HospitalInspections.org

Based on staff interview, medical record review, and policy review, the facility failed to notify patient representatives of patient's rights, in advance of furnishing care (A0117). The facility failed to ensure patient representatives had the right to be involved in care planning and treatment, and were able to request or refuse treatment (A0131). The facility failed to provide patients/patient representatives access to the medical record upon written request within the timeframe established by the facility (A0148).

Based on medical record review, interview, and policy review, the facility failed to notify each patient's representative of patient's rights, in advance of furnishing care for one of 10 medical records reviewed (Patient #2). The active census was 38.

Findings include:

Review of the facility policy titled, Patient Rights, effective 04/14/15 revealed the purpose was to assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights. The Hospital fully supports, endorses and enforces the rights of patients. The Hospital informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements.

Patient #2 was an involuntary admission to the facility on 09/30/22. On 09/30/22 at 7:30 AM, the facility had Patient #2 sign a form stating Patient #2 received notice of her rights. A Progress Note by Staff D on 10/02/22 at 2:30 PM stated Patient #2 was not oriented, does not know where she is, said the year is May, does not know why she is here. "She is unable to answer questions regarding the mental status exam, she just stares at me while I am asking questions." A History and Physical from 10/01/22 at 9:30 AM revealed Patient #2 was disoriented to date, time, and situation. She did state she was in the hospital. A Nursing Note from 09/30/22 at 10:55 AM revealed Patient #2 arrived to the unit alert and oriented to self, very confused, major depressive disorder (MDD), and danger to others.

The medical record for Patient #2 did not contain evidence of the facility providing the notice of Patient Rights to Patient #2's family and/or Healthcare Power of Attorney (HCPOA) in advance of furnishing care.

Staff Z was interviewed on 12/01/22 at 1:39 PM. Staff Z reported the facility provided Patient #2's son with a copy of the facility's Patient Rights after the son provided the facility with HCPOA form.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136877.

Based on medical record review, policy review and interview, the facility failed to ensure the patient's representative had the right to be involved in care planning and treatment, and was able to request or refuse treatment for one of 10 patients reviewed (Patient #2). The facility's census was 38.

Findings include:

Review of the facility policy titled, Patient Rights, effective 04/14/15 revealed the purpose was to assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights. The Hospital fully supports, endorses and enforces the rights of patients. The Hospital informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements. Patient Rights according to federal guidelines include the following at a minimum:
a. The right to participate in the development and implementation of his or her plan of care.
b. The right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right does not include the provision of treatment or services deemed medically unnecessary or inappropriate.

The medical record for Patient #2 contained a State Healthcare Power of Attorney (HCPOA) designation by Patient #2 effective 03/28/13 naming Patient #2's husband as Patient #2's agent and Patient #2's son as an alternate agent.

Patient #2's alternate agent provided the facility a copy of Patient #2's Health Care Power of Attorney on 10/04/22.

Review of a progress note dated 10/13/22 written by the nurse practitioner revealed the patient did have an episode of wheezing yesterday. Nursing reports she did have more wheezing and shortness of breath yesterday. Chest x-ray obtained and showed patchy opacity in the right lower lung with small right pleural effusion. Likely secondary to pulmonary edema, atelectasis, or pneumonia. Nursing reports respirations were 34 but have come down to 24. Patient does have swelling to the bilateral lower extremities.

A Nursing Daily Assessment note from the 7:00 PM to 7:00 AM shift on 10/13/22 revealed Patient #2 was sent to an acute care hospital for wheezing, congested, and having a hard time breathing. Pulse oximetry was 71 percent. Patient placed on oxygen two liters nasal cannula. Sent to the acute care hospital at 11:00 PM

Staff Y was interviewed on 12/01/22 at 11:12 AM. Staff Y reported Patient #2's son requested to have Patient #2 discharged on 10/12/22 because the son wanted to take Patient #2 to an emergency department at an acute care hospital. Staff Y reported denying the son's request alleging Patient #2 was medically stable and the emergency department would have sent Patient #2 right back to this facility.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136877.

