HospitalInspections.org

Based on policy review, medical record reviews, and interviews, the hospital failed to ensure there was a signed consent for admission and treatment for five of 10 sampled patients (Patients 2, 4, 5, 7, and 10). This failure had the potential to affect all patients admitted as an inpatient or for observation.

Findings Include:

Review of the facility policy titled "Informed Consent," revised July 2020, indicated, "Consent for treatment must be obtained from all patients at the time of service as outlined in Section III (Consent for Admission and treatment) below. . . "I. Informed Consent Generally Section . . . C: Procedure for signing. 1. Consent must be signed prior to treatment. 2. The patient must sign the consent form. If patient is physically or mentally incapable of signing the consent form, the reason why he or she cannot sign should be written on the consent form. 3. In the event written informed consent cannot be obtained prior to patient treatment, verbal permission is acceptable under certain circumstances when two (2) witnesses have verified hearing the verbal consent, documenting the verbal consent on the written consent form and signing the written consent form as witnesses to such conversation. . . 5. A member of hospital-affiliated personnel signs the form as witness to the patient's signature. . . III. Consent for Admission and Treatment Section A: Generally. At the time of admission, each patient shall sign a Consent for Admission and Treatment . . . Section B: Responsibility of Admissions Personnel. Admissions personnel shall obtain the patient's signature when admitted through Admissions Office. When two (2) or more registration staff are on duty and the patient is admitted for services and is unable to come to registration or ER [emergency room] registration, one of the registration staff will go to the room for registration and signatures. When there is only one (1) registration staff on duty and a family member is not available to go to registration/ER to register patient, admissions will obtain all the information available to register the patient and will ask the receiving unit or the nursing supervisor to take the forms to the unit for signatures and return to registration. . . Section C: Responsibility of Receiving department Personnel. The Receiving Department will verify that a consent is documented and on the chart upon admission to the unit. . . Section D: Responsibility of Business Office. It will be the responsibility of the business office to ensure that proper signature for admission is obtained."

1. Review of Patient 2's electronic medical record (EMR), navigated by Registered Nurse (RN) 1, indicated there was no documentation of a signed and witnessed consent for admission and treatment. Review of the EMR under the "Visit History" tab indicated Patient 2 was admitted on 05/27/21 with a diagnosis of "poisoning by tricyclic antidepressants, intentional self-harm, initial encounter" and transferred on 05/31/21 for inpatient psychiatric treatment.

During an interview on 08/16/21 at 3:14 PM, Assistant Vice-President of Quality/Accreditation Coordinator (AVPQ) stated the EMR should have a consent for treatment that has "unable to sign" documented.

2. Review of Patient 4's EMR, navigated by RN 1, indicated there was no documentation of a signed and witnessed consent for admission and treatment. Review of the EMR under the "Visit History" tab indicated Patient 4 was admitted on 05/06/21, with a diagnosis of "poisoning by benzodiazepines [a depressant that produces sedation, induces sleep, relieves anxiety, and prevents seizures], accidental (unintentional), initial encounter," and discharged on 05/07/21.

During an interview on 08/17/21 at 2:47 PM, Director of Health Information Management (DHIM) stated the "back-end" documentation (documentation in the financial record) by the business office indicated the consent was unable to be signed. DHIM stated the documentation by the business office staff does not become a part of the patient's medical record. DHIM confirmed there was no documentation of a signed and witnessed consent for admission and treatment in Patient 4's EMR as required by hospital policy.

3. Review of Patient 5's EMR, navigated by RN 1, under the "Visit History" tab indicated Patient 5 was admitted on 08/11/21 with a diagnosis of cellulitis. Review of Patient 5's "Consent for Admission and Treatment," located under the "Consent" tab, indicated the signature line had Patient 5's initials but there was no documentation of a witness signature to Patient 5's signature.

