HospitalInspections.org

Based on a review of hospital documentation, policies and procedures, based on a review of two patient records, and based on interviews with hospital staff members, it was determined that in two of two patient records, the hospital failed to assure that it had informed each patient of his or her rights, as required by this regulation.

Findings include:

The following hospital policies and procedures were reviewed:

"Patient Complaints and Grievances" "review date December 2010"
"Rights and Responsibilities of Patients" "review date January 2011"
"Patient Care Partnership" "reviewed March, 2011"

The following brochures were reviewed:

"Speak Up For Your Health"
"The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities"

A review of patient records to determine the receipt of the patient rights brochure, "The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities," which contained a listing of the numerous rights and responsibilities of a patient of the hospital, was requested. In an interview with I1 on 05/18/11 at 1200 hours, I1 stated: "You won't find anything there (in the patient records). There is no requirement that we document in the patient record that the patient has been given the Patient Care Partnership tri-fold."

I1 further stated that that the hospital had an "overriding policy" which stated that if patients were "bedded," they "automatically" received a copy of the patient rights and responsibilities upon admission to the hospital. When asked to clarify if patients who had been seen in the emergency room but had not been admitted to the hospital received a copy of the patient rights and responsibilities, I1 responded that in this case, patients did not receive a copy of the patient rights, as patients who were admitted and discharged from the emergency room were not considered "bedded." When asked how the hospital could assure that each "bedded" patient had received a copy of his/her rights, I1 referred back to the "Patient Care Partnership" "overriding" policy/procedure which stated, "Admitting staff will provide to bedded patients (including mental Health and Rehab) a copy of 'The Patient Partnership'." I1 clarified that this was the "The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities" brochure.

In an interview with I2 on 05/19/11 at 0810 hours, during which I1 was also present, I2 confirmed the above information, but stated that s/he believed there was a section in the patient record in which a staff member could document that the patient rights brochure had been given to a patient. I2 chose two patient records through the electronic charting system whom s/he believed had been admitted through the general admissions process, clarified to mean: not admitted through the emergency room. I2 opened two patient records to the "nursing chart" section under "educational content" and displayed the following heading:
"Patient Rights."

In both instances, the information that had been documented in the patient record under the "Patient Rights" section was that the patient had been given the "Speak Up for your Health" brochure, which contained information instructing a patient to have his/her questions answered or to make his/her concerns known prior to receiving any care, but which did not contain a complete listing of the patient rights. No mention of the "Patient Care Partnership" patient rights document was included in either of the patient records reviewed. This observation was confirmed with I2, who also stated that nurses were very busy people with other priorities at the time of admission, and a review of patient rights was not likely to be a priority.

The hospital failed to document that patient rights information had been given to each patient receiving care at the hospital. In addition, the hospital denied patients cared for exclusively in the emergency room the same written information about patient rights which was reportedly, but not documented in the patient record, as having been given to inpatients.

Based on a review of hospital documentation, policies and procedures, based on a review of five personnel files, numbered 1, 2, 3, 4, and 5, and based on interviews with hospital staff members, it was determined that an incident did occur in which an employee, employee number 5, photographed a portion of a patient's unclothed body and distributed that photograph via electronic mail, along with a degrading caption, to another hospital employee. It was determined that the hospital failed to protect a patient's privacy.

Findings include:

A review of an unsigned, undated, narrative-style document titled: "Summary of Incident" was completed. I1 stated that this document was authored by the Unit Manager Registered Nurse for the "Short Stay Unit" of the hospital. I1 also stated that the Unit Manager was unavailable for interview at this time, as s/he was out of the country. The "Summary of Incident" document outlined a series of events which reportedly began on February 16, 2011, with the receipt of a photograph of the exposed buttocks of a patient captioned "pic of a hairy ass," and ended on May 4, 2011, during which time an internal investigation failed to reveal the identity of the patient but did reveal that the incident had happened, the termination of employee number 5, and the implementation of corrective measures, had occurred.

The personnel record for employee number 5 was reviewed and was found to contain the following notation:
"Terminated 2/23/11"
"Disciplinary action moving directly to termination: violation of confidentiality and non-disclosure policies related to electronic media (photo)."

The following hospital policies and procedures were reviewed:

Rights and Responsibilities of Patients, review date January 2011
Photography/Videography, dated April 2011

The following brochures were reviewed:

"Culture of Excellence Standards of Behavior," which contained to following information:
"Privacy
The core value of respect underlies our commitment to ensuring privacy for patients and staff. We foster a secure and trusting environment and are aware of its importance in providing the best care possible."

