HospitalInspections.org

Findings:

Based on review of records and interview, the hospital failed to provide written notice of its decision, steps taken, results of the investigation, and date of completion to 6 of 7 grievances received from 01/20/10 through 05/20/10, from patients (Patient #3, #4, #6, #7, #8, and #9) regarding the quality of care and/or allegations of abuse or neglect.

Patient #3 ' s daughter complained that her mom was hit by an employee during Occupational Therapy on 01/20/10. An investigation was done and resolved.

Patient #4 ' s son complained on 01/24/10 that the Respiratory Therapist refused to change the portable oxygen tank on the back of his mom ' s wheelchair and putting her back on oxygen after her nebulizer treatments.

Patient #6 ' s wife complained on 02/06/10 that her husband was left in a wheelchair, wet for 2 hours.

Patient #7 complained on 02/25/10 that her needs were not being met by RN #11, an agency nurse.

Patient #8 complained on 02/28/10 that her nurse is rude, her bed was not made, and her call bell is not answered.

Patient #9 ' s daughter complained that nurse #12 is not giving her mother pain medication when she requests it and the call light is not being answered.


Patient Rights Policy, " Patient Complaint/Grievance Process, " revised, 11/30/09, requires under, " The hospital ' s patient representative, along with the CEO, will prepare a written response to the patient ' s grievance. The written response is required whether a meeting was held to discuss the investigation with the patient. The written response must contain the following: a) a description of the issues raised by the grievance, b) a description of the steps taken to investigate the issue, c) the date the grievance was resolved and what steps were taken to resolve the grievance, and d) the name of a contact person at the hospital that the patient can call with additional questions. "

In an interview with Personnel #2, Director of Quality and Risk Management, on the afternoon of 08/05/10, she was asked if a written notice of the hospitals decision that contained the required components of the grievance process was provided to Patient ' s #3, #4, #6, #7, #8, and #9. She stated, " No. "

Based on observation, review of records and interview, the hospital did not secure and protect confidential patient healthcare information for 8 of 8 boxes of patient medical records who were admitted to the hospital for 11 of 11 months dating from June 1, 2009 through May 28, 2010.

Findings:

During a tour of the facility on the morning of 08/04/10, the surveyor observed 8 unsecured storage boxes labeled with the words, " Medical Records " dating from June 1, 2009 through May 28, 2010 in the Patient Admission Office. The boxes contained files with patient demographics and medical information. The admission office is open to visitors and hospital staff.

In Health Information Management Policy " Security and Retention " , dated 10/01/08, requires, " To protect the confidentiality and originality of all Protected Health Information (PHI) and other patient related data ...all medical records will be stored ...in a protected area in Medical Records ...must be protected from loss ...unauthorized access or theft ... "

In Health Information Management Policy " Security Medical Record " , revised 11/01/09, requires, " The hospital must have a procedure for ensuring the confidentiality of patient records ...must ensure that unauthorized individuals cannot gain access ... "

In Patient Rights and Responsibilities, dated 04/14/09, " The patient has the right to: Expect all communication and records will be held confidential... "

In an interview the morning of 08/04/10, the Director of Health Information Management (Personnel #6), was asked to identify the contents in the 8 boxes labeled " Medical Records " . She was then asked if the boxes contained copies of patient ' s medical information. She stated, " Yes. " She was asked if she knew how long the medical records had been stored in the Admission Office. She stated, " No. " She was then asked if the PHI of the patient records were secured following the required hospital policy and procedure. She stated, " No. "

Based on review of records, and interviews, the hospital delegated and assigned sterile wound care to 1 of 1 unlicensed assistive personnel (UAP) (Personnel #21) without verification of competencies and qualifications from July 15, 201 through August 3, 2010.

Findings Included:
The personnel file (Personnel #21) showed a current certification as a nurse aide in Texas.

Review of Job Description, " Certified Nurses Aide/Patient Care Tech " for Personnel #21 dated 03/19/09, did not address providing sterile treatments or wound care as part of the provision of care/services that she is qualified to perform.

Review of " Core Competency Assessment " for Personnel #21, dated 12/03/08, did not show that she was deemed competent or qualified to perform sterile treatments or wound care.

Nursing policies and procedures did not address Delegation of Nursing tasks to unlicensed assistive personnel.

In an interview with Personnel #21 on the afternoon of 08/06/10, she was asked if she is an employee of the hospital. She stated, " Yes. " She was asked what her current certification is. She stated, " I am a certified nurse aide. " She was asked what her job duties include. She stated, " I was hired by the hospital to do wound care for the doctor (Physician #10) 3 days per week. I come before the doctor gets here and prepare the patient for him by cleaning the wounds and them dressing them after he is finished. I take pictures, measure and document the care on the wound care sheet. The nurse signs it off after I am finished. " She went on to state, " The doctor wants me to have the patient ready before he gets here so he does not have to waste his time hunting down a nurse. " She was asked if the physician or the RN is present when she is performing the wound care. She stated, " No. "

In an interview with the DON (Personnel #1) on the afternoon of 08/06/10, she was asked if she was aware that Personnel #21 was performing sterile procedures and/or wound care without supervision. She stated, " Yes. " She was asked if she considered Personnel #21 competent to perform sterile wound care and dressing changes by qualifications, education and experience. She stated, " No. "

In an interview with the Chief Clinical Officer (Personnel # 3) on the afternoon of 08/06/10, He was asked if he was aware that Personnel #21 was performing sterile procedures and/or wound care without supervision. He stated, " Yes. " He was asked if he considered Personnel #21 competent to perform sterile wound care and dressing changes by qualifications, education and experience. He stated, " No. "

Based on review of records, and interviews, the hospital failed to evaluate clinical activities for 5 of 5 (Personnel #16 through #20) non-employee licensed nurses who provided direct patient care and/or supervised nursing staff between 04/01/10 and 07/31/10.

Findings Included:
Nurse Staffing sheets showed that the following non-employee licensed nurses provided direct patient care:

RN #16 worked the 7pm - 7 am shift on 04/29/10 and 04/30/10.
RN #17 worked the 7 am - 7 pm shift on 04/21/10.
LVN #18 worked the 7 pm - 7 am shift on 04/23/10, 05/27/10, 05/16/10, and 06/04/10.
LVN #19 worked the 7 pm - 7 am shift on 06/12/10.
LVN #20 worked the 7pm - 7 am shift on 06/12/10.

In an interview with the DON (Personnel #1) on the afternoon of 08/05/10, she was asked how non-employee nurses were oriented or evaluated. She stated there was currently no system in place for either orientation or evaluation.

Hospital policy " Utilization and Quality Monitoring of Agency Personnel " , revised 03/03/10, requires that " The Director of Nursing will ensure that each agency personnel ' s performance is evaluated after the first shift and an on-going performance evaluation process ... "