medical records was limited to individuals with a need to know patient information for 1 of 1 storage areas. The findings were:

1. Observation on 3/6/22 at 2:34 PM of a large room showed the area was used for the storage of old medical records from the hospital, patient charts from the clinic, and records from the accounting department. The storage consisted of a large number of boxes stacked on the floor, holding bins for documents awaiting destruction, and various building air handling ducts and equipment.

2. Interview with the director of medical records on 4/7/22 at 9:36 AM revealed access to a master key was available to maintenance personnel and other individuals.

3. Review of the policy "Physical and Electronic Access Controls" showed "This policy establishes physical and electronic access controls to electronic protected health information and its computer systems. The level of control is dependent upon an employee's need and the level of risk and exposure to loss of information. All employees are responsible and accountable for access under their personal identifiers."

Based on observation, staff interview, and review of professional standards, the facility failed to ensure endoscopes were stored in a manner to minimize contamination in 1 of 1 endoscope storage areas. The findings were:

1. Observation on 4/6/22 at 9:46 AM and again at 10:20 AM revealed sterile processing technician #1 took an endoscope that was high-level disinfected to the procedure room. The procedure room contained some hooks on part of a wall with a curtain rod and fabric curtain in front of the hooks. The curtain was observed to be mesh on the top 3 feet of the curtain. On the hooks, there were clean (high-level disinfected) endoscopes hanging. When the technician pulled back the curtain to hang the endoscope, the curtain touched the other endoscopes.

2. During an interview on 4/6/22 at 2 PM the director of surgical services stated the facility did not have a policy on endoscope storage, but that the facility followed Association of periOperative Registered Nurses (AORN) standards. She further stated the facility could look into storage cabinets for the endoscopes.

3. Review of the 2022 Edition "Guidelines for Perioperative Practice" by AORN showed "...9.1. Store flexible endoscopes and endoscope accessories in a manner that minimizes contamination and protects the device or item from damage...9.2. Store flexible endoscopes in cabinets that are situated in a secure location in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room...9.2.1. Use storage cabinets that have doors and are located at least 3 ft (0.9 m) from any sink...9.3.1. Store flexible endoscopes in a drying cabinet...9.3.2. If a drying cabinet is not available, store flexible endoscopes in a closed cabinet with HEPA-filtered air that provides positive pressure and allows air circulation around the flexible endoscopes."