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Based on review of 3 out of 11 medical records, it was determined the hospital failed to provide the patient with her notice of rights.

Patient #7 was 79 years old, admitted to the hospital from rehabilitation on 11/08/14 after a rapid response episode of chest pain and oxygen starvation. Review of the patient's medical record revealed that there was no treatment consent or notice of patient rights information. Interview of the licensed nursing and risk management staff confirmed that these documents were not in the patient's record and not obtained.

Patient #10 was 83 years old, admitted to ICU on 11/11/14 sepsis, diabetic foot ulcer, and becoming unresponsive after dialysis. A review of the patient's medical record revealed that there was no treatment consent and notice of patient rights information.

Patient #11 was 21 years old, admitted to the hospital on 11/03/14 from a community service agency group home and was under guardianship of an uncle. The patient is developmentally disabled, non-verbal, brain damaged, suffers with pulmonary issues (respiratory distress), is tube fed, and contracted. On 11/04/14 the patient was intubated due to shortness of breath. A review of the patient's medical record on 11/12/14 revealed that there was no treatment consent or notice of patient rights information. Interview of the nursing and risk management staff confirmed that these documents were not on the patient's chart. On 11/13/14 the risk management staff provided the surveyor copies of a completed treatment consent and notice of patient rights, and notice of privacy practices. These forms were completed on 11/12/14 at 4:35PM by the obtaining of verbal consent from the patient's guardian.

Based on observation, medical record review, and interview of the licensed nursing and risk management staff, it was determined that not all patients consistently had Advanced Directive information, MOLST, and the Important Message from Medicare(IMFM) This was evident for 3 out of 11 medical record reviews.
The findings were:

1) Patient #1 was a 79 year old patient admitted to the hospital from observation status on 2/10/14 and was discharged from the hospital on 12/17/14. Review of the medical record revealed that there was no evidence that the Important Message from Medicare was given to patient #1 within two days of discharge.

2.) In addition, Patient #7 was 79 years old, admitted to the hospital from rehabilitation on 11/08/14 after a rapid response episode of chest pain and oxygen starvation. The patient had other medical conditions that included dementia, coronary artery disease, chronic obstructive pulmonary disease, and status post fall with a subdural hematoma. Review of the patient's medical record revealed that there was no Important Message from Medicare (IMFM). Interview of the licensed nursing and risk management staff confirmed that these documents were not in the patient's record and not obtained.

3.) Patient #8 was 49 years old and was admitted to the hospital on 11/10/14 to unit 2C from an assisted facility. Patient #3 had multiple medical conditions. Review of the medical record on 11/12/14 revealed that there was no Maryland Order for Life Sustaining Treatment (MOLST) form to indicate the patient's wishes. Interview of the licensed nursing and risk management staff confirmed that a MOLST was not contained in the patient's chart.

3) Patient #11 was 21 years old, admitted to the hospital on 11/03/14 from a community service agency group home and was under guardianship of an uncle. The patient is developmentally disabled, non-verbal, brain damaged, suffers with pulmonary issues (respiratory distress), is tube fed, and contracted. On 11/04/14 the patient was intubated due to shortness of breath. A review of the patient ' s medical record on 11/12/14 revealed that there was no updated MOLST Form. Interview of the nursing and risk management staff confirmed that these document was not on the patient's chart. On 11/13/14 the risk management staff provided the surveyor a copy of a completed treatment consent, notice of patient rights, and notice of privacy practices. These forms were completed on 11/12/14 at 4:35PM by the obtaining of verbal consent from the patient ' s guardian.

Failure to ensure in advance that patients and their representatives receive patient right's information potentially places patients at risk for having care not wanted or care wanted but not provided.

Based on observation and medical record review, interview of the 2C licensed nursing staff and risk management staff on 11/12/14, and interview of the hospital's infection control practitioner on 11/13/14, it was determined that there was a potential breach by hospital staff in the isolation process of a patient with infection. This was evident for 1 of 11 medical record reviews conducted and 1 out of 2 observed isolation patients on the floor.

The findings were:

Patient #3 was 49 years old and admitted from an assisted living facility to the hospital on 11/10/14 for difficulty breathing. The patient had medical conditions that included: chronic kidney disease, diabetes, breast cancer, mental disability, and Clostridium difficile (C. difficile ) infection. A review of the patient's medical record and interview of the licensed nursing staff on 11/12/14 revealed that the physician had ordered on 11/10/14 at 1800 that the patient receive Vancomycin 125mg liquid orally every 6 hours for GI infection (with suspect organism of C. difficile ). However, the physician did not order contact isolation precautions. Observation of the nurse's station information electronic McKesson floor board, indicated that the patient's room on the schematic had no darkened border indicative of isolation. This observation was confirmed by the nurse manager and risk management staff. Additional interview of the nurse manager revealed that if the patient was on Vancomycin for C-difficile infection that isolation would be implemented by the physician ordering contact precautions with a "click" in the upper right hand corner of the electronic physician order sheet.


Review of the patient's Admission Nursing Assessment and Adult Infectious Disease Assessment revealed no information related to a C. difficile infection. Review of the patient's nursing and physician progress notes made no mention of the patient having C. difficile infection, the need for contact precautions or being placed on Contact Isolation. Observation of the patient's room door had signage for Contact Isolation.


Further investigation and interview of the hospital's infection control practitioner it was discovered that the patient had been treated at another area hospital for a C. difficile infection when the patient was discharged from that hospital on C. difficile treatment medications (Flagyl and Zyvox). The patient noticed after the medications were started that there was facial and left eye swelling and came to the hospital for treatment. The infection control practitioner researched the patient's stool status and found out that: 1) patient was "colonized," and 2) not having active diarrhea.

Failure to communicate a patient's need for contact precautions by the hospital staff through early identification, a medical order and utilized communication systems, potentially placed the public, staff, and compromised patients at risk for the transmission and exposure to serious gastrointestinal infection. Communication between staff verbally and the written record of care, is important in mitigating the risks of hospital acquired infection.