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Based on interview, and record review, the facility failed to ensure informed consents (a process where the patient gives permission for a treatment or procedure after risks, benefits and alternatives are explained) and facility transfer forms were fully completed prior to transfer to another facility, and an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition), for seven of 30 sampled patients (Patients 6, 8, 20, 22, 26, 27, and 29), when:

1. For Patients 6, 8, 20, 22, 26, 27, and 29, informed consent forms were not completed prior to invasive procedures;

2. For Patient 20, consent for transfer to another facility was not obtained prior to transfer.

These failures had the potential to result in patients, or their responsible parties, not having the information needed to make informed decisions regarding their procedures and medical treatment.

Findings:

1a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6's record was conducted with the Manager of the Orthopedic Program (MO). A facility document titled, "History and Physical (H&P)," dated September 28, 2024, indicated Patient 6 was admitted to the facility for worsening shortness of breath, and transaminitis (higher than normal levels of liver enzymes in the blood due liver irritation and/or inflammation).

A facility document titled, "Progress Note-Physician," dated October 2, 2024, was reviewed, and indicated. "...I [Name of Physician (MD 1)], discussed the purpose and indications with the patient regarding placement of a peripherally inserted central catheter (PICC, a long, thin flexible tube inserted into a vein in the arm used to deliver medications or fluids into the bloodstream or to draw blood). The purpose of placement is for IV [intravenous] Antibiotics...I explained the risks of the procedure which included...I explained the procedure in detail and drew out a diagram demonstrating the steps of the procedure and how it will be completed...The patient is of sound mind and judgement and is able to provide consent for the procedure...All questions have been answered and the patient understands all risk and benefits...The patient [Name of Patient 6] has provided oral consent to the procedure..."

A facility document titled, "Nursing Admission Assessment" dated September 28, 2024, was reviewed, and indicated, Patient 6's primary language was "Punjabi (language spoken by people from the Punjab region of India and Pakistan)." The MO stated an interpreter, utilizing the facility approved services, should have been utilized to obtain the PICC line consent and the physician should not be utilized as an interpreter.

On January 8, 2025, at 1 p.m., an interview was conducted with the Quality Supervisor (QS). The QS stated GLOBO (interpreters language services)/translator line should have been utilized for obtaining the PICC line consent for Patient 6. The QS stated MD 1 should not have been utilized for translation.

On January 8, 2025, at 2:20 p.m., an interview was conducted with MD 2. MD 2 stated Patient 6 spoke Punjabi. MD 2 stated all procedures were explained in detail to the patient by MD 1 who spoke the same language as the patient.

A review of Policy & Procedure (P&P), titled, "[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients," dated October 2022, was conducted. The P&P indicated, "...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider...LEP Needs...GLOBO interpreters services can be used..."

A facility document titled, "Procedure Note," dated September 30, 2024, was reviewed, and indicated, Patient 6 underwent a thoracentesis (a procedure where a needle is used to remove fluid from around the lungs). No written form for consent or documentation of consent was found in the medical record. The MO stated there was no documented evidence a consent was obtained prior to Patient 6's thoracentesis.

On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated a consent for the thoracentesis should have been obtained prior to Patient 6's thoracentesis and this was not done.

A review of P&P, titled, "[Name of Facility] Consents," dated May 2024, was conducted. The P&P indicated, "...Informed consent is a process of communication between a treating practitioner and a patient that results in the patient's authorization or agreement to undergo a specific medical intervention...The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment...Established processes are in place to ensure that prior to conducting the informed consent discussion, the patient/legal guardian's preferred language is identified, and a medical interpreter is provided, and the consent form or electronic medical record indicated whether an interpreter was used...It is the treating physician's duty to obtain informed consent...The physician will explain to the patient (or appropriate surrogate decision maker)...The nature of the treatment or procedure...The risks, complications and expected benefits or effects of the procedure...Any alternatives to the treatment/procedures and their risks and benefits...If this required documentation is absent, the procedure will not be allowed...The physician must document in the medical record that he/she explained the nature of the treatment, its risk and benefits, and the alternatives and their risk and benefits, and that the patient (or surrogate decision maker) consented to have the procedure...This documentation is evidence for the patient ,the hospital and the physician that informed consent has been obtained prior to the procedure...By signing the "consent" form, the patient acknowledges that the physician adequately explained the operation or procedure to the patient and gave the patient all the information he or she desired...The informed consent form may be evidence for the patient, hospital and the physician that informed consent was obtained prior to the procedure..."

