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.

THOMAS JEFFERSON UNIVERSITY HOSPITAL 111 SOUTH 11TH STREET PHILADELPHIA, PA 19107 Nov. 9, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of the facility's policy, facility documents, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to follow its policy for resolution of a grievance for three of three medical records reviewed (MR11, MR12 and MR18).

A review of the Thomas Jefferson University Hospital policy entitled "Patient Complaints/Grievances-Management Of", last reviewed October 8, 2015, revealed, "... Grievances should be resolved in 7 (seven ) business days ... will send a letter within seven (7) business days stating the hospital is working to resolve the patient grievance and that a final response will be sent within thirty (30) business days. ... If resolution still cannot be completed within the thirty (30) business days, a letter will be sent to the complainant providing an update about the review process. ... 6. A written response must be provided for all patient grievances. The explanation must be in a manner the patient will understand. ... "

1. A review on November 9, 2016, of the "Grievance Letters Log-2016" revealed there was a grievance regarding the care of MR11 received on September 6, 2016. Review of the log revealed the grievance was not completed and was 63 days old and there was no 30 day letter sent to the complainant.

A review on November 9, 2016, of MR11 revealed the patient was admitted on July 8, 2016, with a diagnosis of Metastatic Cancer and expired on July 9, 2016.

2. A review on November 9, 2016, of the "Grievance Letters Log-2016" revealed there was a grievance regarding the care of MR12 received on September 23, 2016. Review of the log revealed the grievance was not completed and was 46 days old and there was no 30 day letter sent to the complainant.

A review on November 9, 2016, of MR12 revealed the patient was admitted on [DATE], for Cystoscopy (visualize the urinary bladder) and discharged on [DATE].

3. A review on November 9, 2016, of the "Grievance Letters Log-2016" revealed there was a grievance regarding the care of MR18 received on September 12, 2016. Review of the log revealed the grievance was not completed and was 53 days old and there was no acknowledgement letter nor 30 day letter sent to the complainant.

A review on November 9, 2016, of MR12 revealed the patient was admitted on [DATE], for treatment of chronic respiratory illness and discharged on [DATE].

An interview on November 9, 2016, at 1:16 PM with EMP1 confirmed that no acknowledgment letter and 30 day letter was sent to the complainant associated with MR18. EMP1 further confirmed that no 30 day letters were sent for the grievances associated with MR11 and MR12 and all three grievances were still unresolved.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on a review of medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure the patient's right to have a family member and primary care provider notified of admission to the hospital for six of 10 currently hospitalized inpatients (MR1,MR2, MR3, MR7, MR8 and MR9).

Findings include:

A review on November 9, 2016, of Thomas Jefferson University Hospital policy entitled, "Patient Rights and Responsibilities", last reviewed, December 15, 2014, revealed there was no provision to notify the patient's family member or primary care physician of admission to the hospital.

1. A review on November 8, 2016, of MR2 and MR3 revealed there was no documentation contained in the MR that the patients were asked if they wanted the primary care physician notified of their admission to the hospital.

Further review of MR 1 revealed there was no documentation contained in the MR that the patient was asked if they wanted a family member notified of their admission to the hospital.

An interview conducted on November 8, 2016, with EMP2 at 1:15 PM confirmed that the patients were not asked specifically if they wanted their family member or primary care physician notified of their admission to the hospital.

2. A review on November 9, 2016, of MR7, MR8 and MR9 revealed there was no documentation contained in the MR that the patients were asked if they wanted the primary care physician and family member notified of their admission to the hospital.

An interview conducted on November 9, 2016, with EMP3 at 11:15 AM confirmed that there was no documentation in the MR that patients were not asked if they wanted their family member or primary care physician notified of their admission to the hospital.