HospitalInspections.org

Based on document reviews and interviews, the hospital failed to inform a patient of his/her rights in advance of providing care for two (2) of twenty (20) sampled patients (ES #5 and PR #9).

Findings:

The hospital's "Patient Rights and Responsibilities" policy, last revised 9/21/2020, stated, in part, "Mercy will inform patients, and when appropriate, their representative, about their rights and responsibilities by providing the patient with a written copy of the Hospital's statement of patients' rights upon admission. Mercy will provide assistance, including an interpreter, to any patient in need of help in understanding the Patient Rights and Responsibilities. This assistance will be appropriate to the patient's age and ability to understand..."; the consent would be signed upon every emergency department visit.

The Consent to Treatment form, in the signature section, states in part, I have received or declined a copy of the Patient's Rights and Responsibilities, and there was an area for the patient or the authorized representative to sign, date, and enter the time.

On 11/1/2022 at approximately 11:00 AM, ES #5 and PR #9's medical record were reviewed. There was no evidence for either record that a consent to treatment form was provided or signed by the patient or an authorized representative or any notes documented on this form as to the reason there was no signature.

On 11/1/2022 at approximately 11:30 AM, the Emergency Department Clinical Nurse Leader and the Emergency Department Nurse Director confirmed that there was no evidence on the form that provides patients the opportunity to receive information about their rights in advance of providing care.

Based on document reviews and interviews, the hospital failed to provide a written notice of its determination regarding a grievance in accordance with their policy for three (3) of five (5) sampled patients who filed grievances (Patient 1G, 4G and 5G).

Findings:

The hospitals "Managing Patient Complaints" policy and procedure, last revised 10/2/2020, states in part, "The Director of Mission Services and Patient Advocate, or designee, will review all new complaints and grievances to identify the appropriate manager or responsible person to resolve each complaint and otherwise ensure optimal handling of and responses to complaints...B. Grievance response timeline is defined as an average time frame of 7 days. If the resolution will take longer than 7 days, the hospital will inform the patient or patient's representative of the delay and anticipated period for completion. C. In its responses to a grievance, the hospital must provide adequate information to address each stated item of the grievance. The hospital does not have to provide the patient with exhaustive detail of every action taken to investigate or resolve the complaints, but CMS will require evidence of all compliance efforts. The response to the patient does not have to include statements that might be used in a legal action against the hospital. All grievances must receive a written response".

On 11/2/2022 at 2:30 PM, five (5) grievances were reviewed. This revealed the following:

1. On 2/7/2022, the hospital received a grievance from Patient 1G. On 11/1/2022, there was only evidence of an undated, hand written letter of condolence sent from the Director of Mission Services and Patient Advocate. As of 11/2/2022, there is no evidence of written notice of determination.

2. On 3/22/2022, the hospital received a grievance from Patient 4G. As of 11/2/2022, there is no evidence of written notice of determination.

3. On 6/22/2022, the hospital received a grievance from Patient 5G. As of 11/2/2022, there is no evidence of written notice of determination.

On 11/2/2022 at approximately 3:15 PM, the above findings were confirmed with the Director of Mission Services and Patient Advocate. However, the Director of Mission Services Patient Advocate stated that Patient 1G's undated, handwritten letter of condolence was evidence of a letter, but not in compliance with their policy and the regulatory requirements.

Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for one (1) of five (5) patients (Patient 2R).

Finding:

The Northern Light Mercy Hospital policy, "Restraint or Seclusion Use for Violent Behaviors", last reviewed on 10/19/2020, states, "...A face to face physical and behavioral assessment must be conducted by the physician or HPA [Health Professional Affiliate] responsible for the care of the patient at the time of restraint application or seclusion or within one hour of initiation...".

On 11/1/2022 at 12:30 PM, Patient 2R's medical record was reviewed with the Clinical Nurse Leader. This review revealed the following:

- On 8/25/2022 from 6:04 PM to 8:00 PM, Patient 2R was in four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

On 11/1/2022 at 12:38 PM, this finding was confirmed by the Clinical Nurse Leader at the time of the document review.