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Based on interviews, document review and during the course of a complaint investigation, it was determined hospital staff failed to ensure the patient/family member or other designated individual was provided the information needed to make an informed decision about the patient's care.

The findings are:

Patient #1 was a planned admit to the hospital on 6/18/20 after undergoing a robotic assist surgery for sigmoid volvulus (a condition in which the sigmoid colon wraps around itself and its own mesentery).

Review of the operative note entered 6/18/2020 at 11:39 AM by Staff Member (SM) #37 found a decision was made to proceed with an open anastomosis due to difficulties including stool spillage from both the rectum and the proximal colon. Patient #1 was taken to the PACU (post-anesthesia care unit) in stable condition.

On 6/18/20 at 4:24 PM Patient #1 was transferred to the surgical intermediate care unit. At 6:18 PM, SM #26 documents "Pt. still very drowsy, and becomes agitated when moved up in bed by staff". At 6:52 PM, SM #26 documents a call was made to the on-call provider regarding Patient #1's increasing agitation and intermittent confusion. Patient #1 was noted by SM #26 to be intermittently pulling on foley catheter, pulse ox and IV tubing. An order for Ativan (a benzodiazepine used to treat anxiety) was obtained and Ativan 1mg IV was administered at 7:05 PM. At 8:49 PM, SM #27 documents Patient #1's spouse had called twice and been updated, and Patient #1 was resting with eyes closed.

On 6/19/20, SM #26 documents at 11:24 AM Patient #1 has decreased urinary output (50 ml since 6 AM) MD notified, at 2:15 PM, SM #26 documents Patient #1 "tried to pull IV out", "shouting and moaning" , "Ativan given per MAR". At 6:06 PM, Patient #1 continues to have decreased urinary output. MD notified and new order given for bolus of LR (lactated ringer's solution). At 6:48 PM, SM #26 notes "Pt's wife updated on plan of care". At 9:12 PM, SM #40, documents Patient #1 "very agitated and restless" "IV ativan given as PRN". At 11:12 PM, Patient #1 is noted to be "oliguric, 30 ml in 5 hrs. Hypotensive 90/70, Tachycardic HR 110-122. Oxygenation drops to 88% 3 L NC applied. SPO2 now 91-95%." SM #27 (physician) notified. New order received to bolus of 1000ml/hr, increase continuous IVF to 150 ml/hr after bolus.

On 6/20/20 at 2:29 AM SM #28 was contacted and notified that Patient #1 remained oliguric (50 ml in 4 hours) hypotensive, tachycardic, confused, lethargic, responding to pain stimuli but not following commands. New orders received for bolus of 1000/ml hr, increase IVF to 200ml/hr after bolus. ABG (arterial blood gas) due to confusion. On 6/20/20 at 5:04 AM, SM #29 (physician) documents responding to MRT (medical response team) called for Patient #1 at approximately 3:00 AM. SM #29 documents that on arrival to the bedside Patient #1 had a blood pressure of 85/55 with heart rate above 120 and oxygen saturation within 89-94% on a nonrebreather mask. Labs showed acute kidney injury with a creatinine of 3.3. Use of BIPAP was considered but after evaluating Patient #1, SM #27 determined Patient #1 should be intubated and transferred to ICU. The transfer occurred at 4:10 AM.

At 4:20 AM on 6/20/20, SM #40 documents the Patient's spouse was notified at the home number on file (571-***-****), unfortunately no one answered. SM #40 left a message for the spouse to call back for patient updates. Phone numbers for emergency contacts included the phone number of Patient #1's two adult children. In addition, there is no evidence of a physician contacting the spouse or adult children on 6/19/20 addressing Patient #1's declining condition or on 6/20/20 when the Patient was transferred to a higher level of care.

Patient #1's spouse called at 6:48 AM, on 6/20/20, asking for updates on the Patient's condition. Spouse stated he/she did not receive a voice message on the home phone. It was determined later the area code had been entered incorrectly on the "face sheet" that was reviewed by the Patient on 6/18/20. SM #40 updated the spouse on the condition of Patient #1 and provided the Charge ICU Nurse telephone number.

On 6/21/20 at 2:55 PM, SM # 23 (nurse) documents: "Phone call received by (SM #23) from patient's (spouse), Name: (name). The family member was able to verify the established HIPAA password prior to receiving information. (Spouse) updated with patient's current condition, today's updates, the care plan for the next 12 hours, and items we'll be looking out for over the next shift. Discussed: Overnight events, plan of care. Questions answered regarding: Overnight events, plan of care". Review of the EHR for 6/21/20 found three physicians (SM #28, SM #34, and SM #35 had documented a progress note. There is no documentation by SM #28, SM #34 and SM #35 of any discussion with a family member about the condition of the Patient #1.

At 12:00 PM on 6/23/20 SM #24 documents "(Family Member) called this RN. (Family Member) upset with care. (Family member) notified that concerns will be relayed to manager." SM #32, (Patient Advocate) documents on 6/23/20 at 5:30 PM, of meeting with Patient #1's family per request. I introduced myself and discussed my role. The patient/family expressed concerns. The appropriate nurse, manager, physician, other staff or leader has been notified. The patient/family were provided with my (SM #32) contact information."

