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Based on medical review, policy review and staff interview the facility failed to ensure Patient #25 was provided informed consent for care planning and treatment. This affected Patient #25 with the potential to affect all 113 patients in the hospital.

Findings include:

The medical record for Patient #25 was reviewed on 03/04/24. Patient #25 was admitted to the emergency department (ED) by squad from a skilled nursing facility (SNF) on 12/08/24 at 11:10 PM. Pre-arrival note at 10:00 PM from the squad listed stroke symptoms possible facial droop on the right.

Notes from Emergency Medical Services (EMS) revealed this patient's pupils were equal and reactive to light, level of consciousness (LOC) stated alert, pain 0 moving extremities spontaneously with history listed as dementia.

The facility demographics and contact information form list this patient's son as power of attorney (POA) emergency contact with a phone number listed for the state of Virginia.

Informed consent for treatment and Financial Responsibility form was on file dated 10/20/21 and 12/08/21 but no consent to treat was on file for 12/08/23.

Note from the ED physician (Staff B) on 12/08/23 at 11:42 PM revealed Patient #25 came in for evaluation of possible facial droop. Her family was in Virginia. They reported she had a history of dementia. The facility was concerned that she had altered mental status. Physician notes revealed the patient is awake, alert, and oriented. The note was not clear if the patient was oriented to person place and time. Notes further revealed this patient was answering questions appropriately, she was calm relaxed and reports no numbness or tingling, she could move her arms and legs. Physical completed with neuro assessment listing facial sensation was intact bilaterally without asymmetry, pupils are equal round react to light. This patient could stick their tongue out it is midline, could shrug her shoulders, moving extremities bilaterally.

Physician medical decision portion of the record revealed Patient #25 came to the ED with reported altered mental status and facial droop from a nursing home for evaluation and medical screening exam. Patient had no complaints. The family was contacted as they are in Virginia, they report that the patient was at baseline, and had dementia. The patient did not currently have any new neurologic symptoms; she was resting comfortable, did not appear to have any acute illness. She had normal vital signs, she was not febrile is interactive, and believed she could be discharged back to the nursing home without difficulty her, medical status examination (MSE) was complete.

Nursing assessment on 12/08/23 at 11:47 PM by Staff F, listed this patient was alert, identifies self, affect appropriate, calm cooperative with a pain assessment of 0. Vital signs (VS) on admission were temperature 36.6 Celsius (c), heart rate (HR) 75, respiratory rate (RR) 18, blood pressure (BP) 134/77 and oxygen saturation of 95 percent (%). Vital signs on 12/09/23 at 12:59 AM prior to discharge lists BP of 122/68, HR 69, RR 14, and oxygen saturation of 97%. Discharged per EMS back to skilled nursing facility with instructions or education related to Caring for the End-Stage Dementia.

Interview with Staff C on 03/05/24 at 9:57 AM revealed there are two processes to obtain consent. If you walk in the front door we have you sign a consent for treatment. If they are alert and oriented or if they have a guardian due to dementia or underage, we will contact parents or guardian. If a patient comes in by ambulance the provider completes a medical screening exam, then registration staff or our secretary obtains consent and insurance information.

Review of the policy titled "Consent for Treatment and Financial Responsibility," (01/2022) revealed if patient was incapable of providing consent because they are temporarily or permanently incapacitated due to age, illness etc. the consent must be executed by the patients legally authorized representative, legal guardian, health care power of attorney or other surrogate.

Review of the policy titled "Rights and Responsibilities of Patients" (9/2019), stated for patients to be informed about proposed care options including the risks and benefits, other care options, and the outcome of any medical care provided. This policy further stated they may need to sign their name before the start of any procedure and/or care but this is not required in the case of an emergency.

Staff C verified on 03/05/24 at 10:30 AM that consents were on file for 2021 but no consents were on file for this visit on 12/08/23 as the policies titled Consent for Treatment and Financial Responsibility and Rights and Responsibilities of Patients instructs. Staff C further verified no clear documentation was found the patients son, who was the POA, was notified of this visit or attempts made to gain a consent from them.