During an interview on 08/17/21 at 3:34 PM, Director of Patient Financial Services (DPF) stated he/she doesn't know why the admission personnel's name didn't electronically fill on the consent. DPF confirmed the admission personnel's signature as a witness was on the assignment of benefits form but not on the "Consent for Admission and Treatment" form. DPF stated the signatures is "an auto-fill signature electronically."

4. Review of Patient 7's EMR, navigated by RN 1, under the "Visit History" tab indicated Patient 7 was admitted on 08/02/21 with a diagnosis of small bowel perforation of the intestine. Review of Patient 7's EMR indicated there was no documentation of a signed and witnessed consent for admission and treatment.

During an interview on 08/17/21 at 4:54 PM, DHIM stated he/she checked Patient 7's paper record located on the unit where Patient 7 was admitted and saw no signed and witnessed consent for admission and treatment in Patient 7's paper medical record.

5. Review of Patient 10's EMR, navigated by RN 1, under the "Visit History" tab indicated Patient 10 was admitted on 12/18/20 with a diagnosis of "chronic or unspecified duodenal ulcer with perforation." Review of the "Transfer Certification Form," located under the "Physician Certification" tab, indicated Patient 10 was transferred to an acute care hospital on 12/19/20. Review of Patient 10's "Consent for Admission and Treatment" form, located under the "Consent" tab, showed the form was not signed by the patient. No reason was documented for why the form was not signed by the patient or the patient's representative. The form was not witnessed by admission personnel as required by hospital policy.

During an interview on 08/18/21 at 8:36 AM, DHIM confirmed the registration clerk is the individual who gets consent for admission and treatment for all patients. DHIM confirmed Patient 10's consent was not signed by Patient 10 and had no reason documented for it not being signed, and was not witnessed by admission personnel.

Based on policy review, record review, and staff interview, the hospital failed to have an effective discharge planning process in place that includes reduction of factors leading to preventable hospital readmission. Specifically, the hospital failed to discharge a patient to an appropriate post-acute care service provider for one of 10 sampled patient records (Patient 1) reviewed for discharge planning.

The cumulative effect of the hospital's failure to have an effective discharge planning process has the potential to affect the current 27 inpatients and all future patients requiring discharge from the hospital.


Findings Include:

The hospital failed to transfer a patient to an appropriate post-acute care setting for one of 10 sampled patient records (Patient 1) reviewed for discharge planning. In addition to schizophrenia (a disorder characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities. Difficulty with concentration and memory may also be present), Patient 1 had multiple medical problems including high blood pressure, congestive heart failure, chronic kidney disease, scrotal edema (swelling), bilateral leg edema, and new onset of insulin dependent diabetes mellitus. The hospital discharged Patient 1 to a Psychiatric Hospital (Hospital C) on 11/13/21. Within one hour of Patient 1's arrival to Hospital C and after the Nurse Practitioner (NP) examined Patient, it was determined that Patient 1's medical problems needed immediate attention that Hospital C could not provide and arranged for his transfer to Acute Care Hospital B. (Refer to A0813).

Based on policy review, medical record review, document review, and interview, the hospital failed to discharge the patient to an appropriate post-acute care service provider for one of 10 sampled patient records (Patient 1) reviewed for discharge planning. The hospital discharged Patient 1 to a psychiatric hospital (Hospital C), that did not have the capability to provide care to a patient with Patient 1's medical needs. This failure had the potential to affect the health and safety of the current 27 inpatients and all future patients requiring discharge from the hospital.

