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Based upon observation, interview, and document review the facility failed to present the Important Message from Medicare (IMM) to 4 of 9 (patients #2, #3, #23, and #31) to the patient, patient's guardian, or patient's representative to appeal discharge; failed to ensure general consent was obtained from 8 of 28 patients (patients #2,#3,#6,#10,#13,#14,#22,#30) who presented to the facility for treatment or who presented to the facility with altered mental status, confusion, dementia, cognitive impairment or under guardianship; and failed to provide care in a safe setting for 1 of 8 patients (#28) with admission to the facility with suicidal ideation in an environment with ligature risk beds resulting in denying patients the right to appeal discharge, denying patients, patient's guardian, or patient's representative the right to refuse treatment, and resulting in the potential for severe self-inflicted harm including the potential for death. Findings include:

1. Failure to ensure the Important Message from Medicare (IMM) was presented to either the patient, patient's guardian, or a patient's representative to appeal discharget. See tag A - 0117.

2. Failure to obtain general consent from the patient, patient's guardian, or patient's representative, for patients presenting to the facility and patients presenting to the facility with confusion, altered mental status, psychiatric diagnosis, and/or dementia for 8 of 28 patients ( pts. #2,#3,#6,#10,#13,#14,#22, and #30) resulting in the potential of providing medical care against the patient's, patient's guardian, or patient's representative approval. See tag A -0131.

3. Failure to provide a ligature free environment for psychiatric patients with a diagnosis or history of suicidal ideation. See tag A - 0144.

Based on document review and interview the facility failed to present protect the rights of four of seven patients (#3, #21, #23, #31) presenting to the facility for treatment was presented to either the patient, patient's guardian, or a patient's representative to appeal discharge for those patients reviewed as requiring the Important Message for Medicare (IMM) notice resulting in the failure to inform the patient or patient's representative of the right to appeal discharge and potential loss of rights for the patient. Findings include:

On 2/16/2022 at 1020 during the medical record review of patient #3 , it was revealed the patient upon admission was noted to be "poor historian and at baseline A&O X 1 (oriented to self only)" and "unable to provide information " related to diagnosis of dementia." Further document review of the patient's medical record revealed Patient #3 signed the IMM on 11/11/2021. The patient did not have a second IMM prior to discharge and was discharged on 11/19/2021.

Document review of patient #21 medical records occurred on 2/16/2022 at 1050 revealed the patient signed for her IMM on 12/14/2021 although she had a temporary court appointed guardian on 12/7/2022. Further review of the patient's medical record revealed he patient was brought to the hospital with a petition filed by the guardian. The IMM failed to have the guardian's name or any indication that the IMM was mailed to the guardian.

On 2/16/2022 at 1045 during document review of pt. #23. During record review of the patient's medical record revealed the signature of the patient or representative stated, "unable to obtain". No date was available on the form. The medical record contained only one IMM. The patient was admitted on 2/8/2022 and was still in-patient at the time of document review.

On 2/16/2022 at 1100 document review of patient #31 medical reocord revealed the patient admitted to the facility on 2/14/2022 for altered mental status. The patient was noted to be disoriented to place and time. Review of the patient's IMM stated "verbal." Documentation failed to include if the patient's representative or the mailing of the IMM.

Based on document review, interview, and policy review the facility failed to obtain general consent from the patient or obtained general consent for patients with an assigned guardian or a patient's representative for patients with confusion, altered mental status, and/or dementia for 8 of 28 patients ( pts. #2,#3,#6,#10,#13,#14,#22, and #30) resulting in the potential of providing medical care against the patient or guardian's approval. Findings include:

On 2/16/2022 at 1000 during document review of the medical record of patient #2 it was revealed that the consent for treatment was documented as "verbal". Patient #2 arrived at the facility on 2/15/2022 at 0840. No further consent was sought from the patient.

On 2/16/2022 at 1020 during the medical record review of patient #3 , it was revealed the general consent for treatment on 11/10/2021 stated "verbal." The patient upon admission was noted to be "poor historian and at baseline A&O X 1 (alert to self)" and "unable to provide information "dementia." No further consent was sought from the guardian or the patient's representative.