A facility document titled, "Procedure Note," dated October 2, 2024, was reviewed, and indicated, Patient 6 underwent a central line placement (a procedure where a thin, flexible tube is inserted into a large vein, usually in the neck or chest and is used to give medications or fluids directly into the bloodstream or to draw blood). No written form for consent or documentation of consent was found in the medical record. The MO stated consent should have been obtained prior to Patient 6's central line placement.

On January 8, 2025, at 2 p.m., an interview was conducted with MD 3. MD 3 stated they were informed a consent form for the central line had already been completed. MD 3 stated there should always be a consent present in the chart prior to a central line placement.

On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated consent for central line placement should have been obtained prior to Patient 6's central line placement and this was not done.


1b. On January 8, 2025, at 3:30 p.m., a concurrent interview and review of Patient 8's record was conducted with the MO. A facility document titled, H&P, dated November 28, 2024, was reviewed, and indicated Patient 8 was admitted to the facility for gastrointestinal bleeding.

A facility document titled, "Procedure Note," dated November 28, 2024, was reviewed, and indicated, Patient 8 underwent an Arterial line placement (a thin tube placed into an artery used to monitor blood pressure continuously).

A facility document titled, "AUTHORIZATION FOR AND CONSENT TO SURGERY OR SPECIAL DIAGNOSTIC OR THERAPEUTIC PROCEDURES," dated November 28, 2024, was reviewed, and indicated, a "phone [telephone] consent" was obtained for the Arterial line. There was no documentation of who provided the telephone consent. Additionally, there was no signature on the "Witness" line. The MO stated the consent should have been witnessed by a hospital employee and the name of the person whom the physician spoke to, in order to obtain telephone consent should have been documented in the medical record however, this was not done.

A facility document titled, "Procedure Note," dated November 28, 2024, was reviewed, and indicated, Patient 8 underwent a Central Venous Catheter placement (a procedure where a thin, flexible tube is inserted into a large vein, usually in the neck or chest and is used to give medications or fluids directly into the bloodstream or to draw blood).

A facility document titled, "AUTHORIZATION FOR AND CONSENT TO SURGERY OR SPECIAL DIAGNOSTIC OR THERAPEUTIC PROCEDURES," dated November 28, 2024, was reviewed, and indicated, a "phone [telephone] consent" was obtained for the Central Venous Catheter. There was no documentation of who provided the telephone consent. Additionally, there was no signature on the "Witness" line. The MO stated the consent should have been witnessed by a hospital employee and the name of the person whom the physician spoke to in order to obtain consent should be documented in the medical record however, this was not done.

On January 8, 2025, at 3:45 p.m., an interview was conducted with the QS. The QS stated the Arterial line and Central line consents for Patient 8 should have the name of the person whom the physician obtained the verbal/telephone consent and should have been witnessed by a staff member and this was not done per the facility's policy.

1c. On January 7, 2025, at 3:25 p.m., a concurrent interview and record review of Patient 20's record was conducted with the QS and the Cardiac Services Manager (CSM). A review of the facility document titled, "History and Physical," dated October 30, 2024, at 6:39 p.m., indicated Patient 22 had a history of squamous cell carcinoma (A type of cancer that can affect the skin, respiratory tract or digestive tract) of the tongue, and thyroid disease, and was admitted to the facility for a fall and weakness.

On January 7, 2025, at 3:28 p.m., a review of the facility document titled, "Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures," dated November 1, 2024, at 1:22 p.m., indicated a consent for Central Line Placement. The document further indicated there was no witness signature, no signature or verification of documentation with the Licensed Healthcare Provider, and no signature from Patient 22, a family member or a witness. The document further indicated, "emergent" written under Physician Certification with MD 3 signature and signature of RN.

