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Based on staff interviews and document review, it was determined the hospital failed to ensure each patient's family member or representative of his or her choice was promptly notified of his or her admission to the hospital in one (1) of seven (7) medical records reviewed in the survey sample. Medical record #1.

Findings:

Seven (7) medical records were reviewed 07/11-12/22 with the Quality Improvement Specialist (staff member #5) assisting in the navigation of the electronic record.

The clinical record for patient #1 contained documentation that the patient was sent from an assisted living facility to the emergency department (ED) following an outburst of violent behavior and change in mental status on 05/02/22 at approximately 9:50 PM. The patient was examined in the ED. A chest x-ray, cat scan of the head, EKG, and lab studies were performed. The physician documented, "The patient has been pleasant and alert the entire time [they have] been here in the emergency department. [Their] vital signs are stable. There is no sign of underlying sepsis. There is no sign of underlying stroke." The patient was to be discharged back to the assisted living facility with a diagnosis of agitation due to dementia. The physician ordered discharge at 05/02/22 at 8:40 PM. The medical record contained a clinical note by the physician on 05/03/22 at 6:29 PM. "Patient initially discharged back to nursing facility. Nursing facility refused to take patient due to complaints that he [unknown]. Patient has been calm throughout ED visit. Will have patient evaluated by case management in the morning to assist in finding placement...Patient was evaluated by our psychiatrist, Dr. [name of physician]. [They] recommends admission to the hospitalist service for delirium and Parkinson's dementia." The patient was admitted to the med/surg unit on May 3, 2022 at 6:56 PM.

The first documented attempt to contact the patient's family was on 05/04/22 at 4:36 PM (approximately 22 hours after the patient was admitted and 42.5 hours after the patient arrived in the ED) The case manager attempted to contact the patient's daughter and was unable to leave a message. The clinical record contained documentation of a form titled "Resident Face Sheet" sent from the assisted living facility to the ED that contained the phone numbers of both the patient's daughter and son. The case manager again called the patient's daughter and notified her of the admission at 2:56 PM on 05/05/22 (Approximately 44.5 hours after the patient's admission and 65 hours after the patient arrived in the ED).

Interviews:

An interview was conducted with the VP of Quality (staff member #4) on 07/13/22 at 10:45 AM regarding the notification of family members when the patient is admitted to the hospital. Staff member #4 stated that it was the physician's responsibility to notify the family of admission.

Document Review:

The hospital's policy, Admitting the Patient to the Hospital (ED) was reviewed and partially reads as follows, "The ED physician and/or staff physician will examine and evaluate the patient to determine the need for admission. Physician and patient will discuss admission. The patient must agree to admission or if a minor or incompetent, the appropriate designee (i.e. parent/guardian, POA) will agree to the admission." The policy did not address what measures the hospital should take to identify and notify a family member if the patient was unable to communicate.

The medical record for patient #1 failed to contain documentation that the ED physician attempted to discuss the patient's admission with the patient's family.