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Based on document review and interview the Critical Access Hospital (CAH) failed to ensure written policies and procedures were available for care and testing for 2 of 4 (Patient 1 and 2) patients reviewed, failed to have available training or competencies policies for 6 of 6 (Staff C, D, E, F, G and H) staff, and failed to follow the grievance policy for 1 of 2 (Patient 4's DPOA, F5) grievances filed. This deficient practice has the potential to affect all patients and may lead to harm or other adverse outcomes.


Findings Include:


1. Review of Kansas Regulation §28-34-8(a)(c) showed "Administrative Services, Policies and Procedures: Personnel policies and procedures. The governing body, through the CEO, shall establish and maintain written personnel policies and procedures which adequately support sound patient care. These policies and procedures shall be reviewed at least every 2 years. A procedure shall be established for advising employees of policy and procedure changes."

Review of the CAH's document titled "Job Description, Position Title: Director of Nursing Service," dated March 2009, showed, "The director of nursing is responsible for generating and approving nursing policies and procedures. The Director of nursing will ensure the adequacy of the content of policies and procedures."


Patient 1

Review of Patient 1's medical record showed that Patient 1 was admitted on 09/30/22 at 5:00 PM to the senior behavioral health (SBH) unit due to aggressive sexual behaviors toward his staff at his assisted living facility (ALF). Patient 1 was discharged to a skilled nursing facility (SNF) on 10/10/22.

Review of Patient 1's "Certificate of Care Assessment," dated 10/06/22, showed, "The Preadmission Screening and Annual Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed.

Staff B, Director of Nursing/Risk Manager, Quality Assurance (DON/RMQA), was asked for and failed to provide a policy and procedure for PASARR assessments.

Review of Patient 1's "Master Treatment Plan," dated 10/01/22 at 1:53 PM showed that the care plan was not electronically signed by the Registered Nurse (RN). The plan failed to include two signatures witnessing the education, participation, and agreement to the treatment plan by the durable power of attorney (DPOA).
During an interview on 01/05/23 at 9:16 AM, Staff D, RN, stated that DPOA's are provided the education and discharge instructions if you can get a hold of them or when they attend the family meeting. Staff D stated that you must document if you are unable to contact them. Staff D stated that if you provide the information over the phone, two staff sign as witness that the information was provided over the phone to the DPOA.

Staff B, DON/RMQA, was asked for and failed to provide a policy and procedure for treatment plans.

During an interview on 01/03/23 at 1:48 PM, Staff B, DON/RMQA, stated that the nursing care plan policy could not be found.

Review of Patient 1's "SLUMS (Saint Louis University Mental Status) Examination (a screening tool to assess cognitive functioning)" dated 09/30/22, showed that Patient 1 had a total score of 19 (a score of one through 20 indicates dementia).

Staff B, DON/RMQA was asked for and failed to provide a policy and procedure for SLUMS examination.

During an interview on 01/05/23 at 2:55 PM, Staff H, Program Director (PD) of Senior Behavioral Health (SBH), stated that she looks at the SBH policies and procedures every three years to ensure they are still pertinent. Staff H stated that there are no policy and procedures for PASRR or SLUMS (Saint Louis University Mental Status Examination, a screening test for Alzheimer's disease and other kinds of dementia).

Review of Patient 1's medical record showed that on 10/04/22 at 12:51 PM, five referral packets that included protected health information were faxed to various skilled nursing facilities (SNF). Further review showed that on 10/04/22 two additional referral packets were sent to SNFs.

Review of Patient 1's medical record showed no evidence of a release of information, to these SNFs, had been signed by Patient 1 or the responsible person.

Staff B, DON/RMQA was asked for and failed to provide a policy and procedure release of information.


Patient 2

Review of Patient 2's medical record showed that Patient 2 was admitted on 12/30/22 at 12:55 PM for the treatment of possible aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, vomit, and even small foreign objects)."

Review of Patient 2's "Medication Record," showed that Patient 2 was receiving regular nebulizer treatments (breathing treatment that turns liquid medications into a mist that is inhaled into the lungs).

Review of Patient 2's "Physician Orders," showed an order written on 12/30/22 at 1:04 PM to give ipratropium/albuterol inhaled solution (duo-neb) (medication used to open airways to make it easier to breathe) 3 milliliters (ML), by nebulizer, four times a day for respiratory.

Review of Patient 2's "Medication Administration Record (MAR)," showed that Patient 2 was refusing many of her nebulizer treatments.

Staff B, DON/RMQA was asked for and failed to provide a policy and procedure for nebulizer treatments or respiratory care.

Review of Patient 2's medical record showed that on 12/30/22 at 3:06 PM, Patient 2 was placed on specialized precautions including "aspiration precautions."

Review of Patient 2's "Physician Orders," dated 12/30/22 at 3:02 PM showed an order for "dietary, Pureed 1 X." Patient 2 was otherwise on a regular diet.