On January 7, 2025, at 3:30 p.m., a review of the facility document titled, "Procedure Note," dated November 1, 2024, at 7:19 a.m., authored by MD 3, indicated a right femoral vein central venous catheter insertion was completed by MD 3. Documentation further indicated, "...Consent was obtained from the patient, indications risks and benefits were explained at length..." There was no documentation to indicate the procedure was done emergently or that any delay in treatment would jeopardize the health of the patient.

On January 8, 2025, at 10:30 a.m., an interview was conducted with the QS. The QS stated, "...the consent should have been filled out completely or a note documented by the physician indicating the delay of the procedure would jeopardize the patient's health..." The QS further indicated there was no note in the patient's chart indicating the procedure was initiated emergently or would jeopardize health of patient.

1d. On January 7, 2025, at 4 p.m., a concurrent interview and review of Patient 22's record was conducted with the QS and the CSM. A review of the facility document titled, "History and Physical," dated October 21, 2024, at 4:19 p.m., indicated Patient 22 was admitted to the facility for abdominal pain with history of ventral hernia.

On January 7, 2025, at 4:05 p.m., a review of the facility document titled, "[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures," dated October 23, 2024, at 8:40 a.m., indicated Central Line Placement with no name of patient documented on the first page of consent document. The document further indicated no signature for the Licensed Healthcare Provider and no witness signature under patient signature.

On January 7, 2025, at 4:10 p.m., a review of the facility document titled, "[Name of Facility] Procedure Note," dated October 24, 2024, at 9:46 p.m., indicated, "...Central Venous Catheter Procedure Details...Right Internal Jugular Vein Central Venous Catheter Placement...informed consent...taken and place in the chart..." was performed by MD 2.

On January 8, 2025, at 8:30 a.m., an interview with the QS was conducted. The QS indicated, "...A signature from the witness, a signature from the healthcare provider acknowledging documentation of required elements in the chart, and consent document should have been filled out completely per policy..."

1e. On January 8, 2025, at 8:30 a.m., a concurrent interview and review of Patient 26's record was conducted with the QS and the CSM. A review of the facility document titled, "History and Physical", dated November 23, 2024, at 11:21 a.m., indicated, Patient 26 was admitted from a dialysis center due to not being able to receive hemodialysis (a treatment to filter wastes and water from your blood) due to bilateral leg weakness and shaking. Patient 26 had a history of Myocardial Infarction (a medical emergency that occurs when blood flow to the heart is suddenly cut off or reduced), Hemodialysis, and Diabetes (a chronic disease that occurs when the body doesn't produce enough insulin or can't use it properly).

On January 8, 2025, at 9:30 a.m., a review of the facility document titled, "[Name of Facility] Consult Nephrology [the study of the kidneys]," dated November 23, 2024, at 5:06 p.m., indicated, "...Patient agreeable for HD [hemodialysis] for today, r/b [risks and benefits] discussed..."

On January 8, 2025, at 9:35 a.m., a review of the facility flowsheet document titled, "Order for Hemodialysis", dated November 23, 2024, at 4:53 p.m., indicated an order was placed for hemodialysis.

On January 8, 2025, at 9:40 a.m., a review of the facility flowsheet document titled, "Hemodialysis", dated November 23, 2024, at 10:10 p.m., indicated hemodialysis was conducted.

On January 8, 2025, at 9:45 a.m., a review of the facility document titled, "[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures," dated November 23, 2024, at 2 p.m., indicated, there was no signature from a witness for hemodialysis procedure.

On January 8, 2025, at 9:50 a.m., an interview with the QS was conducted. The QS stated, "...there should have been a signature from the witness on the consent per facility policy."

1f. On January 8, 2025, at 8:30 a.m., a concurrent interview and review of Patient 27's record was conducted with the QS and the CSM. A review of the facility document titled, "History and Physical," dated December 10, 2024, at 8:40 a.m., indicated Patient 27 was admitted to the facility with complaints of chest pressure. The document further stated Patient 27 had a history of Hemodialysis.