On 2/16/2022 at 1027 during document review of the medical record review of patient #6, it was revealed the patient admitted to the facility on 10/13/2021. The patient's general consent stated, "unable to obtain." The patient was noted to have "dementia and acute confusion" the patient was admitted from a nursing home for altered mental status and normal pressure hydrocephalus evaluation. The patient did have a durable power of attorney, which was listed as the patient's spouse.

On 2/16/2022 at 1035 during document review of the medical record review of patient #10 it was revealed the patient was admitted to the facility 1/27/2022 for altered mental status . Further review of the patient's medical record revealed the facility failed to obtain a general consent. No consent signed was for the patient either by the patient, patient's guardian, or patient's representative.

On 2/16/2022 at 1042 during document review of the medical record revealed patient #13 was admitted to the hospital on 9/16/2022 with a fall from a ladder. The patient's general consent was marked "verbal."

On 2/16/2022 at 1050 during document review of patient #14's medical record revealed the patient was admitted on 9/17/2021 with complaints of dizziness. The patient's general consent was marked "verbal."

On 2/16/2022 at 1055 during document review of patient #22's medical record revealed the patient was admitted to the hospital on 2/8/2022 for depression. Document review of the patient's medical record revealed the patient's general consent was blank.

On 2/16/2022 at 1100 during document review of patient #30's medical record revealed the patient was admitted to the facility on 2/01/2022 for shortness of breath. Document review of the patient's medical record revealed the patient's general consent was marked as "verbal."

On 2/16/2022 at 1400, a document review occurred of the policy, "Tier 1: Informed Consent," policy ID# 7524256, last approval date of 2/16/2020. According to the policy it states the following, "Informed Consent requires 3 steps: A. Determine competence or capacity to consent, B. Inform the patient - Effective communication, C. Document in the Medical Record ...Incapacitated and/or mentally handicapped adults ...In consideration of the incapacitated and/or mentally handicapped adult, the health care team should anticipate any apparent lack of competence to give informed consent as early as possible in the hospitalization and begin appropriate measures to obtain a legal guardian through the family if the patient does not have one."

An interview occurred with staff HH, the Manager of Patient Access on 2/16/2022 at 1445. Staff HH was asked if she was aware that general consents were being obtained from patients who were identified as being unable to give consent or that "verbal" and "unable to obtain" were being documented in lieu of seeking legal guardian consent or next of kin consent. Staff HH responded, "No I am not aware of that practice." Staff HH stated that she would be in contact with the registration team and reeducate the registration staff.

Based on observation, interview, document review, the facility failed to ensure a ligature-free environment for 1 of 1 patients (#28) with a self-harm and/or suicidal ideation diagnosis resulting in the potential of self-harm or death. Findings include:

On 2/15/2022 at 1520 during tour of the psychiatric / behavioral units it was revealed that the geriatric unit contained 10 ligature risk beds of which 5 beds were occupied by patients. Upon tour of the geriatric psychiatric / behavioral unit it was revealed that one bed on the unit identified as a ligature risk bed was occupied by patient # 28.

On 2/15/2022 at 1525 during tour of the general psychiatric / behavioral unit it was revealed 1 patient was occupying a ligature risk bed.

On 2/15/2022 at 1600 document review of the patients occupying the ligature risk beds revealed 1 of 5 patients (patient #28) was admitted to the facility with suicidal ideation on 1/29/2022.

On 2/15/2022 at 1530 an interview occurred with Staff H, the Director of the Psychiatric / Behavioral Units. Staff H was queried why beds with ligature risks were being used on the units. Staff H stated that with the geriatric patients and special needs patients (i.e. paraplegia patients, contracted patients, physically deformed or challenged patients) the beds were necessary in order to turn and position patients and provide comfort care measures. Staff H stated, "We were provided guidance that the beds were approved and given as example of beds that were allowed."

On 2/17/2022 at 0920 document review occurred of the policy titled, "Tier 1: Suicide Precautions and Management for the Acute Care Patient," dated 3/28/2019. Under section G it states, "Special attention should be paid to potential hazards present in the hospital room and eliminating these to the greatest extent possible (for example, saline lock an IV to eliminate the tubing, IV Pump and electrical cord when patient is clinically stable)."