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 KENTUCKY HOSPITAL 800 ROSE STREET LEXINGTON, KY 40536 Oct. 30, 2012
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure notice of rights requirements were met by having no documentation in the clinical record that the patient received a "Notice of Privacy Practices" for two (2) of ten sampled (10) patients (Patient #1 and #4).

The findings include:

Review of facility policy, "Notice of Privacy Practices and Receipt of Privacy Practices", policy number A05-125, review/revision date 08/2011, revealed all patients receiving treatment from the facility would receive a "Notice of Privacy Practices" and sign a "Receipt of Notice of Privacy Practices".

Review of the clinical record of Patient #1 revealed he/she was brought to the facility's Emergency Department (ED) on 04/29/12 and transferred to their Burn Unit the next day for burns sustained to his/her bilateral lower extremities from a grease fire at home. Further review of the record revealed there was no signed "Receipt of Notice of Privacy Practices" in the record.

Review of the clinical record of Patient #4 revealed he/she was admitted to the facility's Burn Unit via the ED on 08/18/12 for burns sustained to his right leg. Further review of the record revealed there was no signed "Receipt of Notice of Privacy Practices" in the record.

Interview with the Medical Records Supervisor, on 10/30/12 at 10:45 AM, confirmed Patient #1 and #4 did not have a "Receipt of Notice of Privacy Practices" in their clinical records. She further revealed all patients should have a "Receipt of Notice of Privacy Practices" completed upon admission, and it did not matter whether the patient came through the ED or was admitted directly to the floor. She also stated this document would be kept in the patient's paper clinical record during the time the patient was in the facility; after discharge, it would be scanned into the electronic medical record (EMR), kept for six (6) months and then destroyed.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview, record review, review of the facility's documents and review of facility's policy, it was determined the facility failed to ensure a patient complaint was handled properly by failing to act upon the complaint in a timely manner and by failing to take appropriate steps to resolve the complaint while the patient was still in the facility for one (1) of ten (10) patients (Patient #1).
The findings include:
Review of facility policy, "Lost and Found", policy number HP10-01, effective date 11/2009, revealed if an employee received a report of lost property, he/she would give the patient a Board of Claims form. Further review revealed if there was reason to believe the property was stolen, the employee would notify security, complete an Incident Report form and give the patient a Board of Claims form.
Review of the "Claim Form, Commonwealth of Kentucky, Board of Claims", undated, revealed through KRS 44.070 the Board of Claims was vested with authority to compensate persons for damages sustained to person or property as a result of negligence on the part of the Commonwealth. Further review of this form revealed the burden of proof that the Commonwealth was negligent rested with the patient, and he/she must provide any proof, along with the completed form, and send to the Board of Claims. The form further revealed the Board of Claims made a determination whether to approve or disapprove the claim.
Review of the e-mail from Registered Nurse (RN) #2 to the Patient Care Manager of the Burn Unit, dated 05/05/12 at 4:25 PM, revealed the family of Patient #1 wanted to take his/her belongings home on that day. It further revealed RN #2 could not find any rings and called security which could not find any rings locked up in their safes. RN #2 stated, in this e-mail, that she was letting the Patient Care Manager of the Burn Unit know about the situation because she did not know what else to do at this point.
Review of the clinical record of Patient #1 revealed he/she arrived at the facility ED on 04/29/12, was admitted and was transported to the Burn Unit on 04/30/12 for burns sustained to his/her bilateral lower extremities. Further review revealed Patient #1 had three (3) yellow rings when in the ED according to the "Emergency Department Clothing/Valuables" sheet. There was no further documentation in the clinical record concerning these three (3) rings. Patient #1 was discharged to another facility on 05/10/12.
Interview with Patient #1, on 10/24/12 at 10:20 AM, revealed he/she did not have any rings when discharged to another facility on 05/10/12. He/she stated nurses on the Burn Unit removed his/her rings, exact date unknown, because his/her hands were swelling. Patient #1 stated there were five (5) rings, two (2) of which had diamonds. He/she further revealed the rings were put in a baggy by the nurse, and he/she was told the rings would be sent to security and locked in a vault. This interview further revealed the patient talked with a nurse a couple of days before he/she was discharged about retrieving the rings, but the nurse stated the rings could not be found.