"The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities," a tri-fold brochure which contained the following information:
"You have the right to:
Receive compassionate, respectful care
Receive care in a safe setting, free from abuse of harassment
Be shown consideration for you personal privacy. The hospital, your physician, and others caring for you will protect your privacy as much as possible."

The hospital failed to assure that a patient's right to personal privacy was upheld.

Based on a review of documentation, and based on interviews with facility staff members and an interview with an employee of the city of Portland, it was determined that the hospital failed to protect a patient from all forms of abuse and harassment. It was also determined that the hospital failed to conduct a thorough investigation, the hospital failed to report the abuse in a timely manner, and the hospital failed to put appropriate and timely safeguards in place to assure that a similar incident would not occur again.

Findings include:

Please see the deficiency cited at Tag 0143

A review of an unsigned, undated, narrative-style document titled: "Summary of Incident" was completed. I1 stated that this document was authored by the Unit Manager Registered Nurse for the "Short Stay Unit" (SSU) of the hospital. I1 also stated that the Unit Manager was unavailable for interview at this time, as s/he was out of the country. The "Summary of Incident" document outlined a series of events which reportedly began on February 16, 2011, with the receipt of a photograph of the exposed buttocks of a patient captioned "pic of a hairy ass," and ended on May 4, 2011, during which time internal investigation had been completed, the termination of employee number 5 had taken place, and the implementation of corrective measures had occurred.

The document "Summary of Incident" included the following information:
"On February 25, 2011, I notified my staff of (the terminated employee)'s termination and spoke in general terms about a violation of Protected Health Information and of the Providence Mission and Core Values.

On March 9th and 10th, I held staff meetings and reinforced the above, with more detail about the offending actions.

On April 25th, 26th, and 28th I held mandatory staff meetings regarding the specific details of this incident and reviewed the components of Protected Health Information in an electronic age. Topics included a review of the Providence Code of Conduct and the dangers inherent in discussing patient issues/information in the social networking milieu."

The "Summary of Incident" document contained the following final written statement: "On May 4th, in order to further limit the opportunities for the above incident to ever again occur in this setting, I restricted the use of personal cell phones in the SSU to only non-clinic, non-patient care areas." This reported action took place 77 days after the incident occurred.

On 05/17/11 at 0930 hours, I1 was asked if the above policy prohibiting staff members from using their personal cellular phones in patient care areas had become a hospital-wide policy. S/he stated that it had not become a hospital-wide policy. A request was made to speak by telephone with the nurse covering for the out-of-country nurse manager of the SSU. I3, the temporary nurse manager, stated that the new policy had not been in writing to his/her knowledge. I3 also stated that s/he did not know of any documentation concerning the meetings that were held in February and March of 2011 with staff members of the SSU concerning this incident, but that s/he recalled that there had been a "Power-Point" presentation.

In an interview on 05/19/11 at 0830 hours, I1 was asked if the quality assurance committee had been involved in the investigation of the incident and in the implementation of corrective measures. I1 stated that the nurse manager of the SSU and the Human Resources Department had handled the investigation of the incident and the corrective measures, and that quality management had only been made aware of the incident "recently."

A document dated "05/05/2011," titled: "Providence Portland Medical Center Complaint Report," and authored by I1, contained a narrative account of the verbal report of the incident from the SSU manager to the Quality Manager. The documentation also contained acknowledgment of the strong recommendation from Centers for Medicare and Medicaid Services that a police report be filed, and documented a conversation with "inhouse (sic) legal counsel" stating that there was no requirement to file a police report about the incident. This document reflected that it had been written 78 days after the incident occurred.

A copy of electronic mail from the nurse manager of SSU to Centers for Medicare and Medicaid Services on 5/13/2011 was reviewed, which indicated that a police report concerning this incident with the case number 1138914 had been submitted to the Portland Police bureau. A telephone call on 05/19/11 at 1155 hours to the Portland Police records department 503.823.0044 confirmed that police report case number 1138914 had been filed by Providence Portland Hospital on 5/13/11. This report was made 86 days after the incident occurred.

Documentation that corrective measures to prevent the reoccurrence of a similar abusive situation was requested but not presented at the time of this investigation. The reported corrective measures were put into place only on the unit specifically involved in this incident, thus offered no protection to similarly vulnerable patients throughout the entire hospital.

An internal investigation confirmed that an unidentified patient had been abused by a hospital employee. The hospital failed to report and analyze, and put into place corrective measures, in a timely and thorough manner, as required by this regulation.