HospitalInspections.org

Based on document reviews and interviews, the hospital failed to inform a patient/patient representative of patient's rights in advance of providing care for one (1) of ten (10) patients reviewed (Patient #1).

Finding:

The MaineGeneral Medical Center "Informed Consent" policy's purpose, last reviewed/revised in 01/25, states in part, "To establish the right of a patient or their representative, as allowed under Maine law, to make informed decisions regarding their health care. The patient's rights include being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment."

In addition, it states, "Health care decisions for incompetent adults may be made by others expressly authorized to make such decisions or by family members in certain circumstances. Authorized decision-makers do NOT have the authority to make decisions contrary to the decisions made by the patient while competent. Authorized decision-makers are determined in the following order of priority: ... Guardians: If there is no agent under a power of attorney and a guardian has been appointed by a court, consent should be obtained from the guardian if consent to medical care is included in the court order."

On 04/02/2025 from 10:30 AM to 11:30 AM, ten (10) medical records were reviewed with the Nurse Director and the Assistant Nurse Director of the Emergency Department. This review indicated the following:
- Patient #1 had a Guardian;
- Patient #1 had ten (10) visits to the hospital between 10/28/2024 and 03/29/2025; and
- Seven (7) visits contained no documented evidence that the Guardian was informed of patient rights in advance of care being provided, as no notification or contact was initiated by the Patient Access Team at the time of registration.

On 04/02/2025 at 3:16 PM, an interview was conducted with the Manager of Patient Access which indicated the following:
- I became aware of this [in regard to Patient #1] in January;
- [Paperwork such as Guardianship] gets scanned into the medical record system, but the Patient Access Team would not be notified immediately;
- I ensured that the guardianship information was in the system on 1/23/2025; and
- I was aware of the continued issues with Guardian consent and have been working with staff members on an individual basis.

On 04/02/2025, the ED Nurse Director confirmed that seven (7) of ten (10) visits contained no evidence of Guardian notification.

Based on document reviews and interviews, the hospital failed to inform a patient/patient representative of his/her rights in regards to having the right to participate in the development and implementation of the plan of care for one (1) of ten (10) patients reviewed (Patient #1).

Finding:

The MaineGeneral Medical Center "Informed Consent" policy's purpose, last reviewed/revised in 01/25, states in part, "To establish the right of a patient or their representative, as allowed under Maine law, to make informed decisions regarding their health care. The patient's rights include being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. ... When indicated, each patient or the patient's legal representative, signs a general consent or verbally expresses their consent and MGMC staff will document as part of the registration process. This general consent documents the patient's consent to routine medical care. Oral consent from a patient or their designated representative may be substituted for written consent if the verbal consent is documented on the general consent form. These forms of consent must be given by an authorized individual. The individual providing oral consent must provide adequate information to confirm their identity as well as that of the individual they are consenting for. In person and telehealth verbal consents may be accepted and documented by one representative of MaineGeneral... ."

In addition, "The patient or the patient's legal representative should receive adequate information provided in a manner that the patient or the patient's legal representative can understand to assure that the patient can effectively exercise the right to make informed decisions. The responsible practitioner must provide as much information about treatment options as is necessary based upon a patient's understanding of the practitioner's explanation of the risks, benefits and likely outcomes of the treatment.

On 04/02/2025 from 10:30 AM to 11:30 AM, ten (10) medical records were reviewed with the Nurse Director and the Assistant Nurse Director of the Emergency Department. This review indicated the following:
- Patient #1 had a Guardian;
- Patient #1 had ten (10) visits to the hospital between 10/28/2024 and 03/29/2025; and
- Seven (7) visits contained no documented evidence that the Guardian was informed of their rights about participating in the plan of care.

On 04/02/2025, the ED Nurse Director confirmed that seven (7) of ten (10) visits contained no evidence of Guardian notification.

Based on document reviews and interviews, it was determined that the hospital failed provide notice to a patient's representative about the right to make informed decisions regarding care for one (1) of ten (10) patients reviewed (Patient #1).