On January 8, 2025, at 8:40 a.m., a review of the facility document titled, "Orders," dated December 11, 2024, was at 6:50 a.m., indicated an order was placed for Hemodialysis for Patient 27.

On January 8, 2025, at 8:42 a.m., a review of the facility document titled, "Consult-Nephrology," dated December 11, 2024, at 10:16 a.m., indicated, "...plan for HD [Hemodialysis] today..."

On January 8, 2025, at 8:45 a.m., a review of the facility document titled, "Nursing flowsheet-Hemodialysis," dated December 13, 2024, at 4:20 p.m., indicated Hemodialysis was completed.

On January 8, 2025, at 8:49 a.m., a review of the facility document titled, "[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures," indicated no name of the patient, date, time, physician name, or signature of Licensed Healthcare Provider on the consent form.

On January 8, 2025, at 9:01 a.m., an interview was conducted with the QS. The QS stated, "...the consent document should have been filled out completely and the name of the patient, date, time, and Licensed Healthcare Provider should have been filled out on the consent..."

1g. On January 8, 2025, at 10:40 a.m., a concurrent interview and review of Patient 29's record was conducted with the QS and the CSM. A review of the facility document titled, "[Name of Facility]History and Physical," dated January 1, 2025, at 4:02 p.m., indicated Patient 29 was admitted to the facility for a fall and with right sided weakness.

On January 8, 2025, at 10:45 a.m., a review of the facility document titled, "ED Physician Record," dated, January 1, 2025, at 1:49 p.m., by MD 1, indicated a lumbar puncture (a needle is inserted into the space between two back bones to retrieve cerebral spinal fluid) was performed and CSF (cerebral spinal fluid) was obtained.

On January 8, 2025, at 10:50 a.m., a review of the facility document titled, "[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures," dated January 1, 2025, at 3 p.m., indicated no signature from Licensed Healthcare Provider or witness.

On January 8, 2025, at 10:55 a.m., an interview was conducted with the QS. The QS stated, "...There should have been a witness signature and signature from a Licensed Healthcare Provider on the consent form...The policy was not followed..."

On January 9, 2025, at 10:30 a.m., a review of the facility P&P titled, "[Name of Facility] Patient's Rights and Responsibilities", dated February 14, 2022, indicated, "...The patient or the patient's designated representative has the right to receive as much information about any proposed treatment or procedure needed in order to make treatment decisions that reflect the patient's wishes and give informed consent or to refuse the course of treatment. The patient has the right to know who is responsible for authorizing and performing the procedures or treatment..."

On January 9, 2025, at 10:45 a.m., a review of the facility P&P titled, "[Name of Facility] Consents," dated May 13, 2024, indicated, "...It is the responsibility of the treating provider to apprise the patient of nature, risks, and alternatives of a medical procedure or treatment before the treating provider...begins any course...the witness serves only as a witness to the signature on the consent form by the patient or decision maker..." The document further indicated, "...in the case of a medical emergency, treatment may proceed without the patient's consent if the patient or his legal representative is unable to give consent...the attending physician shall...Determine if there is an appropriate surrogate decision-maker to make decisions on behalf of the patient...Document in the medical record that a delay in treatment would jeopardize the health of the patient...consent is obtained at a later time if at all possible..."

A review of P&P, titled, "[Name of Facility] Consents," dated May 2024, was conducted. The P&P indicated, "...Informed consent is a process of communication between a treating practitioner and a patient that results in the patient's authorization or agreement to undergo a specific medical intervention...The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment...Established processes are in place to ensure that prior to conducting the informed consent discussion, the patient/legal guardian's preferred language is identified, and a medical interpreter is provided, and the consent form or electronic medical record indicated whether an interpreter was used...It is the treating physician's duty to obtain informed consent...The physician will explain to the patient (or appropriate surrogate decision maker)...The nature of the treatment or procedure...The risks, complications and expected benefits or effects of the procedure...Any alternatives to the treatment/procedures and their risks and benefits...If this required documentation is absent, the procedure will not be allowed...The physician must document in the medical record that he/she explained the nature of the treatment, its risk and benefits, and the alternatives and their risk and benefits, and that the patient (or surrogate decision maker) consented to have the procedure...This documentation is evidence for the patient, the hospital and the physician that informed consent has been obtained prior to the procedure...By signing the "consent" form, the patient acknowledges that the physician adequately explained the operation or procedure to the patient and gave the patient all the information he or she desired...The informed consent form may be evidence for the patient, hospital and the physician that informed consent was obtained prior to the procedure..."


