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.
|LAUREL REGIONAL MEDICAL CENTER||7300 VAN DUSEN ROAD LAUREL, MD 20707||July 20, 2017|
|VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS||Tag No: A0117|
|Based on a review of 7 open and 3 closed medical records, policies and procedures, the hospital failed to provide 2 Medicare recipients with the standardized notice, "An Important Message from Medicare," (IM) as required to beneficiaries within 48 hours of admission and discharge.
Patient #1 was admitted for nine days and the medical record revealed no evidence or documentation of receipt of the initial IM.
A review of patient #2's medical record revealed no evidence or documentation of a secondary IM after stay of five days.
|VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES||Tag No: A0122|
|Based on review of hospital policy and procedures, it was determined the hospital did not have a specified time frame in their grievance policy for follow-up of a written response.
Review of hospital policy, "Patient Complaints and Grievances, 200-5" (reviewed 06/2017) states under the "Grievance Process": "The hospital must attempt to resolve all grievances as soon as possible or if the investigation is not or will not be completed within 7 days, the patient or patient's representative will be informed that the hospital is still working to resolve the grievance. The letter is to be sent to the patient/patients' representative within 7 days and must state an anticipated resolution date." The policy does not specify an end date for completing grievance investigations.
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|Based on review of 10 medical records and hospital policy and procedures, it was determined the hospital failed to follow their policy regarding documentation of interpreter services in a patient's medical record.
Patient #1 was a Spanish-speaking, elderly patient with a history of dementia who required interpreter services. Review of the medical record revealed a "Communication Assessment Form (Spanish)" that had the check box next to "Espaol" marked off for oral and written communication and "Si" was marked for the need of an interpreter. Review of the record revealed that there were times interpreter services were used. The second page of the form was titled "Interpretive Service Log." There was no documentation on this page. Review of hospital policy, "Language Assistance to Persons with Limited English Proficiency, 200-31," (reviewed July 2017) has as a procedure to "Document the date and time of the request for interpretative services on the reverse side of the Communication Assessment Form" for interpretive services on-site, by phone and interpretive services via video.
|VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION||Tag No: A0123|
|Based on a review of the complaint and grievance files it was determined that thre was no documentation that the complainants were contacted at the conclusion of the investigation for six of seven grievances reviewed.
Grievance #1, 2 and 3 were opened in March 2017. Grievance #1 and #2 were never contacted post the acknowledgment letter and did not have a resolution letter sent to them. Grievance #1, 2 and 3 were each informed by letter that they would be notified of the findings "within two weeks" of Grievance Committee meeting that was held in March 23, 2017. While a physician was reported to have followed up by phone for grievance #3, there was no resolution letter found. Grievance #4 was opened in April 2017. There was no record of a resolution letter. Grievances #6 and #7 were opened in May 2017. Grievance #6 was informed by letter dated May 15, 2010 that they would be notified of the findings "within two weeks" of Grievance Committee meeting that was held in May. There was no follow up after the 2 weeks. Grievance #7 was informed by letter dated May 31, 2017 that stated "Please allow us at least thirty (30 days) to complete the investigation." There was no follow up after the thirty days. There was no resolution letter found in either case.
|VIOLATION: USE OF RESTRAINT OR SECLUSION||Tag No: A0154|
|Based on review of hospital policy and procedures it was determined that the hospital included inappropriate criterion for the cessation of violent restraints/seclusion in their policy.
Review of hospital policy, "Use of Restraint and Seclusion" (reviewed 5/2017) revealed "discontinuation criteria" listed under section "10. Seclusion and restraint for violent/self destructive behavior" to include "Patient no longer exhibits aggressive/violent behavior" and "patient is aware of surroundings, coherent and demonstrates ability to follow directions." The latter criterion is inappropriate as the use of restraint and seclusion must be based on actual and imminently dangerous behaviors not contingent on patient's awareness or cooperation. Of note, the "criteria for release" under "Section #1 Physician's Order #" in the packet titled "Laurel Regional Hospital Soft Restraint/ Seclusion/ Leathers (Tuff Cuff)" does not contain this criterion for release.