Interview with Patient #1, on 10/28/12 at 7:40 PM, revealed he/she did not get a claim ticket when he/she gave the rings to the nurses on the Burn Unit. He/she again stated a bag was brought into his/her room, and his/her rings were placed in a bag. Patient #1 stated the nurses said they were going to call security to get the bag, and security would place the rings in a locked vault. He/she also revealed the nurses said he/she could get the rings at discharge.
Interview with the individual that was the Patient Care Manager of the Burn Unit in April 2012, on 10/29/12 at 11:40 AM, revealed he remembered a patient that claimed lost valuables. He revealed he was contacted by Office of Service Excellence (OSE) Employee #1, after the patient's discharge and not by nursing staff while Patient #1 was in the facility, to look into the matter. He further stated he asked RN #1 and #2 about the situation. He revealed one of these RN ' s, whom he could not remember, told him she had seen rings in Patient #1's room, and she assumed family members of Patient #1 had taken them home. This Patient Care Manager further stated he talked with Patient #1 and told him/her he could not find the rings, but he would send the patient a Board of Claims form to complete for possible reimbursement.
Interview with OSE Employee #1, on 10/29/12 at 12:43 PM, revealed the first time he was made aware of the concern of lost rings by Patient #1 was on 05/25/12. He revealed the social worker from the facility where Patient #1 was sent on 05/10/12 after discharge from the facility contacted him about the situation. OSE Employee #1 stated he contacted the Patient Care Manager of the Burn Unit to look into the situation. He further revealed a Board of Claims Form was sent to the patient via the social worker at the facility where the patient currently resided. OSE Employee #1 also stated the OSE office did not hear anything additionally from Patient #1 about his/her lost rings.
Interview with RN #2, on 10/30/12 at 11:25 AM, revealed the family of Patient #1 brought the matter of the missing rings to her attention on 05/05/12. She further stated she sent an e-mail to the Patient Care Manager of the Burn Unit, on 05/05/12 at 4:25 PM, alerting him to the situation. She further revealed she showed the family of Patient #1 the ED Valuables Sheet and tried to locate the rings with security, but the rings could not be found. RN #2 further stated she assumed once she had notified her supervisor, her responsibility for this matter had ended.
Interview with the Patient Care Manager of the Burn Unit, on 10/30/12 at 2:15 PM, revealed he really could not specifically remember what had happened with this incident. He further revealed he thought RN #2 had done all he could have done concerning the missing rings. He further stated if Patient #1 had been there on Monday, 05/07/12, he would have had her nurse give her a claims form.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of facility ' s documents and review of facility ' s policy, it was determined the facility failed to ensure patients received care in an environment which promoted respect by failing to properly account for patient valuables as evidenced by no documentation of disposition of valuables for one (1) of ten (10) patients, Patient #1.
Review of facility ' s policy, " Patient Personal Effects and Valuables, " policy number A10-015, review/revision date 08/2011, revealed if the nurse removes valuables from a patient for any reason, they shall inventory the valuables removed and transport them to security which shall place the valuables in a valuables envelope for safekeeping. The nurse shall document the removal of all valuables on a Valuables/Personal Effects Certification and Inventory (H703) form, sign the form and secure the signature of a witness. The nurse shall file the form in the patient chart. The nurse shall then notify the nursing care technician (NCT) to pick up the valuables envelope for delivery to security. The policy further revealed security staff shall verify the inventory of the valuables upon receipt of the valuables envelope. A claim check indicating the number of the valuables envelope shall be returned to the unit where the patient had been admitted . The policy further stated the nurse on the unit would attach the claim check to the inside front cover of the patient ' s chart so that valuables could be claimed at time of discharge. If the patient insisted upon retaining their valuables, the nurse should document the patient ' s refusal to comply with the policy in the nursing notes.
