HospitalInspections.org

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Based on document review and staff interview, in one (1) of three (3) Grievance Reports reviewed, Facility Staff did not implement the Complaint Policy ensuring that a complete investigation was done for a patient grievance. This lack of a complete investigation could result in the facility not identifying and correcting patient care issues.

Findings include:

The facility Policy and Procedure titled "Patient / Visitor Complaints and Grievances", last reviewed 02/22/18, states the following: "... grievances are thoroughly investigated by reviewing all related records and having interviews with staff and caregivers ... file documentation includes steps taken to complete a full review ...".

On 04/23/18 the father of Patient #19 filed a grievance alleging that: (a) the Nurse obtained the medication list and doses from the patient, which the father had to call and correct, (b) the patient was in emotional distress at the time of discharge due to not taking his medications, (c) the patient should have been re-evaluated in the Psychiatric Emergency Room and (d) the staff failed to identify themselves or resolve his concerns.

The facility "2018 Regulatory Grievance File Report" from March 2018 to May 2018" revealed that the facility received a telephone complaint about Patient #19, but the investigation did not address all the allegations made by the complainants.

The report stated: "a review was conducted the discharge was appropriate and no medical indication for an additional evaluation was (indicated)." However, the report lacked documented evidence of a review of the patient's medication, information from the Medical Record review about the patient's emotional state prior to discharge and interviews with the staff involved.

During interview in the afternoon on 06/07/18 both Directors, Staff Members Q and R, acknowledged the findings. Staff R stated: "we have a responsibility to make sure all the concerns are addressed and to farm them out (concerns) to the right person."
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Based on observation, document review and interview, the facility did not ensure that patient privacy was protected. This was evident in three (3) of five (5) observations of unsecured patient information at Nursing Work Stations.

These lapses in the protection of patient privacy places all patients at risk for potential Health Information breaches.

Findings include:

During observations in the facility's Cardiothoracic Intensive Care Unit at 11:15AM on 06/06/18, Patient #35's Laboratory Requisition Sheet was observed unsecured and unattended in a box, on a Nursing Station in front of Room #708.

This observation was made in the presence on Staff M (Assistant Director of Nursing) who confirmed the finding.

During observations of the 16 South Nursing Unit on 06/07/18 at 11:55AM, a Patient Assignment Sheet containing the patient information for twenty-four (24) patients was observed unsecured and unattended at a Nursing Station.

On 06/07/18 at 12:05PM information was observed on a label for Patient #22 on a medication cart in the hallway unsecured and unattended.

These observations were made in the presence of Staff O (Deputy Nursing Director) who confirmed the findings.

During an interview with Staff P (Registered Nurse) at the time of the observation, the staff member acknowledged that the patient information should have been secured.

The facility Policy and Procedure titled "Confidentiality of Protected Health Information (PHI)" last revised October 28, 2016, directed workforce staff to, "keep PHI safe from public viewing ... to ensure PHI is not left in conference rooms, on desks, on counters or other areas where the information may be accessible to the public, to employees or individuals who do not have a need to know the PHI."
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Based on observation, document review, Medical Record review and interview, in one (1) of four (4) records reviewed, the facility failed to ensure that staff documented the restraint monitoring every two (2) hours for non-violent restraints as required by the facility's Policy.

This failure to monitor may place patient's safety at risk.

Findings include:

The facility Policy and Procedure titled "Restraints and Seclusion" last revised 02/22/18 stated that "Minimally, an RN assesses the patient at initiation of restraints or seclusion and every 30 minutes thereafter documenting in the Electronic Patient Record ... Every 2 hours and as needed."

Observation in the facility's 18 South Unit during a tour between 1:35PM and 3:00PM on 06/05/18 identified that Patient #5 had an Order for non-violent two (2) point restraints. Review of the patient's Electronic Medical Record revealed that Staff J (Registered Nurse) failed to document the Restraint Monitoring between 15:00PM and 19:30PM on 06/04/18.

This finding was confirmed with Staff I (Nurse Manager) who agreed that Staff J was supposed to document every two (2) hours.

Per interview at the time of the observation, Staff J confirmed that he must have forgotten to document the restraint monitoring for the missing time frame.
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Based on Medical Record review, document review and interview, in one (1) of five (5) Medical Records, the staff did not ensure that Health Care Proxy (HCP) information was documented accurately.

This lapse in accurate HCP documentation may result in staff and practitioners' inability to comply with patients' Advance Directives.

Findings include:

Patient #39's Medical Record identified that a copy of the patient's HCP documentation was not placed in the paper Medical Record. In the Eclipsys Management System [for electronic forms], the Advance Directives Note dated 06/05/18 at 11:12PM stated: "Health Care Proxy (HCP): No, patient states does not have HCP. Advance Directive Requesting Assistance: No, patient refused."

Case Management Assessment Note dated 06/06/18 at 10:42AM stated "Patient reports health care proxy in chart. SW [Social Worker] reviewed HCP in Eclipsys and confirmed primary healthcare agent ...".

Medicine Progress Note dated 06/06/18 at 5:39PM stated: "...daughter, HCP, number in chart ...".

This finding was confirmed with Staff T (Nurse Manager) who stated: "This information [in Eclipsys] is not correct."

The facility Policy and Procedure titled "Advance Directives" last published 05/01/15 stated: "For inpatients, the admitting nurse ascertains the following from all adult patients or a patient's legal representative: An advance directive exists and has been brought to the hospital: a current copy is placed in the medical record ... or if provided previously, is available and viewable in the Eclipsys management system."

This Policy directed staff to view current HCP information in the paper Medical Record, or in an electronic version in the Eclipsys System. Although Patient #39's HCP information was verified in the Medical Record by staff on 06/06/18, the most recent HCP information available in Eclipsys was dated 06/05/18 and stated that the patient did not have a HCP. This inaccurate documentation can potentially misinform staff to determine that Patient #39 did not have a designated HCP. This finding was discussed and acknowledged by Staff Q (Executive Administrator) on 06/08/18 at 11:00AM.