The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UNIVERSITY OF KANSAS HOSPITAL 4000 CAMBRIDGE STREET KANSAS CITY, KS 66160 May 17, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interview, and policy review the Hospital failed to document the provision of patient rights to 9 of 10 medical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9). Failure to inform patients of their rights prior to treatment places all patients at risk of not knowing and acting on all rights.

Findings include:

- Patient #1's open medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #2's open medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #3's open medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #4's open medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #5's open medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #6's closed medical record review on 5/16/2017 revealed an admitted ,d+[DATE]//2017. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #7's closed medical record review on 5/16/2017 revealed an admitted ,d+[DATE]//2017. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #8's closed medical record review on 5/16/2017 revealed an admitted ,d+[DATE]//2017. There is no evidence the patient received the Patient Bill of Rights folder.

- Patient #9's closed medical record review on 5/16/2017 revealed an admission date of [DATE]. There is no evidence the patient received the Patient Bill of Rights folder.

Director of Psychotherapy and Behavioral Health Staff B confirmed receipt of patient rights documentation is absent from the records and that until within the "last three to four months" it was being signed but the signature page had "been removed from the admission paperwork, but is currently being added back in. All patients are to get a handbook at admissions with the rights listed in the handbook."

"Patient's Rights" policy reviewed 5/16/2017 at 1:30 pm directs " ...Inpatient/Procedure Patient: As part of the registration process, each patient or representative will receive an admission packet, which includes Patient Rights and Responsibilities ..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, interview, and policy review, a registered nurse failed to document a nursing assessment at least once every shift in one of ten charts reviewed (Patient #4). Failure to perform a nursing assessment every shift puts all patients at risk of not receiving appropriate oversite of medical, social, and psychological needs and interventions.

Findings include:

- Patient #4's open medical record review on 5/16/2017 revealed no documentation a nursing assessment was completed during the 7am to 7pm shift on 5/15/2017.

Interview with RN Staff C on 5/16/2017 acknowledged that nursing assessments are to be performed at a minimum of once per shift with exceptions only if the assessments are documented more frequently. The assessment is to include the following elements: vital signs, pain assessment and interventions, neurological assessment, gastrointestinal assessment with documentation of bowel movements, skin assessment, nutrition to include meal intake, activities of daily living (ADL's), and any cause for use of restraints. The assessments are normally performed at the beginning of each shift. Nursing Care Plans and education are updated every shift as well and at least one element is to be updated each shift.

Policy titled "Assessment-Interdisciplinary Patient Care-TUKH-Marillac" reviewed on 5/16/2017 directs " ...A physical assessment will be documented each shift as applicable to the patient's condition (i.e. skin integrity of patients in diapers; patients with medical devises; patients with wounds; other injuries; etc.) ..."