Findings Include:

Review of the policy titled "Transitional Care Planning," revised July 2021, indicated "Purpose: Discharge planning is a process that involves determining the appropriate post-hospital transitional care planning needs of all patients. Staff will identify each patient's needs to achieve a safe transition to post-hospital destination. In addition, high risk or complex discharge needs patients will be identified as early as possible. . . All patients, inpatient and observation, will be assessed in a timely manner before discharge to determine their transitional care planning needs. Every patient, inpatient and observation, shall have a discharge screen initiated by the nurse when completing the Initial Interview. The hospital will identify at an early stage of the hospital stay all patients who are likely to suffer adverse health consequences upon discharge if there is not an adequate discharge plan. . . Should the patient's anticipated needs upon discharge be identified by nursing as being more intensive than their current situation is able to meet, Case Management/Social Services will be notified by nursing. . . The hospital must transfer or refer patients, along with necessary medical information (which should be available at time of transfer), to appropriate facilities, agencies or outpatient services as needed for follow up or ancillary care. . ."

Review of the policy titled "Interfacility Transfer of Patients From [Hospital]," dated October 2020 indicated, " The original copies of all transfer forms will be sent with the patient and copies will be maintained with the patient record. . . The transferring QMP and hospital qualified staff will complete the Transfer Certification (Form 402) Information will include: 1. Reason for transfer, including whether the transfer was necessitated by the failure or a refusal of an on-call provider to appear within a reasonable time to examine and/or provide treatment for reasons other than immediate involvement in caring for another patient in compliance with EMTALA. 2. Medical condition and QMP certification. All certifications for transfer by non-physician QMPs must be countersigned by the physician who was consulted regarding the patient transfer. 3. The risks and benefits of the transfer. . . should be specific to the patient's condition upon transfer. 4. Name of the individual at the receiving hospital who has confirmed available space and is a qualified personal [sic] and agreed to accept transfer. 5. Facility-to-facility communication. Nursing will assist as necessary. The name of the person making the contact (from Hospital) and the name of the person contacted (receiving facility) shall be documented. The name of the physician accepting transfer of the patient at the receiving facility should also be documented. 6. Medical support required for transfer should be documented. 7. Accompanying medical records/documentation should be noted on the form. 8. Patient consent for transfer should be obtained and documented. . ."

Review of Patient 1's electronic medical record (EMR), with Registered Nurse (RN) 1 navigating the electronic medical record (EMR), indicated under the "Visit History" tab that Patient 1 was admitted to the intensive care unit as a transfer from the hospital's off-site emergency department on 11/11/20 with a diagnosis of "hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease."

Review of Patient 1's "History and Physical" located under the "Clinical History" tab," in the EMR indicated it was completed on 11/11/20 by Physician 1 (PHYS). The document indicated Patient 1's chief complaint was "Nephrotic syndrome vs [versus] Glomulonephritis" [sic] [inflammation of the tiny filters in the kidneys (glomeruli) that remove excess fluid, electrolytes and waste from the bloodstream and pass them into the urine]. Further review indicated Patient 1 "exhibits schizophrenic behaviro [sic]. [Patient 1] was picked up by the [name of city] police for being agitted [sic] and placed in custody. [Patient 1] was placed in involuntary admit due to care for [himself/herself]. [Patient 1] reports [he/she] is homeless. . . [Patient 1] is noted to have bilateral leg edema, and scrotal edema."

Review of the "Assessment and plan" indicated "1. Schizophrenic behavior . . . limiting care plans and interventions - patient declines and is not interested in medical care - patient does not seem to have capacity to grasp medical complexity . . . 2. Hypertension: suspect longstanding uncontrolled hypertension - Essential does not appear urgent or emergency hypertension - will start CCB Amlodipine [an antihypertensive drug that is used in treatment of high blood pressure and chest pain] 5 mg [milligrams] po [by mouth] Qam [every morning], give does [sic] now. . . Check lipids and urinary electrolytes if able to capture. 3. REnal [sic] failure: appears t [sic] be glomulonephritis [sic] probably chronic . . . 4. Diabetes with Blood sugar greater than 200 at ER [emergency room] - Check FSBS [finger stick blood sugar] and usine [sic] sliding scale novolog [a hormone that works by lowering levels of glucose (sugar) in the blood to control diabetes; fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] to control - due to behavior and schizophrenia elected to not do DM [diabetes mellitus] diet as the risk for agitation and self or staff harm. - Follow urine output. 5. DC [discharge] planning will be difficult, Swer [social worker] consult placed."

