HospitalInspections.org

Based on review of hospital policies/procedures, facility document, medical records, and interviews, it was determined that the facility failed to require that the patient's representative was informed of a test prior to the test being performed. The failure to inform or communicate with the patient, and/or the patient's representative, has a potential risk for systemic failure of informing the patient, and/or the patient's representative regarding tests procedures needed/required for patient care, and is a violation of patient rights. .

Finding includes:

Policy titled "Dignity Health East Valley Patient Rights & Responsibilities" (last revised 11/2018) revealed: "...The hospital has adopted the following statements concerning the personal rights of its patients...these rights and responsibilities may also apply as appropriate to the parents and/or guardians of those patients not of majority age (i.e., neonates)...Patient's Rights...you have the right to designate a representative to participate in your care, including at a minimum the right to participate in the development and implementation of your inpatient treatment/care plan...you or your representative has the right to have information contour health status, diagnosis, and prognosis...this information will be provided to you by your doctor, and on-going status will be discussed with you during bedside report...."

Policy titled "Admission to the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU)" (#6080-S-02, last reviewed: 01/2019) revealed: "...Parents will be provided with the following education on admission...discussion to address parent questions and concerns regarding process of care for their baby, and infant concerns...."

Policy titled "Level II EQ Nursery Standards of Care Guidelines" (#6060-L-03, last reviewed 11/2017) revealed: "...all patients admitted to the NICU or SCN will receive consistency and continuity of care to ensure the best possible outcome...all infants will be provided family focused care...."

The Dignity Health CRMC Patient Visitor Guide revealed: "...Patient Rights & Responsibilities...receive information about your health status, diagnosis, prognosis, course of treatment...right to effective communication and to participate in the development and implementation of your plan of care...."

The Electronic Medical Record (EMR) dated [specific date identified] revealed that a non-invasive ultrasound of the [specific part of the body identified] (encephalogram)] was ordered by Provider #8 on [specified date and time identified] due to the diagnosis of [specific diagnosis]. The procedure was completed on [specified date and time], and the results were read by Provider #12 on [specified date and time]. The impression was [specific medical diagnosis documented].

The EMR confirmed that Patient #14 was evaluated/assessed daily from [date through date] by Providers #2, #3, #4, #5, #6, #8, #13, and #14. Additionally, the EMR confirmed no documented evidence of communication by a provider to Patient #14's legal representative specific to the reasons for the ultrasound of [body part identified] prior to or on the actual date of the ultrasound of [body part identified].

Personnel #4 and #5 confirmed during EMR review, 05/07/2019 (0853), that there was no documented evidence of communication by a provider to Patient #14's legal representative specific to the reasons for the ultrasound of [the body part identified] prior to or on the actual date of the ultrasound.

Provider #5 confirmed during an interview conducted 05/08/2019 (0930-0939) that when an ultrasound of the [body part identified] is required, that it is usually discussed with the parent(s) during rounds, and that sometimes the parents are there, and sometimes they are not there. Additionally, Provider #5 revealed that it is standard practice to obtain an ultrasound of the [body part identified] for a diagnosis of [name of the condition].

Provider #2 confirmed during an interview conducted 05/07/2019 (1500-1510), that s/he did not talk with the parent(s) prior to Patient #14's ultrasound of the [body part identified]. Additionally Provider #2 revealed that s/he assumed or took for granted, that someone talked with the patient's parent(s) before the ultrasound of the [body part identified] was performed.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the facility failed to report an incident per facility policy. The failure to report an incident, has a potential risk for systemic failure of reporting events related to patient care.

Finding includes:

Policy titled "Patient Safety Event Reporting and Management" (#100.5.006, last reviewed: 02/27/2019) revealed: "...Dignity Health Facilities support a culture of open communication, safety and organizational learning related to event reporting...employees are required to report events that result in/pose an actual or potential risk of harm...to establish a structure to evaluate and improve the quality of care provided to patients...to promote a safe and healthful environment for patients...understanding the factors that contributed to an event...to reduce the probability of such an event in the future...Event...situation of event that is not consistent with routine patient care...care setting...results in or has the potential to result in injury to a person...events may be the result of...system failure and/or human error...examples of events subject to this policy and procedure include, but not limited to...patient or visitor fall, with or without harm (injury)...Close Call...near miss...good catch...a patient safety event that did not reach the patient...Patient Safety Event...an event incident or condition that could have resulted or did result in harm to a patient...patient safety events also include...no-harm events, close calls...Event Notification...staff who observe, discover, or are directly involved in an event should initiate an event report within 24 hours of becoming aware of the event or request that one be completed on their behalf...an event report is electronically directed to the department manager when entered into the Event Reporting System (ERS/iVOS)...the department manager/designee reviews the event to determine if follow-up is necessary within 72 hours, and has 7 days to investigate, and complete their response...."

Policy titled "Patient Safety/Risk Management Program" (last reviewed: 09/2018) revealed: "...The organization...is committed to promoting a safe environment for all patients...by effective identification, evaluation, reduction...that could negatively impact safe patient care...purpose...to ensure that systems are in place to improve patient safety, reduce risk...Goal...the safety of all patients...is a leadership commitment, and a priority for organizational performance improvement...identify actual or potential safety exposures in an effort to reduce, prevent, or eliminate the probability of injury...Actions...establish and maintain a culture of safety...promote safety by recognizing and reducing risks...that may result in medical/healthcare errors, and patient injury...analyze occurrence reports for potential serious safety events..."Board"...has the overall responsibility of governance for the patient safety actives...Event Reporting...process for when an unplanned event occurs, the patient care team will...perform the necessary interventions to care for the patient...preserve any information related to the event...documentation of facts regarding the event...in the medical record, and completing an on-line event report...."

Personnel #2 and Personnel # 6 confirmed during an interview conducted 05/07/2019 (1315), that the facility received two separate grievances via telephone on [specific date in April 2019] regarding an incident that occurred [specific date in February 2019], and that there was no documented evidence that facility personnel entered the incident regarding Patient #14 into the facility's event reporting system until [specific date in April 2019].

Personnel #11 confirmed during an interview conducted 05/07/2019 (1315-1345), that s/he was made aware of the incident regarding Patient #14 on [specific date in February 2019], and that s/he conducted an internal investigation with the staff and providers involved. It was revealed that the L&D personnel, and Nursery personnel, each thought the other department was going to enter the event into the system as required per policy/procedure. Personnel #11 confirmed that s/he did not enter the incident into the facility's event reporting system, as it was determined that there was no harm to Patient #14. Additionally Personnel #11 confirmed during an second interview conducted 05/08/2019 (0917-0928), that s/he did not report the incident until the facility received a telephone grievance on [specific date in April 2019], and that this was the first time that the incident was reported following the chain-of command.

Personnel #12 confirmed during an interview conducted on 05/08/2019 (0845-0919) that s/he was aware of the incident regarding Patient #14, and that s/he reported it to his/her manager, but that s/he did not enter the incident in the facility's event reporting system.

Personnel #4 confirmed during an interview conducted 05/06/2019 (1530), that an incident report would be entered into the facility's event reporting system for anything unexpected during a delivery.

Provider #4 confirmed during an interview conducted on 05/08/2019 (0755-0840), that providers can report an incident/unusual occurrence, but that s/he did not enter the incident in the facility's event reporting system.