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Based on record review and interview, the facility failed to ensure each patient was informed of the patient's rights (or when appropriate, the patient's representative as allowed under State law), citing

7 of 7 patients (Patient #12, #13, #14, #15, #16, #17, and #18) were not informed of the patient's rights including the mechanism to report patient complaints.

FINDINGS

Patient #12, #13, #14, #15, #16, #17, and #18 were not informed of the patient's rights including the mechanism to report patient complaints. The signed consent form used on 7/14/2024 for each of the patients did not include the required patient rights and complaints information.

During record review and interview on 7/16/2024 ending at 2:15 PM, Personnel #2 reviewed the records and confirmed the rights/complaint information was not included on the signed consent form for each patient. After record review revealed the form being used on 7/14/2024 with patients did not contain the patient rights and complaint information, Personnel #2 provided an updated form that included Rights and Complaints information that could be implemented.

Based on record review and interview, the facility failed to ensure each patient was informed of the patient's rights (or when appropriate, the patient's representative as allowed under State law), citing

7 of 7 patients (Patient #12, #13, #14, #15, #16, #17, and #18) were not informed of the patient's rights including the mechanism to report patient complaints/grievances.

FINDINGS

Patient #12, #13, #14, #15, #16, #17, and #18 were not informed of the patient's rights including the mechanism to report patient complaints/grievances. The signed consent form used on 7/14/2024 for each of the patients did not include the required patient rights and complaints/grievance information.

During record review and interview on 7/16/2024 ending at 2:15 PM, Personnel #2 reviewed the records and confirmed the rights/complaint information was not included on the signed consent form for each patient. After record review revealed the form being used on 7/14/2024 with patients did not contain the patient rights and complaint information, Personnel #2 provided an updated form that included Rights and Complaints information that could be implemented.

Based on record review and interview, the facility failed to ensure the incident reporting system was engaged to document all incidents with evaluation, follow-up, and corrective actions, citing

11 of 11 patients did not have incident reports documented to show the deviation of intended intervention/care.

5 of 5 patients (Patient #1, #2, #3, #4, and #5) did not have Troponin results as ordered; AND

6 of 6 patients (Patient #6, #7, #8, #9, #10, and #11) did not have Potassium results as ordered.

FINDINGS

Patient #1, #2, #3, #4, and #5 had Troponin (lab work) ordered with no result.

Patient #6, #7, #8, #9, #10, and #11 had Potassium (Lab work) ordered with no timely result.


During an interview on 7/16/2024 at 9:10 AM, Personnel #1 stated was asked about both Troponin and CMP labs. Personnel #1 stated we had issues with lab reagents on 6/12/2024. The troponin and potassium labs were effected. The results were delayed until reagents could be secured.

During an interview on 7/16/2024 ending at 10:17 AM, Personnel #2, #3, and #4 were present. Personnel #2 stated only one Potassium was not resulted. It was for a outpatient surgery that was scheduled. The patient did not have pre-op labs and they wanted a potassium prior to going into surgery. Due to reagent issues, the lab could not result it by that time and due to proximity and pick up they could not result within the hour if it was sent to the reference lab. The Surgeon decided to cancel for that day. There were no other potassiums without result. They were asked for a list of un-resulted potassiums. A stack of 5 patients (2 STAT orders, 3 Routine orders) with potassium orders that could not be resulted at the time of the order was provided. Personnel #2 stated later in the day results were completed after reagent was secured. They were asked for documentation of the incidents. They stated there were no incident reports completed.

The facility's April 2024 revised "Occurrence_ Incident Reporting" policy required, "a confidential, non-punitive, systems-based approach to the identification and reporting of incidents and near misses...comfortable in reporting all incidents and near misses...leaders of the organization are responsible for fostering such an environment through their personal example and by establishing mechanisms that support effective responses to actual occurrences..Unintentional Unsafe Acts Are unintended acts, either of omission or commission, or an act that does not achieve its intended outcome...Incident: An unintended event, unexpected or out of the ordinary, no matter how trivial, that could have harmed or did harm to a patient. A clinical incident is an occurrence inconsistent with the accepted professional standards of patient care, or routine organizational policies and procedures...Hazardous Condition: Any set of circumstances (exclusive of the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome...Adverse Events: Are events that may result from acts of commission or omission such as administration of the wrong medication, FAILURE to make a TIMELY diagnosis or INSTITUTE THE APPROPRIATE THERAPUTIC INTERVENTION, adverse reactions or negative outcomes of treatment...An occurrence report is completed whenever there is an event involving a patient, which is:
1. Inconsistent with the accepted routine operation of the hospital, regardless of outcome.
2. Inconsistent with the routine care of a patient, regardless of outcome.
3. An unusual or unexpected response by the patient to standard treatment or medical
intervention."