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Based on interview,record review, and policy review the facility failed to (1) obtain patient/patient representative signature(s) for informed consent for treatment for 1 (#28) of 20 patients reviewed for patient rights from a total of 20 sampled patients and (2) provide 2 (#14 and # 21) of 20 patients reviewed for patients rights a standardized notice, "An Important Message from Medicare" (IM) in a timely manner from a total of 20 sampled patients resulting in the increased potential for violations of patient rights including treatments without conformed consent, lack of knowledge regarding decision making for hospital services, discharge planning, reporting of concerns, and the right to appeal a hospital discharge. Findings include:

On 10/5/16 at approximately 1440 a review of the clinical record for patient #14 was conducted with Registered Nurse (I). According to Staff I the facility used an electronic record and a hard copy record (paper). She explained the paper chart was mostly used for patient consents for treatments and diagnostic test results. A review of the clinical record revealed patient #14 was 39 year old female admitted to the facility on 9/27/16 with a diagnosis of Sepsis. The admission face sheet listed the patient's primary insurance was Medicare due to a disability.

A review of the patient's, "An Important Message from Medicare" (IM) About Your Rights form revealed the form was signed by the patient on 10/3/16 (6 days after the patient's admission). There was no further evidence in the clinical record that documented why the patient signature was not obtained until 10/3/16.

When queried Staff I stated, "Usually those forms (consent for treatment and IMM are completed on the patient's admission). There is nothing on the form that indicates why it was not signed on her admission."

On 10/6/16 at 1130 a review of the facility's policy titled "Admission Process" (dated 1/27/16), documented:
Policy: "...7. d. Explanation of Additional forms required for Medicare patients:
i. Inpatients-An Important Message from Medicare/Champus-This form shall be given to the patient within 2 calendar days of admission and be signed by the patient representative. A follow-up copy of the form signed ay admission shall be given to the patient within 2 calendar days of discharge. This form requires the address of the state Quality Improvement Organization (QIO) be pre-printed. It is the responsibility of the DQM to ensure that this information is accurate...".





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On 10/4/2016 at approximately 1430 during the record review of patient #21 medical record it was noted the name of the durable power of attorney (DPOA) was printed on the Important Message from Medicare (IMM) without a date or time. During continued review of the record the consent to treat document stated telephone consent was received but failed to have a date and time of receiving consent. Staff F was queried as to how it could be ensured that the DPOA had received the information of the IMM. Staff F responded "I can't answer that question."

On 10/6/2016 at approximately 1045 a review occurred of the policy "Patient discharge and appeal rights" dated 1/2011 with a revision date of 1/2016. According to the policy "the IM (important message) notice should be delivered to and initialed by the patient or patient's representative, this then become the follow IM notice... 2) The beneficiary (or representative) should initial the signed IM copy and it should be dated and timed.


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At the Taylor campus on 10/4/2016 at 1600, Patient #28's medical record was reviewed and it was discovered that there was a lack of patient/patient representative signature on both the "Admissions Agreement/Conditions of Treatment" form and the "Acknowledgment of Receipt of Health Care Information and Consent to Text Messaging Communications" form. Each form had the patient representative's first name only printed on the "Signature of Patient or Patient Representative" line. The forms were both witnessed by Staff W on 9/30/2016 at 10:04. Additionally, the "Advance Directive and Patient Self-Determination" form, also dated 9/30/2016 and timed 10:04, stated, "Telephone consent" on the "Signature of Patient or Patient Representative" line without indication of who gave the telephone consent. Staff W also witnessed this form. There was no second witness as to the telephone consent being given.

On 10/5/2016 at 1510, Staff W was queried regarding these forms. Staff W stated she had spoken with the patient representative over the phone and had printed the patient representative's first name on the signature line for the "Admissions Agreement/Conditions of Treatment" form and the "Acknowledgment of Receipt of Health Care Information and Consent to Text Messaging Communications" form because she "felt uncomfortable" signing the patient representative's name and "wasn't sure what to do." Additionally, Staff W admitted that she "didn't realize" she should indicate who was giving the telephone consent on the "Advance Directive and Patient Self-Determination" form.

On 10/5/2016 at 1520, Staff T was queried as to the expectations of obtaining patient/patient representative signatures and phone consents. Staff T stated, "The staff should obtain the patient/patient representative signature whenever possible. Phone consents are expected to have a witness confirm."

On 10/6/2016 at 1300, facility policy titled "Admission Process", last revised 1/27/2016, was reviewed. On page three, number 6, c, iii, policy states, "Ensure that all fields are completed on admission documents and that the documents are signed by the patient/representative upon admission."