A review of P&P titled, "[Name of Facility] Consents," dated May, 2024, was conducted. The P&P indicated, "Consent By Other Means...The responsible physician or designee shall discuss the patient's condition and the recommended treatment with patient's legal representative for healthcare treatment...Telephone Consent...Telephone discussion between physician or designee and patient's legal representative for health care treatment must be witnessed by a hospital employee...Documentation in the form of a signature from both the witness and the physician, of the telephone consent shall be on all forms for admission to the hospital and informed consent forms..."


2. On January 7, 2025, at 12:27 p.m., a concurrent interview and review of Patient 20's record was conducted with the QS and the CSM. A review of the document titled, "Progress Note - Physician," dated November 18, 2024, at 11:49 a.m., by MD 4, indicated "...Discharge Planning: Discharge to, Anticipated: Acute Care Facility..." No indication of transfer to accepting facility or accepting physician name was documented.

On January 7, 2025, at 12:35 p.m., a review of the facility document titled, "Progress Note-Nurse", dated November 18, 2024, at 10:23 p.m., indicated, "...[Name of facility] transport team at bedside at 2122 [9:22 p.m.], leaving with pt off unit at 2145 [9:45 p.m.]..."

On January 7, 2025, at 1 p.m., an interview was conducted with the QS. The QS indicated, "...there was no transfer form found in the patients' medical record...or documentation of accepting physician in the physician notes..."

On January 9, 2025, at 10 a.m., a review of the facility P&P document titled, "[Name of Facility]...Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skill Nursing Facility," dated June 10, 2024, indicated, "...Physician signature will be obtained on transfer summary and a copy given to patient and/or patient's legal representative...The sending physician obtains an accepting physician. The physician must have a physician-to-physician report...A transfer report will be completed by the Registered Nurse on the discharging unit. A copy stays with chart..."

Based on interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for five of 30 sample patients (Patients 6, 19, 22, 24, and 29), when:

1. For Patient 6, Oxygen therapy (treatment that provides extra oxygen to help breathe better when the body isn't getting enough on its own) was administered without a physician order (Refer to A-0398);

2. For Patient 22, a central venous catheter (a thin, flexible tube that's inserted into a vein in the neck, chest, arm, or groin and threaded into a large vein above the heart) was inserted without a physician order (Refer to A-0398);

3. For Patient 29, a lumbar puncture (procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid) was performed without a physician order (Refer to A-0398);

4. For Patients 6, and 24, Translation Services were not utilized for the non-English speaking patient (Refer to A-0398);

5. For Patient 6, and 29, Universal Protocol (UP, process used to identify the correct patient, the correct procedure, the correct proceduralist and the correct site) was not completed prior to an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition) (Refer to A-0398);

6. For Patient 19, the discharge paperwork placed in the medical record was missing a signature from a witness. (Refer to ....)

The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.

Based on interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for five of 30 sample patients (Patients 6, 19, 22, 24 and 29), when:

1. For Patient 6, Oxygen therapy (treatment that provides extra oxygen to aide in breathing) was administered without a physician order;

2. For Patient 22, a central venous catheter (a thin, flexible tube that is inserted into a vein in the neck, chest, arm, or groin and threaded into a large vein above the heart) was inserted without a physician order;

3. For Patient 29, a lumbar puncture (procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid) was administered without a physician order;

4. For Patients 6 and 24, Translation Services were not utilized for the non-English speaking patient;

5. For Patients 6 and 29, Universal Protocol (UP, a process used to identify the correct patient, the correct procedure, the correct proceduralist and the correct site) was not completed prior to an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition);

6. For Patient 19, discharge paperwork placed in the medical record was missing a required signature from a witness.

These failures had the potential to cause a delay in patient care and harm to the patients.