Review of Patient 1's blood pressure results, located under the "Patient Progress Notes" tab in the EMR, showed Patient 1's blood pressures documented as following:
11/11/20 at 5:15 PM - 117/116 lying
11/11/20 at 8:04 PM - 157/109
11/11/20 at 11:28 PM - 165/116
11/12/20 at 1:51 AM - 110/98
11/12/20 at 8:06 AM - 161/96
11/12/20 at 12:10 PM - 165/95
11/12/20 at 7:49 PM - 178/105
11/12/20 at 10:53 PM - 170/99
11/13/20 at 3:47 AM - 146/112
11/13/20 at 9:15 AM - 160/111
11/13/20 at 11:14 AM - 165/110
11/13/20 at 12:05 PM - 160/95

Review of Patient 1's lab results, located under the "Patient Progress Notes" tab in the EMR, indicated the following abnormal results:

11/12/20 at 5:15 AM - BNP (B-Type Natriuretic Peptide [BNP] is a protein secreted by the heart as a response to excessive stretching of the heart's muscle cells; the test measures levels of BNP to diagnose heart failure and to determine its severity) 4029 (normal range is 0 - 100 pg/ml (picograms per milliliter); BNP was 2430 when the test was done on 11/11/20 at 1:07 AM);

11/13/20 at 8:00 AM:
Hemoglobin (protein in the red blood cells that carries oxygen from the lungs to tissues) 12.4 low (normal range is 14.0 - 18.0);
BUN (blood urea nitrogen test that reveals information about how well the kidneys and liver are working) 38 high (normal range is 9 - 20);
Creatinine (a test reveals information about the kidneys) 3.54 high (normal range is 0.70 - 1.30).

Review of Patient 1's physician orders, located under the "Physician Orders" tab in the EMR, indicated the following orders by Physician (PHYS) 1:
11/11/20 at 5:54 PM "Admit to Inpatient Status ICU [intensive care unit] care due to Behavior and Hypertension"
11/11/20 at 5:54 PM Colace (stool softener) 100 mg by mouth twice a day.
11/11/20 at 5:54 PM Lorazepam (Ativan) (used to treat anxiety) 1 mg (milligram) intravenous push prn (as needed) with no documentation of the indication for use.
11/11/20 at 5:54 PM Lasix (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) 20 mg intravenous push daily.
11/11/20 at 5:54 PM Novolog insulin 11 units per ml (milliliter), 10 ml per protocol subcutaneous as needed (dose range was documented).
11/11/20 at 5:56 PM Amlodipine 5 mg by mouth daily.
11/11/20 at 9:27 PM Lorazepam 1 mg by mouth as needed with no documentation of indication for use.
11/11/20 at 7:46 PM "Consult mental health Re:eval [sic] for chronic mental health issues and inability to care for self. He has inability to maintain his Diabetes or HTN [hypertension] and has chronic renal disease"
11/13/20 at 11:22 AM Nitroglycerin (Nitrobid) Ointment 2 % (per cent) 1 gm (gram) 0.5 inch topical every six hours, remove prior dose before reapplication.
11/13/20 at 11:33 AM Lasix 20 mg by mouth daily.