Based on interview and record review the facility failed to ensure that all medical records were completed within 30 days after discharge resulting in the potential for inaccessible information necessary for health care staff to provide for the patients health care needs. Findings include:

During record review on 10/06/16 starting at 0845, with medical records staff K present, the combined delinquent medical records percentages where reviewed from September 2015 through October 06, 2016. The results were, as follows:

Month/Year Percentage of Delinquent Medical Records
09/15 24.0%
10/15 43.0%
11/15 44.0%
12/15 57.0%
01/16 36.0%
02/16 34.5%
03/16 39.0%
04/16 32.4%
05/16 37.1%
06/16 31.3%
07/16 37.0%
08/16 33.4%
09/16 30.5%
10/16 38.1% (as of 10/06/16)

During an interview with medical records staff K on 10/06/16 at 1000, staff K said the facility had notification systems in place to remind clinicians when documentation becomes deficient and/or delinquent but, despite utilizing these systems, some clinicians do not complete the required documentation in a timely manner. Staff K also said the facility had systems in place to suspend clinicians who do not complete required documentation in a timely manner.

Review of facility policy titled, "Completion/Delinquency of Medical Records" revised September 2010 defined medical record delinquency as, "...when it has not been completed within 30 days of discharge." The policy also indicated, "All medical records shall be completed within 30 days following discharge."

Based on observation, interview, record review, and policy review the facility failed to provide and maintain a clean, sanitary environment resulting in the potential to spread infectious agents to all 67 patients served by the facility. Findings include:

On 10/4/2016 at 1009, during initial tour of the Lincoln Park facility's fifth floor, Room 519, a room which had been cleaned and was ready for a new patient, was entered. An accumulation of dust was found on top of the pulse oximetry unit as well as the light. This finding was confirmed by Staff D on 10/4/2016 at 1011.

On 10/4/2016 at 1013, during initial tour of the Lincoln Park facility's fifth floor, a reddish brown sign board was noted across from the nurses station near the hallway leading to the elevators. An accumulation of dust was found on the top horizontal surface of the sign board. This finding was confirmed by Staff D on 10/4/2016 at 1013.

On 10/4/2016 at 1015, during initial tour of the Lincoln Park facility's fifth floor, Room 573 was entered. An accumulation of dust was found on the top surface of the pulse oximetry unit as well as the light. This finding was confirmed by Staff D on 10/4/2016 at 1015.

On 10/4/2016 at 1322, during initial tour of the DMC 7th floor facility, Room 730 was entered. This was a semi-private room which was empty in both bays and had been cleaned and was ready for a new patient admissions. An accumulation of dust was found on the top surface of the pulse oximetry unit and light in both bays. This finding was confirmed by Staff B on 10/4/2016 at 1323.

On 10/4/2016 at 1528, during initial tour of the Taylor 2nd floor facility, Room 205 was entered with Staff J. Staff J stated that this room had been recently vacated and had not yet been cleaned. It was noted that there was no contact isolation sign posted. An accumulation of dust was found on the top surface of the pulse oximetry unit. This was confirmed by Staff J on 10/4/2016 at 1529.

On 10/5/2016 at 1148 facility policy titled "Initiation of Transmission-based Precautions", last revised 2/2016, was reviewed. On page three, under the section "Routine and Terminal Cleaning" policy states, "1. The room or cubicles are cleaned daily according to the cleaning procedures unless the patients are in special isolation."







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On 10/4/2016 at approximately 1600 during the initial tour of the facility (campus B) 8 of 8 rooms identified as isolation precautions were observed to contain a plastic rolling storage unit placed approximately 8 feet inside of the room with personal protective equipment (PPE). The PPE within those rolling storage containers were designated for the use of both staff and visitors. Staff F and staff J were both queried why PPE was not outside of the patient room for staff and visitors to utilize clean PPE prior to going into the room. Staff J stated that the rolling storage containers were discussed with corporate management and the facility had been told the rolling storage units were considered a fire safety hazard. Staff J was then queried as to the potential risk of cross contamination having PPE within the room open directly to areas of where the patient could possibly contaminate the rolling storage device and having staff and visitors exposed while obtaining PPE. Staff J responded the area in which the container was kept was considered an "ante-space".

Staff J was then questioned to define "ante-space". Staff J stated it was an area deemed far enough away from the patient that posed no risk to staff or visitors while gowning up similar to an "anteroom". According to the Centers for Disease Control (2007) isolation precautions requires staff and visitors to gown, glove, and/or mask upon entry into the room is indicated to address unintentional exposure with environmental contaminated surfaces (or contact with a patient).

On 10/5/2016 at approximately 0930 a policy review occurred of "Initiation of transmission based precautions" dated 12/2013 with a revision date of 02/2016. According to the policy states the following: "Preparation of the room: 1. Outside the door: a. isolation carts: a pre-stocked isolation cart that contains equipmentand supplies required for all types of standard or transmission based precautions." During an interview with staff D on 10/6/2016 at 1000 it was confirmed that the policy was not being followed as defined.