HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (Pt. #5) clinical records reviewed for informed consent. The Hospital failed to ensure the consent for admission and treatment was obtained from the legal guardian.

Findings include:

1. On 09/29/2021 at approximately 11:00 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was brought in by ambulance crew from a Nursing Home to the Emergency Room on 05/25/2021, at 9:52 AM, with a chief complaint of chest pain. Pt. #5 was admitted to the In-patient Medical-Surgical/Telemetry Unit on 05/26/2021, at 2:36 PM, with a diagnosis Chronic Chest Pain. Pt. #5 was transferred via ambulance to a Skilled Nursing Facility on 05/29/2021, at 10:27 AM.

Pt. #5's clinical record included the following:

- The condition of admission and consent to medical treatment inpatient/outpatient form (3 pages) and Patient Rights and Responsibilities form, signed by the patient on 05/25/2021, at 10:39 AM. The patient's signature was witnessed by the registration desk Registrar (E #8) on 05/25/2021, at 10:37 AM. The Medicare outpatient observation notice form, dated 05/25/2021, at 2:34 PM, indicating, " ...pt. [Pt. #5] unable to sign due to medical condition ..." witnessed by registration staff.

- The scanned copy of admission record from Nursing Home, with picture of the patient (Pt. #5), demographics and included the contact information - [Name of individual] listed as Office of State Guardian; Relationship: Guardian; and Cell phone information.

-Pt. #5's clinical record lacked the documentation of the rationale of why the consent for admission and treatment was not obtained from the Legal Guardian.

2. On 09/30/2021 at approximately 2:50 PM, the Hospital's policy titled, "Informed Consent" dated 04/2021, was reviewed and included, " ...Consent for treatment obtained by the Patient Access staff upon registration for treatment ...Proper signature needed (no initials or first name only) ...Case Management will follow-up the following business day with patient and/or family in order to acquire consent for treatment ...The patient or legal guardian must sign, date, and time the consent form ...appropriate individual to sign consent form ...Legal guardian of patient who has been legally declared incompetent ..."

3. On 09/29/2021 at approximately 2:00 PM, the Patient Access Director (E #6) was interviewed. E #6 stated that she is not sure why the Registrar (E #8) did not contact the State Guardian as listed in the transfer form from the Nursing Home.

Based on document review and interview it was determined that for 1 of 5 patient (Pt. #5) clinical records reviewed for inpatient admission notification, the Hospital failed to ensure the Legal Guardian was notified of admission.

Findings include:

1. On 09/29/2021 at approximately 11:00 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was brought in by ambulance crew from a Nursing Home to the Emergency Room on 05/25/2021 at 9:52 AM, with a chief complaint of chest pain. Pt. #5 was admitted to the In-patient Medical-Surgical/Telemetry Unit on 05/26/2021 at 2:36 PM, with a diagnosis Chronic Chest Pain. Pt. #5 was transferred via ambulance to a Skilled Nursing Facility on 05/29/2021, at 10:27 AM.

Pt. #5's clinical record included the following:

- The scanned copy of admission record from Nursing Home, with picture of the patient (Pt. #5), demographics also included the contact information - [Name of individual] listed as Office of State Guardian; Relationship: Guardian; and Cell phone information.

- The discharge planning note by Case Manager (E #9) dated 05/27/2021, at 6:28 PM, " ...from home to ED, inpt. [inpatient] status with dx [diagnosis] of chronic chest pain, ...being tx [treatment] with O2 [oxygen] tele [telemetry - cardiac monitoring] physical therapy is recommending SNF (Skilled Nursing Facility) placement, but patient wants to go home ...will continue to follow for d/c [discharge] planning needs ..."

- The Case Manager (E #9) note dated 05/28/2021, at 8:00 PM, " ...faxed referral info [information] to [names of three skilled nursing facility] ...patient [Pt. #5] is unable to transferred to the SNF today, must meet the 72 hr. Medicare inpt. [inpatient] status prior to transfer ..."

- The discharge nursing note by Registered Nurse (E #15) dated 05/29/2021, at 10:10 AM, included, " ...Report given to RN at SNF-C, ...Pt. [Pt. #5] transferred via ambulance to the SNF-C..."

-Pt. #5's clinical record lacked the documentation by the Case Manager notification of the family member/legal guardian of patient admission to Hospital and transfer to Skilled Nursing Facility.

2. On 09/30/2021 at approximately 2:45 PM, the Hospital's policy titled, "Case Management Plan of Discharge Planning Policy" dated 03/2021, was reviewed and included, "...The Case Manager will assess the patient's discharge plan for appropriateness and factors that may impact the patient's continuing care needs...The patient will be involved in planning and preparing for post hospital care. Family members and other will be involved as needed..."

3. On 09/29/2021 at approximately 1:30 PM, the Director of Case Management (E #5) was interviewed. E #5 stated that the case manager should have called the Nursing Home, where the patient (Pt. #5) came from to confirm the information about the family and State Guardian. E #5 stated that she is not sure why the State Guardian was not contacted. E #5 stated that although the Case Manager had initiated the discharge planning and arrangements made to place the patient (Pt. #5) in a SNF, per physician orders for continuity of care.

4. On 09/30/2021 at approximately 9:15 AM, the Registered Nurse (E #15) that discharged the patient was interviewed. E #15 stated that patient (Pt. #5) was transferred via ambulance to (SNF-C). E #15 stated that she does not recall calling any family member to notify regarding the transfer to the SNF. E #15 stated that Pt. #5 was alert and awake, was oriented to only self. E #15 stated that, the patient was not aware of who he was speaking to, and that she had to remind the patient frequently that he is in a Hospital.

5. On 09/30/2021 at approximately 1:00 PM, the Attending Physician, (MD #5) was interviewed. MD #5 stated that he was not sure why the Case Manager did not contact the Nursing Home that the patient came from to the Hospital. MD #5 stated that he has known this patient (Pt. #5) for several years and is aware that patient has a State Guardian.

6. On 09/30/2021 at approximately 2:25 PM, the Chairman of Ethics Committee (MD #6) was interviewed. MD #6 stated that she is not sure why the State Guardian for the patient was not notified, if the name and number to contact the State Guardian was written in the admission papers from the Nursing Home.