HospitalInspections.org

Based on document review and interview, the hospital failed to ensure patient rights for informed consent included keeping the patient's medical power of attorney (POA) informed of the patient's health status, care planning and treatment for 1 of 1 patients (P4) with a POA.

Findings include:

1. Review of the policy titled Patient Rights and Responsibilities, last approved 7/2019, indicated the following:
All Patients have the right to, and are encouraged to, obtain from physicians and other direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis.
All Patients have the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment plan... The hospital shall provide the patient or surrogate decision-maker with the information about outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions.
All Patients have the right to have an Advance Directive (such as a Living Will, Health Care Proxy or Durable Power of Attorney for Health Care) concerning treatment or designating a surrogate decision maker...

Review of the policy titled Behavioral Health Patient Rights, last approved 11/2021, indicated all patients in the Behavioral Health (BH) inpatient units have the following rights: professional consultation for legal or medical concerns. If the patient is cognitively and/or physically unable to comprehend this information about their rights, the patient's guardian or a family member will be so informed.

Review of the Medical Staff Bylaws, Rules and Regulations, approved 11/4/21, indicated the following: The Attending Physician shall keep the patient and the patient's family informed concerning the patient's condition throughout the patient's term of treatment.

2. Review of the medical record (MR) for patient P4 indicated the patient was incapable of making his/her own decisions and had a POA. Behavioral Medicine Progress Note (BMPN), 10/30/21 at 12:30 hours indicated the following plan: Discontinue (dc/DC) exelon patch, due to now more likely to cause increased side effects. The MR lacked documentation of the POA having been informed of the plan in order to make an informed decision. Hospitalist Progress Notes (HPN) lacked documentation of a hospitalist/attending physician having communicated with the POA or other family to keep them informed of the patient's conditions, treatment and/or treatment changes. BMPNs lacked documentation of a mental health provider/attending physician having communicated treatment plans with the POA/family prior to 11/14/21.

3. On 11/30/21, beginning at approximately 3:30 PM, A6, Behavioral Health Director, indicated the MR lacked documentation of communication between the providers and the POA of P4.

Based on document review and interview, the hospital failed to ensure for behavioral health patient's rights to visitation in one facility.

Findings include:

1. a. Review of the policy titled Unit Visitation and Patient Visitors, last approved 12/2018, indicated the following:
Visitation with the patient on the BHU is permitted at specified times based on the visitors knowledge of the patient ID (identification) number.

b. Review of guidelines, August 11/2021 indicated the following:
Visiting hours are 10 a.m. to 7 p.m. for all inpatient units excluding BHU. All inpatient units, except those in isolation, may have one visitor...
Behavioral Health Services and Inpatient Units: No visitors allowed.

c. Review of the document titled Indiana Disability Rights, Rights of Adults Receiving Treatment in an Indiana Mental Health Facility, revised July 2017, indicated the following:
Should a facility restrict a conditional right, notice of the denial or limitation of rights must be given to the patient patient and guardian...
Unless restricted for good cause, an individual conditionally HAS THE RIGHT TO: Be visited at reasonable times.

2. On 11/30/21, beginning at approximately 2:00 PM, A1, Senior Quality Specialist and A6, Behavioral Health Director, verified that the current hospital policy allowed for visitation on all units except the BHU.

Based on document review and interview, the hospital failed to ensure nursing care for 1 of 10 patients (P4) was provided in accordance with policies and that variances from within defined limits (WDL) included adequate information for identification and severity.

Findings include:

1. Review of the policy titled Skin Care, last approved 08/2021, indicated the following:
An assessment of the integumentary system will be completed upon admission and with each shift.
Skin will be evaluated for integrity, color, temperature, texture, hair distribution, capillary refill and turgor.

2. Review of the MR for patient P4 lacked documentation of initial skin assessment findings outside of normal limits upon admission 10/30/21. Shift Progress Notes (SPN), entered 11/2/21 at 13:51 hours indicated the patient's skin characteristics/integrity to be bruised/ecchymotic. The entry lacked documentation of bruise characteristics, size, or location(s). SPN 11/9/21 at 15:22 hours indicated the patient's skin was bruised/ecchymotic - location/area(s) were not documented. SPN 11/11/21, entered at 15:03 hours indicated the patient's skin integrity had bruise(s); wound(s) without location and/or characteristics documented. The Brief Summary note of that entry indicated the patient had an old wound to the heel of his/her right foot and the wound was dressed with Mepalex (sic), but lacked documentation of a wound description. SPN 11/11/21 at 22:34 hours indicated the patient's skin to be WDL except: blister(s); bruise(s); wound(s) without documentation of blister, bruise, and/or wound location, size(s) or other characteristics. The Brief Summary indicated the patient had a blister to lower back, but lacked size and/or other characteristics. The Brief Summary from the SPN entered 11/12/21 at 13:30 hours indicated the nurse made rounds with MD1 (physician), together they performed a skin assessment and the nurse was instructed to contact wound care for further instructions for care to the right heel wound. The note also indicated that a "friction blister" was noted on the patient's back "that was not there yesterday." The MR lacked further detail of wounds.

3. On 11/30/21, beginning at approximately 3:30 PM, A6 verified skin/wound assessments should have included detailed description of findings outside of normal limits.

Based on document review and interview, the hospital failed to ensure pharmaceutical services met the needs of the patient for 2 of 10 patients (P1 and P4) whose home medications were not appropriately reconciled for a regularly taken medication.

Findings include:

1. Review of the hospital policy titled Medication Reconciliation, last approved 04/2018, indicated the following:
Within 24 hours of admission, each patient's medications will be reconciled across the continuum of care: The information is complied by hospital staff and reviewed by a qualified clinician for omissions, duplications, contraindications, interactions and potential changes. Who Does What: RN (Registered Nurse)/LPN (Licensed Practical Nurse)/Med Rec Tech (Medication Reconciliation Technician): Obtains information on the medications the patient is currently taking and documents in the Outpatient Medication Review (OMR) section of Allscripts (the electronic medical record). Admitting Physician: Reviews medication list in the Order Reconciliation Manager and electronically decides on which medicines are to be continued, held, or discontinued. Pharmacist: Verified electronic medication orders submitted by the physician. Acts as a consultant in this process by identifying potential problems or errors.

2. a. The MR of patient P1 indicated the following: On 11/3/21, the patient presented to the ED (Emergency Department). Triage notes, dated 11/3/21 at 09:06 hours, listed the patient's home medications to include Depakote, Voltaren gel, Lasix, Norco 5, and Vivitrol. Order Reconciliation (medication reconciliation) lacked documentation of the following home medications having been listed for reconciliation: Depakote, Voltaren gel, Lasix, Norco 5, and Vivitrol. The discharge summary indicated the following: Additionally, we did resume Depakote...as his/her medication reconciliation revealed did not have the medication on it. The MR lacked documentation of the other medications having been ordered in the Emergency Department (ED) or upon admission to the hospital.

b. The MR of patient P4 admitted on 10/30/21, indicated in Triage notes that the patient's home medications, obtained from a nursing home list, included an Exelon patch. Order Reconciliation (medication reconciliation) lacked documentation of the Exelon patch having been listed for reconciliation.

3. On 11/29/21, beginning at approximately 1:00 PM, A6, Behavioral Health Director, and A1, Senior Quality Specialist, verified the MR of patient P1 lacked documentation of all home medications having been included in medication reconciliation.

4. On 11/30/21, beginning at approximately 10:00 AM, A6 verified the medication reconciliation of P4 lacked inclusion of an Exelon patch.