HospitalInspections.org

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

(482.13(a)(1) Tag- 0117)
The documentation reviewed during the survey provided evidence that the facility failed to provide the "Important Message for Medicare on Admission and Discharge.

(482.13(c)-Tag-0142)
The observation tour and documentation reviewed during the survey provided evidence that the facility failed to provide the delivery of patient care in a safe environment by professional staff.

(482.13(c)(2)-Tag-0144)
The documentation reviewed during the survey provided evidence that the facility failed to ensure patient rights and privacy during the delivery of patient care.

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to comply with its policy in providing a copy of the Important Message from Medicare (IMM) within two (2) days of admission or a copy of the IMM no more than two (2) days prior to discharge for three of six medical records reviewed (MR13, MR15 and MR16).

Findings include:

A review of facility policy "Important Message from Medicare" last reviewed November 2018, revealed, "...A minimum of one Important Message will be issued to Medicare patients who stay 2 days or less. For Medicare patients staying more than two (2) days, a minimum of two (2) notices must be provided to each Medicare patient..."

A review on May 15, 2019, of MR13 revealed an admission date of March 29, 2019, and a date of discharged on April 2, 2019. Further review revealed no evidence of documentation that a copy of the IMM was provided to MR13 on admission.

A review on May 15, 2019, of MR15 revealed an admission date of May 2, 2019, and a date of discharged on May 7, 2019. Further review revealed no evidence of documentation that a copy of the IMM was provided to MR15 on discharge.

A review on May 15, 2019, of MR16 revealed an admission date of April 7, 2019, and a date of discharged on April 10, 2019. Further review revealed no evidence of documentation that a copy of the IMM was provided to MR16 on discharge.

An interview conducted on May 15, 2019, at approximately 2:45 PM with EMP9 confirmed that an IMM was not provided to MR13 on admission, nor was a copy of the IMM provided to MR15 and MR16 on discharge.


Cross Reference:
482.13(c): Patient Rights-Privacy and Safety
482.13 (c) (2): Patient Rights-Care in Safe Setting

Based on an observation tour, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure patient privacy during discussion of patient care, patient examinations and treatment for three of three Emergency Department (ED) patients (MR5, MR6 and MR7) located in ED hallway beds.


Findings include:

Review of facility policy "Patient Rights and Responsibilities' date May 2019, revealed "Patient's Rights...You have the right to keep your medical record and other healthcare information confidential...You have the right to personal privacy...You have the right to good quality care and high professional standards that are continually maintained and reviewed..."

An observation tour conducted in the facility's Emergency Department on May 14, 2019, at 2:55 PM through 4:10 PM with EMP1, EMP8 and EMP11 revealed the following:

1. Observation of MR5, a female patient lying on a stretcher in the hallway of the Emergency Department lateral to Exam Room 9 (seclusion room) revealed MR5 actively vomiting into an emesis bag. Further observation revealed a male and female visitor to the ED sitting infront of the stretcher of MR5 with facemasks.

2. Observation of MR6, a male patient lying on a stretcher in the ED hallway infront of the nurse's station revealed MR6 and EMP25, a registered nurse assessing the blood pressure and lungs of MR6 requesting the patient should "Cough and Deep Breathe." Further observation revealed EMP25 was speaking very loudly and positioned her mouth to the left hear of MR6. The patient repeated to EMP25, that she should speak louder to ensure he could hear the results of her assessment when she spoke. EMP1 approached EMP25 and requested that the patient moved to the Trauma Room to continue the assessment for privacy.

3. Observation of MR7, a male patient lying on a stretcher in the ED hallway infront of the nurse's station revealed MR7 and EMP26, a registered nurse completing a nursing assessment. Further observation revealed EMP26 altering the intravenous tubing and fluids hanging from a pole attached to the stretcher.

A request was made of the facility for privacy screens for MR5, MR6 and MR7. The facility was unable to provide the privacy screens requested for each of the hallway patients.