Findings:

1. On January 7, 2025, at 12 p.m., a concurrent interview and review of Patient 6's record was conducted with the Manager of the Orthopedic Program (MO). A facility document titled, "History and Physical," dated September 14, 2024, indicated Patient 6 was admitted to the facility for shortness of breath and pneumonia (lung infection).

The facility documents titled, "Clinical Info - Respiratory," from September 14, 2024, to September 24, 2024, were reviewed. The documents indicated Patient 6 had oxygen therapy every day. No physician order was found for the administration of oxygen.

On January 7, 2025, at 3:20 p.m., an interview was conducted with the Quality Supervisor (QS). The QS stated patients require a physician order for oxygen therapy. The QS stated there was not an order for oxygen therapy for Patient 6 and further stated there should have been an order for oxygen therapy entered by the physician for Patient 6, however, this was not done.

On January 8, 2025, at 8:45 a.m., an interview was conducted with the Director of Medical/Surgical/Telemetry (DMST). The DMST stated patients require an active order from the physician for oxygen therapy.

A review of a Policy and Procedure (P&P), titled, "[Name of Facility] Criteria of Care for the ICU [Intensive Care Unit], PCU [Progressive Care Unit], Medical Surgical, Cardiac Telemetry Patient," dated November 2024, was conducted. The P&P indicated, "...Oxygen therapy...delivery device as ordered by physician..."

2. On January 7, 2025, at 3:30 p.m., a concurrent interview and record review of Patient 22's record was conducted with the QS and the Cardiac Services Manager (CSM). A review of the facility document titled, "Procedure Note", dated October 24, 2024, at 9:46 a.m., by [Name of Medical Doctor 2] indicated "...Right Internal Jugular Vein Central Venous Catheter..." was placed. There was no indication per documentation that the procedure was performed on an emergent basis..

On January 7, 2025, at 3:45 p.m. an interview was conducted with the QS. The QS stated, "...an order for a central line should have been placed in the patient's chart per policy..."

On January 8, 2025, at 1:30 p.m., a review of the facility P&P document titled, [Name of Facility] Central Venous Catheters- Insertion, Care, Maintenance, and Removal", revised June 10, 2024, indicated, "...Central Venous Catheters (CVC)...Must have a physician's order documented in the patients medical record to access or remove any central venous access device for any purpose..."

3. On January 8, 2025, at 9:30 a.m., a concurrent interview and record review of Patient 29's record was conducted with the QS and the CSM. A facility document titled, "ED [Emergency Department] Physician Record", dated January 1, 2025, at 1:49 p.m., indicated a lumbar puncture was completed by MD 1. The document further indicated, "...the second attempt, the needle was advanced into the spinal canal and clear CSF [Cerebral Spinal Fluid] was obtained..." There was no indication of emergent status documented for Patient 29..

On January 8, 2025, at 9:35 a.m., an interview of the QS was conducted. The QS stated, "...there was no order for a lumbar puncture procedure found in the patient's chart." The QS further stated, "An order should have been documented in the patient's chart per policy..."

On January 8, 2025, at 9:45 a.m., a review of the facility's P&P document titled, "[Name of Facility] Universal Protocol," dated April 28, 2024, indicated, "...Prior to initiating the bedside procedure...The bedside pre-verification will at a minimum include...Procedure confirmed with order in medical record..."

4a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6's record was conducted with the MO. A facility document titled, "Progress Note-Physician," dated October 2, 2024, was reviewed, and indicated, "...RN messaged me to come to patient's bedside to assist with translation...team was placing a central line [tube placed into a large vein used to give medications, fluids or nutrients directly into the bloodstream]..." The MO stated, the RN should have utilized the interpreter line and not called the Physician to interpret for the patient.