Based on policy review, email review and interview, the facility failed to provide a patient's representative access to the medical record upon written request within the timeframe established by the facility for one of 10 patients reviewed (Patient #2). The facility's census was 38.

Findings include:

Review of the facility policy titled, Release of Medical Records, effective 05/01/20, revealed Health Information Management Department shall release medical record information in accordance with established procedure consistent with Federal and State Law. The following time frames shall apply to release of information requests processed by the health record department:
1. Requests pertaining to current treatment of the patient: within one workday.
2. Patient/client request for access to own records: within thirty days.
3. Subpoenas and depositions: no sooner than 15 days after date of subpoena.
4. All other requests: within thirty days (closed records).

An email from Staff H to Staff P on 10/18/22 at 11:11 AM stated "Hello, for Patient #2, her son & POA (power of attorney) signed a request for medical records, they can be mailed to his address which is on the release, he pretty much wants the entirety of the record to include nursing notes, groups, PASRR and such, please provide the copy to the team for review prior to sending."

Staff P was interviewed on 11/30/22 at 12:19 PM. Staff P reported the facility received the record request on 10/18/22 for Patient #2 and it was an email request. Staff P reported the record had not been released yet. Staff P reported the facility had 30 days to release records and reported the record release request for Patient #2 had been received more than 30 days ago.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136877.

Based on medical record review, policy review, and interview, the facility failed to ensure registered nurses supervised and evaluated the nursing care of each patient for one of 10 patient medical records reviewed (Patient #2). The facility's census was 38.

Findings include:

1. Review of the facility's policy titled, Laboratory Services, revised 05/2021, revealed all inpatient care orders, a Patient Care Order sheet, orelectronic order must be documented in the patient's medical record. It is the policy of the facility that all care, treatment, and services provided by the facility are written directly or indirectly by a physician or licensed independent practitioner (LIP) credentialed by the facility as outlined in the Medical Staff Bylaws; and that these orders are clear, concise, and in accordance with all other applicable policies. All care, treatment, and services provided in the facility is supported by a physician's order. No care, treatment, or services may be provided prior to obtaining a physician's order, except in the specific situations outlined in this policy. The RN must notify the physician immediately if unable to carry out an order. Failure to carry out an order without supporting communication, documentation. and clinically appropriate rationale may result in discipline, up to and including termination, and reporting to the State Board of Nursing.

On 10/09/22 at 11:10 AM, an order was written to draw a basic metabolic panel (BMP), indicated for hypertension, from Patient #2 on 10/10/22.

The medical record for Patient #2 did not contain BMP results from 10/10/22. The medical record did not contain evidence of any nursing staff notifying a physician of the inability to draw the ordered BMP

Staff Y was interviewed on 11/30/22 at 3:19 PM. Staff Y reported the facility attempted to draw Patient #2's BMP two times and were unsuccessful. Staff Y reported the facility did not attempt a third time because Patient #2's room was moved to a different floor and the third lab attempt was missed. Staff Y confirmed the facility did not obtain the ordered BMP.

2. Review of the the facility policy titled, Patient Rights, effective 04/14/15 revealed the purpose was to assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights. The Hospital fully supports, endorses and enforces the rights of patients. The Hospital informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements. Patient Rights according to federal guidelines include the following at a minimum:
a. The right to participate in the development and implementation of his or her plan of care.
b. The right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment.

The facility's policy titled, Vital Signs, effective date: 05/01/2020, revealed it is the policy of the Hospital to obtain vital signs at regular intervals and to report vital signs that are out of normal range to the appropriate clinician. Vital signs at the facility include the following:
a. Temperature
b. Pulse (beats per minute)
c. Respirations (breaths per minute)
d. Blood pressure
e. Pulse Oximetry