An interview conducted on May 14, 2019, at 4:15 PM with EMP1, EMP8 and EMP11 confirmed the findings above and the failure of the facility to provide privacy by the staff during the delivery of patient care services. EMP1 stated "I have placed an order for six privacy screens and they should arrive tomorrow."


Cross Reference:
482.13(a)(1) Patient Rights: Notice of Rights
482.13(c)(2): Patient Rights: Care in Safe Setting

Based on observation tour, review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to ensure healthcare services were provided in a safe environment for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Patient Rights and Responsibilities" dated May 2019 revealed "Patient's Rights... You have the right to receive respectful healthcare from competent professionals without necessary delay...You have the right to receive care in a safe setting and to be free from all forms of abuse, Harrassment, neglect, or mistreatment."

Review of facility policy "Patient Safety Plan" last revised August 7, 2018, revealed "The purpose of the Patient Safety Plan is to improve patient safety and reduce risk to patients through an environment in which patient, their families, organizational and medical staff, and leaders can identify and manage actual and potential risks to patient safety. The purpose includes creating an environment that requires all staff to; initiate actions to reduce risks; focus on internal improvement of processes and systems based on analysis of organizational incident reporting; foster an environment that encourages participation in the prevention of patient harm. MCARE" Infrastructure Failure" (A) n undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or discontinuation of significant disruption of a service which could seriously compromise patient safety."

Review on May 17, 2019, of MR1, admitted on April 27, 2019, diagnosed with Suicide Attempt and Major Depression . Further review revealed a physician documentation/notes written by EMP21 which revealed "Pt (patient) found in an SI (suicide attempt). While in the waiting room, pt went into the bathroom and tied the strap of her purse around her neck in an attempt to kill herself."

An interview conducted on May 17, 2019, at 2:48 PM with EMP11 confirmed the event was not reported to the "Division of Acute and Ambulatory Care (Department)." EMP11 stated that the patient had not completed the registration process in the Emergency Department prior to the event therefore the facility did not consider MR1 a patient when this event occurred. . EMP11 confirmed MR1 was sitting in the Emergency Department waiting room seeking emergency department services prior to the event.

_______________________

Based on review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure the delivery of healthcare services were provided by competent personnel for one of one medical record reviewed (MR1).

Review of facility policy "Patient Rights and Responsibilities" dated May 2019 revealed "Patient's Rights... You have the right to receive respectful healthcare from competent professionals without unnecessary delay..."

Review of facility document " Annual Contract Evaluation Review of (name redacted) Hospitals Inc. dated March 31, 2019, revealed Benchmark Goal:" Emergency Department Consultation to contact Telemedicine Consultation should be less than 15 minutes for Teleneurology-Beam-in Time."

Review of facility document "Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment " last revised November 2017 revealed "I consent to virtual health/telemedicine services as part of my treatment. I understand that...telemedicine services include the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communication

Review of facility document TELENEUROLOGY" FY 19 JET Physician Metrics: Average Beam-In Times : FY 19 Quarter 3 Average Beam in Time: 11:67 minutes. Further review revealed OTH1, a physician 10 Consultations, Total Time 198 minutes and Average Time 19.8 minutes for Beam-in"

Review of facility document "Emergency Medicine Committee Meeting Minutes" dated March 26, 2019, and April 30, 2019, revealed no evidence of documentation that the delayed average beam time of 19.8 minutes for imitating the Teleneurology Telemedicine Services was not reported to the committee for OTH1.

An interview conducted on May 17, 2019, at 1:35 PM with EMP2 confirmed that OTH1 had a delayed time for initiating the Teleneurology Telemedicine Service via the telemedicine unit in the Emergency Department. Further interview confirmed the facility had not communicated the Beam-in time information to the Emergency Medicine Committee nor to the addressed it with OTH1.


Cross Reference:
482.13(a)(1): Patient Rights: Notice of Rights
482.13 (c): Patient Rights: Privacy and Safety

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on August 29, 2019. Further details are outlined in that Division of Life Safety Survey Report.