A review of the P&P, titled, "[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients," dated October 2022, was conducted. The P&P indicated, "...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider..."

4b. On January 7, 2025, at 10:00 a.m., a concurrent interview and review of Patient 24's record was conducted with the QS and the CSM. A facility document titled, "Face Sheet", dated January 5, 2025, at 9:50 a.m., indicated Patient 24's language was Spanish.

On January 7, 2025, at 10:10 a.m., a review of the facility undated document titled, "Preferred Mode of Communication for Health Care Discussions", indicated Patient 24 preferred a Language Interpreter for communication.

On January 7, 2025, at 10:15 a.m., a review of the facility document, "History and Physical", dated January 4, 2025, at 8:45 p.m., indicated "...spoke with patient's granddaughter over the phone due to patient's mainly Spanish speaking..." No indication of interpreter usage for translation was documented.

On January 7, 2025, at 10:30 a.m., an interview was conducted with the QS. The QS stated Patient 24 preferred using a Spanish interpreter and no interpreter was used during this visit.

A review of P&P, titled, "[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients," dated October 2022, was conducted. The P&P indicated, "...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider..."

5a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6's record was conducted with the MO. A facility document titled, "Procedure Note," dated September 30, 2024, was reviewed, and indicated, Patient 6 underwent a thoracentesis (a procedure where a needle is used to remove fluid from around the lungs).

A facility document titled, "Preprocedure Checklist," dated September 30, 2024, was reviewed, and indicated, "...Procedural Forms...Procedural Consent Signed...[blank]" not completed. The MO stated the Preprocedure Checklist was not properly completed and the UP documentation was not found in Patient 6's medical record.

On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated UP should have been followed and documented before the thoracentesis was performed on Patient 6 and a consent for the thoracentesis should have been obtained and this was not done.

A review of P&P titled, "[Name of Facility] Universal Protocol," dated April 2024, was conducted. The P&P indicated, "...UP consists of three distinct steps: Pre procedure, Site Marking, and Time Out...Prior to the initiation of an operative or invasive procedure, UP must be followed and documented...Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process...Pre-Procedure Verification- Prior to initiating the operative procedure, the following verification of the correct patient, site, procedure, and proceduralist occurs and must involve the patient or surrogate decision maker when possible...The patient's nurse and proceduralist verify the site and procedure through independent review of the medical records including but not limited to the H&P, consent, radiographs, schedule and/or LP's [Licensed Practitioner] order...If the patient is non-English preferred speaking a credentialed and internal interpreter or remote interpreting service should be used..."

5b. On January 8, 2025, at 9:30 a.m., a concurrent interview and record review of Patient 29's record was conducted with the QS and the CSM. The facility document titled, "ED Physician Record," dated January 1, 2025, at 1:49 p.m., indicated a lumbar puncture was performed by MD 1. The document further indicated, "...the second attempt, the needle was advanced into the spinal canal and clear CSF [Cerebral Spinal Fluid] was obtained..." There was no indication of emergent status documented for Patient 29..

On January 8, 2025, at 9:35 a.m., an interview with the QS was conducted. The QS stated, " ...there was no Universal Protocol procedure documented. The QS stated, "...It should have been done per policy..."

On January 8, 2025, at 9:40 a.m., a review of P&P titled, "[Name of Facility] Universal Protocol [UP]," dated April 2024, was conducted. The P&P indicated, "...UP consists of three distinct steps: Pre procedure, Site Marking, and Time Out...Prior to the initiation of an operative or invasive procedure, UP must be followed and documented...Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process...Pre-Procedure Verification- Prior to initiating the operative procedure, the following verification of the correct patient, site, procedure, and proceduralist occurs and must involve the patient or surrogate decision maker when possible...The patient's nurse and proceduralist verify the site and procedure through independent review of the medical records including but not limited to the H&P, consent, radiographs, schedule and/or LP's order..."

6. On January 7, 2025, at 9:30 a.m., a concurrent interview and review of Patient 19's record was conducted with the QS and the CSM. A review of the facility document titled, "ED Physician Record," dated November 26, 2023, at 5:15 a.m., indicated Patient 19 was stable for discharge.