Review of the " Valuables Log-Security Office, " dated 04/20/12 to 05/17/12, revealed there was no documentation of security receiving rings or any valuables from Patient #1 to be locked in their vault for safekeeping.
Review of the clinical record of Patient #1 revealed he/she was admitted on [DATE] and arrived on the Burn Unit 04/30/12 at 3:20 AM for burns sustained to his/her bilateral lower extremities from a grease fire at home. The " Emergency Department Clothing/Valuables " sheet, dated 04/29/12, revealed three (3) yellow rings were with the patient at that time. There was no additional documentation in Patient #1 ' s record concerning these or any other rings.
Interview with Patient #1, on 10/24/12 at 10:20 AM, revealed he/she did not have any rings when discharged to another facility on 05/10/12. He/she stated nurses on the Burn Unit removed his/her rings, exact date unknown, because his/her hands were swelling. Patient #1 stated there were five (5) rings, two (2) of which had diamonds. He/she further revealed the rings were put in a baggy by the nurses, and he/she was told the rings would be sent to security and locked in a vault. This interview further revealed the patient talked with a nurse a couple of days before he/she was discharged about retrieving the rings, but the nurse stated the rings could not be found.
Interview with Patient #1, on 10/28/12 at 7:40 PM, revealed he/she did not get a claim ticket when he/she gave her rings to the nurses on the Burn Unit. He/she again stated a bag was brought into his/her room, and his/her rings were placed in a bag. Patient #1 stated the nurses said they were going to call security to get the bag, and security would place the rings in a locked vault. He/she also revealed the nurses said he/she could get the rings at discharge.
Interview with the Security Operations Manager, on 10/29/12 at 1:10 PM, revealed he had an incident during the summer months where a patient stated some items were missing, but there was nothing in the logs indicating security had ever received any valuables. He further stated he could not remember if this was Patient #1. The interview further revealed if any valuables are checked into security, there would be documentation and witnesses, usually nursing and security staff.
Interview with UK Legal Department Employee #1, on 10/29/12 at 3:15 PM, revealed one of her duties was to investigate and make a recommendation as to whether or not claims are paid. She revealed Patient #1 ' s claim had been initially denied, and she had recommended it be denied because both nurses involved stated they had taken Patient #1 ' s rings off, placed them in a baggy and then placed in Patient #1 ' s belonging bag or luggage for family to get. She further revealed she found no documentation in Patient #1 ' s clinical record, except for the " Emergency Department Clothing/Valuables " sheet, about jewelry. She further revealed she had found no documentation that security had had any involvement with these rings.
Interview with RN #1, on 10/30/12 at 9:41 AM, revealed she had been involved in removing Patient #1 ' s rings, along with NCT #1, date unknown, because Patient #1 ' s hands were swelling. She further revealed she suggested to Patient #1 that he/she lock the rings in security ' s safe, but Patient #1 wanted to keep the rings with him/her to give to family members later that evening. RN #1 further revealed she could not remember the number of rings; however, she stated the rings were placed in a baggy. RN #1 also revealed she did not document Patient #1 ' s refusal to lock up the rings on form H703 or in the nurses notes.
Interview with NCT #1, on 10/30/12 at 11:03 AM, revealed Patient #1 ' s hands were swelling and she believed if the rings were not removed, they might have to be cut off, as Patient #1 had a surgery scheduled. She further revealed there may have been up to six (6) rings, all a " dingy " gold, and she placed them in a bag with the patient ' s name on the bag, placed this bag inside the patient ' s medicine bag and put the medicine bag inside of the patient ' s piece of luggage. NCT#1 also stated the rings were removed sometime in the afternoon, date unknown, and Patient #1 stated her son would be in to pick up the rings between 8:00 and 9:00 PM that evening. She further revealed because Patient #1 was not confused, was ambulatory in the room and had a family member coming to get the rings in a few hours, the paperwork was not completed and normal procedure was not followed for removing valuables from a patient. Also, NCT #1 stated she assumed the family had taken the rings home; however, she revealed about a month or so after the patient was discharged , she understood Patient #1 ' s daughter had contacted the facility about the rings, and the rings described by the daughter did not match the rings that were taken off by NCT #1.