Findings:

The MaineGeneral Medical Center "Informed Consent" policy's purpose, last reviewed/revised in 01/25, states in part, "To establish the right of a patient or their representative, as allowed under Maine law, to make informed decisions regarding their health care. The patient's rights include being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. ... When indicated, each patient or the patient's legal representative, signs a general consent or verbally expresses their consent and MGMC staff will document as part of the registration process. This general consent documents the patient's consent to routine medical care. Oral consent from a patient or their designated representative may be substituted for written consent if the verbal consent is documented on the general consent form. These forms of consent must be given by an authorized individual. The individual providing oral consent must provide adequate information to confirm their identity as well as that of the individual they are consenting for. In person and telehealth verbal consents may be accepted and documented by one representative of MaineGeneral... . ... "Authorized Decision-Maker: An authorized decision-maker is any person who is: (1) Legally authorized to make medical decisions on behalf of an incompetent patient, (2) the patient's agent as defined in this policy, (3) the patient's guardian if one has been appointed, or (4) the patient's involved family members."

In addition, "The patient or the patient's legal representative should receive adequate information provided in a manner that the patient or the patient's legal representative can understand to assure that the patient can effectively exercise the right to make informed decisions. The responsible practitioner must provide as much information about treatment options as is necessary based upon a patient's understanding of the practitioner's explanation of the risks, benefits and likely outcomes of the treatment.

On 04/02/2025 from 10:30 AM to 11:30 AM, ten (10) medical records were reviewed with the Nurse Director and the Assistant Nurse Director of the Emergency Department. This review indicated the following:
- Patient #1 had a Guardian;
- Patient #1 had ten (10) visits to the hospital between 10/28/2024 and 03/29/2025; and
- Seven (7) visits contained no documented evidence that the Guardian was notified of their right to make informed decisions, as no notification or contact was initiated by the Patient Access Team at the time of registration.

On 04/02/2025, the ED Nurse Director confirmed that seven (7) of ten (10) visits contained no evidence of Guardian notification.

Based on document reviews and interviews, it was determined that the hospital failed to document that a patient's guardian was asked if they had an advanced directive and/or did they want to execute one for one (1) of ten (10) patients reviewed (Patient #1).

Finding:

The MaineGeneral Medical Center ("MGMC") "Advance Directives- Healthcare Decision Making" policy, last reviewed/revised 11/23, states in part, "Decision-Makers for Adults Who Lack Capacity: (1) Healthcare decisions for adults who lack capacity may be made by others expressly authorized to make such decisions or by family members in certain circumstances. Authorized decision-makers are determined in the following order of priority: Guardians ... ."

In addition, it also states, "Documentation: As part of the admission process for all adult individuals, the admitting agent will ask and record whether an advance directive, e.g. Living Will or Durable Healthcare Power of Attorney is in effect and on file with MaineGeneral. A copy of the advance directive will be requested and filed in the medical record ... ."

The MGMC "Patient Visitation Rights" policy, last reviewed/revised 08/23, states in part, "Registration: At the time of admission, MGMC's registration personnel will ask the patient if the patient has an agent under a healthcare power of attorney and whether the patient wishes to rely on his or her agent to exercise the patient's visitation rights. If the patient lacks an available agent, the patient will be asked whether he or she wishes to designate a support person to exercise the patient's visitation rights, or rely on his or her healthcare surrogate designated under Maine law to exercise such visitation rights. Registration personnel will document the patient's decision, and MGMC staff will honor the patient's decision unless an exception applies under this Policy."

On 04/02/2025 from 10:30 AM to 11:30 AM, ten (10) medical records were reviewed with the Nurse Director and the Assistant Nurse Director of the Emergency Department. This review indicated the following:
- Patient #1 had a Guardian;
- Patient #1 had ten (10) visits to the hospital between 10/28/2024 and 03/29/2025; and
- Seven (7) visits contained no documented evidence that the Guardian was asked about advanced directives for Patient #1, as no notification or contact was initiated by the Patient Access Team at the time of registration..

On 04/02/2025, the ED Nurse Director confirmed that seven (7) of ten (10) visits contained no evidence of Guardian notification.