HospitalInspections.org

Based on staff interview and medical record review it was determined that the hospital did not ensure that the notice of rights document was given for 30 our of 30 records reviewed. (Patient Identifiers: 1 through 30.)

Findings include:

1. On 05/28/15, 30 patient's medical records were reviewed with no notice of rights document was found in the individual records.

2. In an interview with the Director of Nursing on 05/28/15 a request was made for further documentation of the patient receipt of their individual notice of rights. No supportive documentation was received.

3. In an interview with the staff of the Information Systems department on 05/28/15, a request was made for assistance in finding further documentation of the patient receipt of their individual notice of rights. No supportive documentation was found in the electronic medical record.

4. An interview was conducted with the Emergency Department admitting clerk on 05/28/15 at 10:15 A.M. The surveyor asked if patients were required to sign acknowledgements that they had been given their patient rights. The admitting clerk stated that they had patients sign consents and HIPAA information, but they didn't have them sign anything regarding patient rights or advanced directives.

5. An interview was held with the admitting staff of the Surgical Department. The surveyor asked if patients were required to sign acknowledgements that they had been given their patient rights. The admitting clerk stated that she was unaware any further documents that reflected patient rights.


31318

Based on observation and interview it was found that the privacy of the patients was not maintained in 1 of 1 patient.

Findings include:

On observation on 05/27/15 at approximately 03:10 P.M. while following the tracer patient through the outpatient surgery area there was a violation of a patient's privacy. The tracer patient was accompanied by her husband. There had been an earlier delay in the tracer patients surgery due to an emergency surgery that was performed.

The violation of privacy was as follows:

The licensed practical nurse (LPN) was starting the tracer patient's intravenous line (I.V.). The spouse of the tracer patient asked the nurse what happened to the little boy from earlier. (This was the emergency surgery that had delayed the tracer patients surgery.) The LPN explained to the spouse that the little boy had fallen out of a tree but had done really well.

An interview was held at 03:25 P.M. on 05/27/15, where the same LPN was asked who the little boy was they were talking about. She stated it was a little girl and she had fallen from a tree and fractured her ankle. She stated that she was doing very well.

A second interview was held with a registered nurse (RN) to ask what their education entailed regarding HIPAA compliance. She explained that it was done on new hire, yearly and in multiple staff meetings.

Based on observation it was found that the confidentiality of the patients were not protected in 1 of 1 instance.

Findings Include:

While touring the Emergency Department (ED) on 05/26/15 it was noted that a lap top computer was partially open and facing the common area of the ED. The laptop was not secured in place and would have been easily accessible to remove from the ED.

35692

Based on observation and interview, it was determined that the radiological out-patient clinic, located in Vernal, did not ensure that all radiology technicians were using their exposure meters. (Employee identifier: 20)

Findings include:

1. On 05/28/2015, at 9:30 AM, employee 20 was observed not wearing an exposure meter. When asked why he did not have one on, he stated that he only does three to four x-rays per day and feels he does not need to wear one.

2. On 05/28/2015, in the afternoon, the radiology manager (RM) was asked what was the hospital policy for radiology technicians wearing their exposure meters. The RM stated that employees should always wear exposure meters while working.

3. The surveyor reviewed the hospital's imaging policy, "Uintah Basin Healthcare Imaging Services". The policy states," A film badge shall be worn at all times while performing any radiographic procedure, including mammograms. The badge shall be worn on the collar or waist, checked monthly, and reviewed by the Radiation Safety Officer monthly. Records shall be kept as required. Any over-exposures shall be reported to the State of Utah Division of Radiation control".

Based on record review and interview, it was determined that the hospital could not provide evidence that their utilization review (UR) committee included at least two doctors of medicine. (Physician identifier: 3)

Findings include:

On 05/26/15, the surveyor requested and received copies of the UR minutes for the past year. According to minutes dated 03/13/14; 06/12/14; 09/18/14; 11/20/14; 02/19/15; and 05/4/15, physician 3 was the only physician present at the meetings. The 11/20/14 minutes contained the following statement under the Conditions of Participation section: "EHR (Executive Health Resources) cannot serve as a second physician for this committee." The minutes included documentation that physician 3 would let the Chief of Staff know that they needed a second physician on the committee.

An interview was held with the UR specialist on 05/26/15. The surveyor asked who comprised the UR committee and was given a list of names. The UR specialist stated that they only have 1 physician on the committee but were working to try to get another physician.