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Based on Medical Record review and interview in one (1) of three (3) Medical Records reviewed, the facility staff did not ensure that the patient representative was notified of significant changes in the patient's condition.

This lack of patient representative notification could potentially compromise the representative's ability to make an informed decision regarding care.

Findings include:

The facility's "Rules and Regulations" last revised 04/07/2017 stated: "Every patient admitted to the hospital shall have a single care giver designated to take the role of physician of record ... the responsibility of the attending of record will include ... the accountable lead of the health care team [and] provide the main line of communication to the patient, their families and other care team members ... a patient going to the operating room is the responsibility of the surgeon or person performing the procedure ...."

The current "Master of Anesthesia Services Agreement" signed and dated 08/01/2018 stated: "The Anesthesia Provider desires to ... provides anesthesia services at the hospital facilities ... [for] anesthesia services ... required by patients ... and immediate post-operative services ... [and] shall cause each Anesthesia Provider to generate and maintain patient records on a timely basis and in the form ... that conforms with the policies of each hospital facility ...."

Review of Patient #1's Medical Record identified the following information: This 50-year-old female presented to the Emergency Room (ER) with palpitations and shortness of breath secondary to heavy vaginal bleeding. The patient was admitted with symptomatic Anemia and required blood transfusions. The Admission Face Sheet dated 06/18/18 at 4:36PM indicated that the patient's emergency contact was her daughter and listed the daughter's contact phone number.

Patient #1 underwent a D&C (Dilation and Curettage) procedure, which was uneventful in the OR (Operating Room). In the PACU (Post Anesthesia Care Unit), the patient developed Hypoxia [an absence of enough Oxygen in the tissues to sustain bodily functions] and was subsequently reintubated. The patient was then transferred to the ICU (Intensive Care Unit) for Respiratory Failure at 6:00PM.

Nursing's "Adult Assessment and Intervention" Progress Note dated 06/19/18 at 7:30PM stated, "plan of care was reviewed with patient and family" approximately seven (7) hours after Patient #1 required intubation.

Physician Progress Notes, including Notes from the Anesthesiologist, Attending Physician, and Consultants, did not state contact with Patient #1's representative had been initiated until 06/20/18 at 12:33AM, when consent was obtained for the placement of a CVC (Central Venous Catheter) and approximately twelve (12) hours after Patient #1 was sedated, intubated, and placed on mechanical ventilation.

Nursing's "Adult Plan of Care" Progress Notes did not include Patient #1's Representative in the development of the patient's care plan until 06/21/18 at 2:00PM, the day after Patient #1 had been extubated.

No documentation indicating Patient #1's representative was notified of changes in the patient's condition was found.

During interview of Staff J (Director) on the morning of 06/25/19, Staff J acknowledged these findings and confirmed there was no documentation in the Medical Record indicating that Patient #1's representative had been notified of the patient's change in condition.