On January 7, 2025, at 9:35 a.m., a review of the document titled, "[Name of Facility] Confirmation of Receipt of Instructions", dated November 26, 2023, indicated a signature from Patient 19, but no signature from the nurse or a hospital witness.

On January 7, 2024, at 1:30 p.m., an interview was conducted with the Emergency Department Director (EDD). The EDD stated, "...there should have been a signature from the Emergency Room Nurse on the discharge signature page...It is expected that every nurse follows the policy..."

On January 7, 2025, at 1:35 p.m., a review of the facility P&P document titled, "[Name of Facility] Discharge Criteria: Emergency Department," dated November 12, 2018, indicated, "...No patient is discharged without discharge instructions, which is signed, dated and witnessed..."

Based on interview and record review, the facility failed to ensure adequate discharge assessments and planning were completed by a Qualified Social Worker for one of 30 sampled patients (Patient 20).

This had the potential for patients to not be assessed for psychosocial needs, care setting needs, functional status, discharge planning, and prioritizing of patient care needs.

Findings:

On January 7, 2025, at 1:30 p.m., a concurrent interview and record review was conducted with the Quality Supervisor (QS) and the Quality Clinical Effectiveness Coordinator. A review of the facility document titled, "History & Physical", dated October 30, 2024, at 8:39 a.m., indicated Patient 20 was admitted for a fall and weakness with a history of tongue cancer and thyroid disease.

On January 7, 2025, at 1:45 p.m., a review of the facility document titled, "Order", dated November 2, 2024, at 1:06 p.m., indicated a consult to Social Services was ordered by Medical Doctor (MD) 4. The document further indicated the order was placed "due to staff concerns regarding wife making medical decisions, wife not competent to make decisions."

On January 7, 2025, at 1:50 p.m., a review of the facility document titled, "Progress Note - Care Manage/Social Work," dated November 6, 2024, at 11:50 a.m., by Case Manager 1 (CM 1) indicated, "...APS [Adult Protective Services] was here to meet w/pt [patient] and wife...[APS Social Worker-APS SW] spoke with Patient 20 privately without wife. APS SW asked Patient 20 if he would be willing to transfer to [Name of Facility] and he nodded "no". Patient 20 acknowledged that the only facility he was willing to go to was [Name of Facility]..."

On January 7, 2025, at 1:50 p.m., an interview was conducted with the Case Management Director (CMD). The CMD stated, "...We had no Social Worker [SW] on site or in house...They would defer Social Worker consults or try and get assistance from sister facilities, Adult Protective Services, or Behavioral health...There was no SW for about three months...For this patient, they had risk and ethics involved and wife was removed from the facility for impeding care..." The CMD further indicated they hired a SW in mid-November 2024. CMD further stated, "...they had lots of interviews, staffing hired three travel SW, but they never came to the facility...if it was something that the nursing or CM couldn't handle, they would escalate..."

On January 7, 2025, at 2 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, "...If a Social worker was not readily available, they would follow the COC [chain of command]..."

On January 8, 2025, at 9:30 a.m., a review of the facility document titled, "[Name of Facility] Annual Performance Evaluation-Staff- Licensed Clinical Social Worker [LCSW]", dated March 6, 2023, indicated, "Position Specific Standards...Assessment: Performs psychosocial assessment according to hospital/unit policy and procedure...Performs initial assessments appropriate to functional status, diagnosis, care setting, age, development level, psychosocial, cultural, and religious orientation in a timely manner...Identifies and prioritizes the need for further assessment based on the patient's clinical presentation/diagnosis, care setting, desire for care and responses to any previous care ...Provides resource information and referrals for follow-up of psychosocial and discharge planning needs...Maintains LCSW licensure..."

On January 9, 2025, at 9 a.m., a review of the facility policy and procedure document titled, "[Name of Facility] Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skilled Nursing Facility," dated June 10, 2024, indicated, "...Supportive counseling by a Social Worker will be available as necessary to patients and families working through the emotional and psychosocial issues surrounding placement process..."