All registered nurses (RNs), mental health technicians (MHTs) and State Tested Nursing Assistant (STNA) will be trained and demonstrated competency on obtaining vital signs. Vital signs will be measured at the interval ordered by the physician and more frequently, if required prior to a particular medication or intervention, or if the RN is concerned that the patient's medical condition has changed. If abnormal vital signs are obtained, the RN, STNA or MHT is to measure a second time unless doing so may impact the patient's immediate survival. If the first vital sign measurement has occurred using a vital sign monitor, the RN or MHT should take the second set of vital signs manually in order to double check the values. The following are normal vital sign ranges and vital sign measurements that require additional interventions: Respirations - normal is 12-20 breaths per minute. If respirations are <12 breaths or >22 breaths notify the RN within 30 minutes. If respirations are <12 breaths or >30 breaths, notify the RN immediately. Blood pressure - normal is 90/60 mm/Hg to 120/80 mm/Hg. If the blood pressure is <90/60 mm/Hg or >130/90 mm/Hg, notify the RN within 30 minutes. If the blood pressure is <80/60 mm/Hg or >150/100 mm/Hg, notify the RN immediately. Pulse oximetry - normal is 95-100 percent If pulse oximetry is <92 percent or <88 percent on oxygen, notify the RN within 30 minutes. If the pulse oximetry is <85 percent, notify the RN immediately.

Patient #2's medical record included the following abnormal vital signs documented on the Nursing Daily Assessment notes:
10/13/22 7:00 PM - 7:00 AM shift Pulse Oximetry 90 percent
10/13/22 7:00 AM - 7:00 PM shift Pulse Oximetry 90 percent, Respirations 34
10/12/22 7:00 PM - 7:00 AM shift Pulse Oximetry 84 percent,
10/12/22 7:00 AM - 7:00 PM shift BP 220/103, Pulse Oximetry 89 percent
10/11/22 7:00 AM - 7:00 PM shift Respirations 36

The Vital Signs Flow Sheet for the Specified Patient stated to "Notify Provider if Vitals are Outside of the Below Ranges"- Temp 97.8-99.1, Pulse 60-100, Respiration 15-20, 02 Sats Less Than 95 percent, BP 90/60 - 140/90. The Specified Patient's vital signs included the following abnormal vital signs (blood pressure = BP, respirations = R, Pulse Oximetry = O2):
09/30/22 (no time) Pulse Oximetry 94 percent
10/01/22 7:00 AM Pulse Oximetry 91 percent
10/01/22 (no time) Pulse Oximetry 93 percent
10/05/22 7:00 PM Pulse Oximetry 92 percent
10/07/22 12:30 PM Pulse Oximetry 87 percent
10/07/22 7:00 PM Pulse Oximetry 92 percent
10/09/22 7:00 AM , Pulse Oximetry 90 percent
10/10/22 7:00 AM Pulse Oximetry 90 percent
10/11/22 7:00 AM , R 36, Pulse Oximetry 92 percent
10/12/22 7:00 AM BP 220/183, Pulse Oximetry 89 percent
10/12/22 7:00 PM Pulse Oximetry 84 percent
10/13/22 8:00 AM R 34, Pulse Oximetry 90 percent
10/13/22 7:00 PM Pulse Oximetry 90 percent

The facility failed to document how the abnormal vitals signs were obtained and there was no evidence the values were double checked. There was no documentation that registered nurses and/or providers were notified of the abnormal measurements in accordance with the required timeframes. There was no documentation the facility notified the patient's Healthcare Power of Attorney/respresentative of the patient's health status.

The findings were shared in an interview with Staff Y on 11/30/22 at 10:06 AM and confirmed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136877.

Based on medical record review, policy review, and interview, the facility failed to ensure all medical records contained other information necessary to monitor the patient's condition for one of 10 medical records reviewed (Patient #2). The facility's census was 38.

Findings include:

Review of the facility's policy titled, Chart Order, effective 05/01/20 revealed the purpose was to ensure that the medical documentation placed in a standardized order securely in the chart. All information (clinical, legal and administrative) relating to an episode of care shall be grouped together.

Patient #2 was a patient at the facility from 09/30/22 through 10/13/22. The medical record for Patient #2 did not contain a Nursing Daily Assessment note from the 7:00 AM to 7:00 PM shift on 10/04/22.

The findings were shared in an interview with Staff Y on 11/30/22 at 10:06 AM and confirmed.