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Based on a review of hospital policy, 5 open and 5 closed patient records, it was determined that the hospital failed to assess whether 2 of 10 patients lacked decision making capacity or certify an incapacity prior to obtaining consents by the patient's surrogate decision maker.

Per hospital policy titled, "Patient Consents" (reviewed 08/18) section B, "Patient Lacks Capacity to Give Consent:" "Physician Certification: In the event that a patient is unable to make informed decisions about his/her healthcare, consent for treatment may be obtained from a healthcare agent appointed by a valid advance directive, or if none has been appointed, from a surrogate authorized by Maryland law, if two physicians have certified in writing that the patient is incapable of making an informed decision regarding treatment."

Patient #6 was a 75+ year old who presented to the hospital with hip fracture. Per patient's history and physical on admission, patient #6 was "alert and oriented to person, place, and time." On the 2th day of admission patient underwent a surgical procedure. Per physician progress note at 07:25, patient was "negative for confusion." Consents for anesthesia, blood transfusion, and the surgical procedure obtained that same day were signed by patient #6's family member. No notation could be found explaining why the surgical team used a surrogate decision maker.

Patient #4 was a 90 + year old that presented to the emergency department after sustaining a fall at an assisted living residence. The patient reported feeling weak and lost balance, falling and striking the back of their head on the floor. Patient denied any loss of consciousness, back pain, or neck pain. The patient was documented as oriented and provided information of past medical history. The patient's admission Consent to Treat and Important Message from Medicare were not signed by the patient. In the medical record next to the signatures was "POA." A request was made to the hospital for a copy of the patient's Advance Directives and Power of Attorney (POA), the hospital was unable to provide the documentation. No Advance Directive, Medical POA, or Living Will was found in the medical record.

In summary, there was no mention in the record that patient #6 and #4 were unable to make their own decisions nor was a certification of an incapacity obtained prior to obtaining consents from a surrogate. Therefore, the hospital failed to honor the patient's right to make informed decisions about their care.

Based on 5 open and 5 closed patient records, it was determined that the hospital failed to assess and /or provide documentation of whether patient #8 and #4 had an advance directive on admission.

Patient #8 was a 70+ year old patient who presented to the hospital with abdominal pain and was admitted for further work up. There was no indication in the record that hospital staff assessed whether patient #8 had an advance directive. Patient was discharged to home the following day in stable condition.

In addition, patient #4 arrived with a Maryland Orders for Life Sustaining Treatment (MOLST) form that indicated the patient's code status was a Do Not Resuscitate option B (DNR-B) on the paper chart. In review of patient #4's chart in the electronic medical record the patient was listed as a full code. The DNR-B order was cancelled and changed to that of a full code; however, there was no documentation of the patient requesting to change code status. Medical record documentation lacked mention of discussion of code status and changes made to the patient's code status with the patient. It is unclear as to if the patient requested a change of their code status and /or who made the decision to change the patient to a full code. The hospital failed to assess and properly document patient #4 changes in advance directive. A valid copy of the MOLST was found in the paper chart, despite the EMR stating full code.

Based on review of 5 open and 5 closed medical records, inclusive of one violent restraint record from the behavioral health unit, it was determined that the medical and nursing staff failed to obtain a restraint order after a violent restraint was applied for patient #1.

Patient #1 was an adult patient who was admitted to the behavioral health unit for suicidal ideations. On the 2nd day of admission, patient #1 was placed in violent 4 point (limb) restraints at 04:55 for displaying harmful behavior towards themselves and released at 05:40. An order for the restraint was not found in the record.