In an interview with SM #4 (chief medical officer) on 8/07/20 at 8:01 AM, the surveyor asked what the expectation was in regard to the physician contacting the family member, SM #4 stated the expectation is for the physician to contact the Patient's family as often as possible but at least daily. After the complaint by family on 6/23/20 regarding lack of communication from the physician(s), review of the EHR provides evidence of at least daily contact with a family member by one or more physicians.

Review of the above found hospital staff failed to provide a patient/family member/ or other designated individual with information needed to make an informed decision regarding care on 6/19 and 6/21/20. On 6/19/20, Patient #1 was acutely ill and suffered a rapid deteriation in condition and was transferred to ICU, sedated and intubated. Patient #1 was confused and agitated when awake and restraints were necessary to protect the patient's airway and multiple iv lines. On 6/21/20 Patient #1 was still a patient in ICU and remained ventilated, sedated and restrained.

Based on interviews, document review and during the course of a complaint investigation, it was determined hospital staff failed to follow hospital policy by restricting visitation to a confused patient. Patient #1.

The findings are:

Patient #1 was a planned admit to the hospital on 6/18/20 after undergoing a robotic assist surgery for sigmoid volvulus (a condition in which the sigmoid colon wraps around itself and its own mesentery).

Review of the operative note entered 6/18/2020 at 11:39 AM by Staff Member (SM) #37 found a decision was made to proceed with an open anastomosis due to difficulties including stool spillage from both the rectum and the proximal colon. Patient #1 was taken to the PACU (post-anesthesia care unit) in stable condition.
On 6/18/20 at 4:24 PM Patient #1 was transferred to the surgical intermediate care unit. At 6:18 PM, SM #26 documents "Pt. still very drowsy, and becomes agitated when moved up in bed by staff". At 6:52 PM, SM #26 documents a call was made to the on-call provider regarding Patient #1's increasing agitation and intermittent confusion. Patient #1 was noted by SM #26 to be intermittently pulling on foley catheter, pulse ox and IV tubing. An order for Ativan (a benzodiazepine used to treat anxiety) was obtained and Ativan 1mg IV was administered at 7:05 PM. At 8:49 PM, SM #27 documents Patient #1's spouse had called twice and been updated, and Patient #1 was resting with eyes closed.

Review of the clinical record for Patient #1 failed to provide evidence of a nursing note by SM # 25 documenting a conversation with the spouse . However in an interview with SM #25 on 8/1/20, SM #25 stated the spouse did call prior to Patient #1's extubation on 6/22/20 and asked about visiting the patient. SM #25 states the spouse was told there was no visitation except for patients at the end of life. Interviews were conducted with SM #23, SM #24, SM #39, SM #25 and SM #40 (all nurses involved in the patient's care). The interviewed nurses (with the exception of SM #25) stated that if a request to visit had been made, the spouse would have been told that visitors were not allowed. When asked about exceptions to this rule, the interviewed nurses stated "end of life patients". At the time of Patient #1's admission, the hospital had suspended all routine visiting due to the COVID-19 virus. Exceptions to the visitor policy included "Patients who have altered mental status or developmental delays (where caregiver provides safety) may have one visitor."

At 12:00 PM on 6/23/20 SM #24 documents "(Family Member) called this RN. (Family Member) upset with care. (Family member) notified that concerns will be relayed to manager." SM #32, (Patient Advocate) documents on 6/23/20 at 5:30 PM, of meeting with Patient #1's family per request. I introduced myself and discussed my role. The patient/family expressed concerns. The appropriate nurse, manager, physician, other staff or leader has been notified. The patient/family were provided with my (SM #32) contact information."

Review of hospital policy "Job Aid: Restraint Alternative and Preventative Strategies for High Risk and Vulnerable Patients" last revised July 2018 found listed under "General Restraint Alternative Strategies: Engage family and friends to sit with the patient". A the time of this hospitalization in response to the COVID-19 pandemic, the hospital had suspended all routine visiting. However there were exceptions which included "Patients who are at the end-of-live may have 2 visitors. Patients who have altered mental status or developmental delays (where care giver provides safety) may have 1 visitor. Minors under the age of 18 may have 1 visitor, Patients visiting the Emergency Department may have 1 person with them. Obstetric patients may have one partner and one birth support person with them. Nursery and NICU patients may have 2 parents, legal guardians or caregivers who must remain in the room for the duration of the visit.

Review of the EHR (electronic health record) provides evidence Patient #1 was confused and agitated beginning 6/18/20 when first arriving the the surgical floor. The EHR failed to provide evidence Patient #1's spouse was given the opportunity to visit the patient who had "altered mental status". Interview confirms that the spouse was refused the right to visit on at least one occasion. The spouse was given the opportunity to visit only after a complaint was filed with the hospital. It is unclear whether the spouse's presence could have reduced the time Patient #1 was restrained.
The clinical record failed to provide evidence the spouse was given the option of visiting with the patient prior to the implementation of restraints for confusion and/or agitation, as is defined in the hospital's visitors policy and the hospital's restraint policy.