Review of Patient 1's "Medications," located under the "Patient Progress Notes" tab in the EMR, indicated the following medications were administered or refused by Patient 1:
11/11/20 at 6:12 PM Amlodipine (Norvasc) 5 mg by mouth.
11/11/20 at 6:12 PM Colace 100 mg by mouth.
11/11/20 at 9:32 PM Lorazepam 1 mg by mouth for restlessness.
11/12/20 at 2:18 AM Lorazepam 1 mg by mouth for restlessness.
11/12/20 at 12:51 PM Lasix refused by Patient 1 (no dose and route documented).
11/12/20 at 12:52 PM Amlodipine refused by Patient 1 (no dose and route documented).
11/12/20 at 8:03 PM Lorazepam 1 mg by mouth for restlessness.
11/12/20 at 10:47 PM Colace 100 mg by mouth refused by Patient 1.
11/13/20 at 2:04 AM Lorazepam 1 mg by mouth for restlessness.
11/13/20 at 10:00 AM Amlodipine refused by Patient 1 (dose and route not documented).
11/13/20 at 10:00 AM Lasix refused by Patient 1 (dose and route not documented).
11/13/20 at 10:00 AM Colace 100 mg capsule refused by Patient 1.
11/13/20 at 11:22 AM Nitroglycerin Ointment 0.5-inch patch applied.


During an interview on 08/17/21 at 1:28 PM, the Administrator stated someone told him that they were having trouble with a patient being transferred to Hospital C. The Administrator stated that he had a conversation with someone at Hospital C and with PHYS 1. The Administrator stated PHYS 1 stated Patient 1 had chronic kidney disease, and there wasn't a reason for Patient 1 to be in a medical hospital, that they needed to get Patient 1 in a psychiatric hospital, so they could treat his psychosis. The Administrator stated he asked PHYS 1 about the labs, and PHYS 1 said Patient 1 was not in acute renal failure and Patient 1 had all these other medical issues, but they could be treated on an outpatient basis as they had been treated prior to incarceration. The Administrator stated he spoke with an administrator at Hospital C and relayed the information.

Review of Patient 1's "Transfer Certification Form" signed by PHYS 1 on 11/13/20 indicated "Patient Is Stable for Transfer: and "Provider certification: I have examined this patient and provided a MSE . . ." Documentation indicated "Medical Benefits outweigh the risks, "Medical Risks: Deterioration of condition in route" and "Risk of traffic delay/accident resulting in condition deterioration or death." "Receiving Facility" listed as [Hospital C] "Accepting/Receiving Provider: [name of psychiatrist accepting Patient 1 at Hospital C Date 11/13/2020 Time: 11:49 am Transferring Provider: [PHYS1]" "The patient is unable to consent due to his/her medical condition or incapacity, and no personal representative is available to provide or refuse consent." There was a hand-written note of "unable to comprehend," and the form was signed by PHYS 1 and witnessed by Licensed Master Level Psychologist (LMLP) and RN 5.

Review of nursing documentation, located under the "Patient Progress Notes" tab under the "Clinical History" tab, on 11/13/20 at 12:10 PM by RN 5 showed "Patient taken per w/c [wheelchair] to vehicle with officer in attendance. Transfer packet given to officer to give to [Hospital C] staff. Report called to nurse at receiving facility."

Review of documentation presented by Nurse Practitioner (NP) from Hospital C, received by secure email, indicated NP's assessment on 11/13/20 at 4:06 PM of Patient 1 indicated that Patient 1 presented "in a police car and was unable to walk. Security needed to secure a wheelchair to get the patient inside the facility. While in the police car it was noticed that the patient's legs were weeping to the point that his pant leg and sock were soaked on the right leg. You could visibly see that his testicles were fluid overloaded through his pants. When in the exam room after we were able to disrobe the patient, his legs were at 3+ pitting all the way up to his abdominal folds with large weeping testicles. His abdomen was enlarged and firm with discoloration to the skin and a "chicken skin" appearance from his feet to his nipple line. A nitroglycerin patch was still taped to his upper back. He was noticeably breathless with crackles and vital signs were 178/106 BP [blood pressure], 106 P [pulse], 97.7 F [Fahrenheit], 94% [per cent] on room air. He was in severe fluid overload with a history of kidney failure, CHF, and new onset diabetes. He has chronic glomerulonephritis per the ED [emergency Department] at [Hospital], who had reported to admissions that the patient was stable with chronic conditions only and able to ambulate. . . The patient was sent to Hospital B by EMS [emergency medical service] for treatment of his severe fluid status. . ."

