HospitalInspections.org

Based on record review, document review, and interview, the hospital failed to ensure notice of patient rights and consent to treatment for 3 patients (Patients 21, 22, and 23) of 26 sample patients.

This deficient practice places all patients at risk for potential patient rights violations.

Findings Include:

Review of the Hospital policy titled, "Hospital and Physician Service Agreement," last reviewed 07/12/21, showed that all patients who register for treatment must sign a service agreement and if a patient is incapacitated and unable to consent to non-emergency treatment, staff will either wait until the patient has capacity to consent or follow hospital policies on substitute decision makers

Review of the Hospital policy titled, "Advance Directives for Medical Treatment or Behavioral Health," last reviewed 07/31/23, showed that if a patient lacks decision making capacity the provider will make reasonable efforts to locate as many "interested persons" (spouse, parent, adult child, sibling or other adult that may be involved and/or knowledgeable about the patient) as possible to inform them that the patient lacks decision making capacity and that a Proxy Decision Maker (a person that has legal authority to make decisions on behalf of a person who is unable to make those decisions) is needed and should be chosen for the patient.


Patient 20

Review of Patient 20's medical record showed an 85-year-old admitted to the hospital on 04/29/25 with a primary diagnosis of acute metabolic encephalopathy and discharged on 05/02/25 to a skilled nursing facility (SNF).

Review of Patient 20's "Hospital Service Agreement" form dated 04/29/25 at 7:58 PM read, "Pt [patient] unable to sign".

Review of Patient 20's "Patient Bill of Rights" form dated 04/29/25 at 7:58 PM read, "Pt [patient] unable to sign".

Review of Patient 20's medical record showed on 04/30/25 at 1:57 AM, "patient has advanced directive, copy in chart ... Decision Maker for Healthcare ... Medical Durable Power of Attorney".

Patient 21

Review of Patient 21's medical record showed a 92-year-old admitted to the hospital on 05/01/25 with a primary diagnosis of community acquired pneumonia and was discharged to home on 05/07/25.

Review of Patient 21's "Hospital Service Agreement" form dated 05/01/25 at 9:33 AM read, "Pt [patient] unable to sign".
Review of Patient 21's "Patient Bill of Rights" form dated 05/01/25 at 9:33 AM read, "Pt [patient] unable to sign".


Patient 22

Review of Patient 22's medical record showed a 79-year-old admitted to the hospital on 05/10/25 with a primary diagnosis of hypernatremia and discharged on 05/19/25.

Review of Patient 22's "Hospital Service Agreement" form dated 05/10/25 11:01 AM read, "Pt [patient] unable to sign".

Review of Patient 22's "Patient Bill of Rights" form dated 05/10/25 at 11:01 AM read, "Pt patient] unable to sign".

Review of Patient 22's record showed on 05/10/25 at 6:39 PM, "patient has advanced directive, copy in chart ... Decision Maker for Healthcare ... Medical Durable Power of Attorney".

During an interview on 07/30/25, Staff H, Patient Access Manager, stated that any patient admitted to the hospital or seen in the Emergency Department (ED) is seen by registration to have consent forms and bill of rights signed. Staff H stated that if the patient is incapacitated or has an altered mental status that they would attempt to get consent from the patient's listed medical durable power of attorney (MDPOA) on hospital records. Staff H stated that if there was no listed MDPOA then registration would reattempt getting a signature on the consent and patient rights form later in the patient hospitalization when either the patient was no longer cognitively impaired or if the patients DPOA became available.