HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) patients without decisional capacity, the Hospital failed to ensure a health care surrogate was assigned to make medical decisions.

Findings include:

1. The Hospital policy titled, "Health Care Surrogate Act (10/5/15)" was reviewed on 8/15/17. The policy required, "Identifying a Surrogate: 1. When a patient lacks decisional capacity, staff must make a reasonable inquiry as to the authority and availability of a health care agent... The attending physician must identify the person who is entitled to make those medical treatment decisions. This is to be documented on the form 250."

2. The clinical record of Pt. #1 was reviewed on 8/15/17. Pt. #1 was a 27 year old female admitted on 9/24/16 with the diagnoses of altered mental status, confusion, and jaundice (yellow tint to skin). The Health Care consent dated 9/24/16 at 10:13 AM, to treat Pt. #1, was signed by Pt. #1's boyfriend (B#1). The Transfer Form Consent dated 9/24/16 at 6:45 PM, to transfer Pt. #1 to another hospital, was signed by B#1.

The Nephrologist's consultation note dated 9/24/16 at 1:58 PM included, " ... was brought in by her boyfriend to the emergency room. In the ED, Labs were done which showed severe hyponatremia (low sodium) for which I was consulted. I saw the patient in the ICU where she was disoriented."

The form 250 included in Pt. #1's clinical record was completed with the boyfriends information, but lacked the attending physician's signature.

3. The Director of Quality and Regulatory Compliance (E#4) was interviewed on 8/16/17 at 9:30 AM. E#4 stated, "The surrogate form should have been completed and signed by the doctor once the patient left the emergency department and went to the ICU (intensive care unit) for continued care."

Based on document review and interview, it was determined for 1 of 2 (Pt. #2) clinical records reviewed regarding the use of non-violent restraint, the Hospital failed to ensure that a physician's order was obtained as required.

Findings include:

1. On 8/15/17 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 39 year old male admitted on 8/11/17 with a diagnoses of dyspnea and pneumonia. The clinical record of Pt. #2 indicated that a non-violent type of restraint (soft limb mitten) was initiated on 8/13/17 at 8:00 PM. However, a physician's order was not obtained until 10:43 PM on 8/13/17 (2 hours and 43 minutes later).

2. On 8/15/17 at approximately 12:00 PM, the Hospital's policy titled "Utilization of Restraint and Seclusion" (review date 8/9/17) was reviewed and indicated, "... IV. Procedure... C. Restraint for Non-Violent or Non-Destructive Behavior... 1. Physician Orders... c. When an RN initiates restraint, an order will be obtained from a physician as soon as possible after the restraint is initiated.

3. On 8/15/17 at approximately 11:30 AM, an interview was conducted with E #1 (ICU Manager). E #1 stated that there should be an order when a patient is placed in restraint.