During a telephone interview on 08/16/21 at 4:45 PM, Nurse Practitioner (NP) stated she spoke with PHYS 1 who "downplayed everything." NP stated the psychiatrist speaks doctor-to-doctor related to psychiatric issues, but the psychiatrist doesn't address medical issues. NP stated when she brought Patient 1 into the treatment room upon Patient 1's arrival to Hospital C by police care and examined Patient 1. The NP stated the fluid "went up to his nipples, and his scrotum was grossly enlarged and weeping."

During an interview on 08/17/21 at 10:39 AM, PHYS 1 stated, "I explained [to the psychiatrist at Hospital C] why the patient was in ICU, not because [Patient 1] had an ICU need, but [Patient 1] needed a monitored bed [behavior], and in this hospital, that is the only monitored bed. [Patient 1] is a schizophrenic . . . with medical issues that [Patient 1] hasn't paid attention to for a very long time. [Patient 1's] issues were chronic issues and not acute issues." PHYS 1 stated the primary issue was that Patient 1's schizophrenia was limiting Patient 1's medical care, and PHYS 1 wasn't able to address the medical issues of Patient 1. PHYS 1 stated the reason Patient 1 was transported by the police was because Patient 1 "was a big [person] and forceful, and the transport of [Patient 1] in an ambulance would be a risk to both the patient and the ambulance attendees, because the patient had been trying to hit staff and pee on people." PHYS 1 stated "the edema was not as concerning as the potential for injury to all involved during transport."

Review of Patient 1's "History and Physical Reports" documented by PHYS 4 on 11/14/20 at 3:02 PM, received by secure email from Hospital B, indicated Patient 1 was admitted to Hospital B on 11/13/20 and presented as a discharge from Hospital C. Further review indicated Patient 1 was at Hospital C "for one hour" then transported by EMS due to "abdominal, testicle, and BLE [bilateral lower extremity] swelling with weeping." Patient 1's blood pressure was documented as 154/102 with oxygen saturation of 96%. Further documentation indicated "Nursing staff unable to place a foley [indwelling urinary catheter] due to the edema." Review of "Assessment/Plan" indicated "Urinary retention: foreskin edema reduced by manual compression for 10 minutes. Then able to visualized [sic] urethral meatus. 16 Fr [French] [indwelling urinary catheter] placed without resistance, with return of 1000 ml [milliliters] yellow urine. . ." Review of "History of Present Illness" indicated ". . . Per records, pt [patient] was homeless, living in [name of city and state] and placed in police custody d/t [due to] psychotic behavior and inability to care for himself. He was taken to the above-named hospital in [name of city and state] for medical clearance in order to transfer to Hospital C. He was cleared despite very abnormal lab results in paperwork. Upon arrival at [Hospital C], staff discovered him to be hypertensive (BP 178/106), grossly edematous, hyperglycemic, and elevated creatinine. He was transferred to [Hospital B ED] and further w/u [work-up]. In ER, pt delusional and restless. . . Abnormal labs include BUN 42, Cr [creatinine] 3.7, Glu [glucose] 133, BNP > [greater than] 33000. CXR -chest x-ray] reports large right pleural effusion (often referred to as "water on the lungs") . . ." Review of PHYS 4's "Assessment/Plan" indicated the following diagnoses: acute exacerbation of CHF, acute kidney injury, anasarca (medical condition that leads to general swelling of the whole body), schizophrenia, hypertensive emergency, right pleural effusion, diabetes mellitus type II uncontrolled.

The above-named hospital discharged Patient 1 to a psychiatric hospital (Hospital C) prior to stabilizing Patient 1's medical needs. This resulted in Patient 1 being discharged from Hospital C and admitted to another acute care hospital (Hospital B) within an hour of arrival. The hospital failed to discharge Patient 1 to an appropriate post acute setting.