Review of Patient 2's "Patient Progress Notes," dated 12/30/22 at 5:27 PM showed, "nutrition/food service: meal served, meal tray setup performed, water pitcher freshened." The medical record failed to identify if the food served was pureed or a bedside swallow screen was completed.

Staff B, DON/RMQA was asked for and failed to provide a policy and procedure for bedside swallow screens.


2. Review of the CAH's document titled, "RN [Registered Nurse] Orientation Handbook," revised December 2021, showed "evaluations will be completed by your department manager at 90 days of employment . . . please turn in your orientation manual at this time . . . the preceptor is to initial each competency with their initials. Initialing the skills completed, indicates that the new employee can locate equipment, demonstrates correct set-up and usage of equipment, provides appropriate nursing interventions, describes troubleshooting techniques, and proves proper documentation techniques. The new employee and the preceptor(s) are expected to sign the competency packet off to indicate that the orientee has successfully completed all areas of the competencies . . . This is a legal document that will be added to the new personnel's file."

Review of 6 of 6 personnel records lacked evidence of orientation, training, ongoing education, and competencies were completed for four nurses, a licensed social worker, and the Program Director of the Senior Behavioral Health Unit.

a. Review of Staff C, Registered Nurse's (RN) personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire or evidence of the completion of ongoing education.

b. Review of Staff D, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire or evidence of the completion of ongoing education.

c. Review of Staff E, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire or evidence of the completion of ongoing education.

d. Review of Staff F, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire or evidence of the completion of ongoing education.

e. Review of Staff G, Licensed Master of Social Work (LMSW)'s personnel file showed that it did not have evidence of orientation, training, or ongoing education.

f. Review of Staff H, Program Director of Senior Behavioral Health's, personnel file showed that it did not have evidence of orientation, training, or ongoing education.


During an interview on 01/03/23 at 12:06 PM, Staff B, DON/RMQA, stated that the hospital is in the process of updating all their nursing policies and that there are some that are old. She stated that she does not have a policy that addresses nursing care.

During an interview on 01/05/23 at 2:55 PM, Staff H, PD, stated that it's been a few years since the hospital have done competencies.

Staff B, DON/RMQA was asked for and failed to provide a policy and procedure for orientation, training, ongoing education, or competencies.

During an interview on 01/06/23 at 9:10 AM, Staff B, DON/RMQA, stated that there is no policy on nursing competencies or ongoing training provided to the nursing staff.


3. Review of Kansas Regulation §28-34-b(b) showed "Grievances. The facility's policies and procedures shall establish a mechanism for responding to patient complaints.

Review of the CAH's policy titled, "Grievance Resolution Process (patient and/or their representative)," dated 11/04/12, showed "staff share the responsibility for recognizing and attempting to address patient and/or their representative grievances and to provide for a timely resolution . . . if a patient and/or their representative's grievance is in writing, emailed, or faxed, a written response must be provided . . . the hospital shall strive to provide a written response within seven (7) days. If the grievance cannot be resolved, or the investigation is or cannot be completed within seven (7) days, the hospital shall inform the patient and/or the representative that the hospital is still working to resolve the grievance and a written response shall be provided as soon as the grievance is resolved . . . written notice of the grievance decision contains the name of the [CAH's] contact person, the steps taken on behalf of the patient and/or their representative to investigate the grievance, the results, and the date of completion." The policy failed to define the differences between complaints and grievances or outline what an investigation included.

Review of the CAH's document presented as the "Incident and Grievance Log," dated 10/01/22 to 12/31/22 showed two entries listed as complaints.

Review of a letter addressed to Staff H, Program Director, Staff J, Doctor of Osteopathy (DO), and Staff G, Social Worker, undated, showed Patient 4's wife and DPOA (F5) submitted a written grievance. The grievance outlined her concerns with a nurse told F5 that she needed to find a placement for Patient 4 as soon as possible. Further, F5 was requested to attend an in-person meeting with the psychologist; however, F5 could not hear the psychologist due to the psychologist's child screaming in the background. Lastly, F5 reported that while visiting Patient 4, an unidentified staff got onto the phone asking what the procedure was if a visitor refused to hand a purse and cell phone over to staff.

Review of an unsigned, unlabeled note provided with the hospital's copy of the grievance from F5, dated 11/25/22, showed that F5 was still waiting for copies of Patient 4's records that were requested.

Review of "Quality Data," dated 11/25/22 showed that Staff H, Program Director, documented ..."Follow up: none at this time . . . completion date 12/22/2022." The section "final review," was left blank.

During an interview on 01/05/23 at 2:03 PM, Staff B, DON/RMQA, stated that a response letter is required for all grievances within five to seven days. Staff B stated that she does not meet that deadline. Staff B stated that she thought Staff A, Chief Executive Officer (CEO), had written the grievance letter for Patient 4. Staff B stated that there was a communication error and that a letter was not done. Staff B stated that it was her responsibility to ensure the completion of the grievance process.

Based on state regulation review, document review, and interview the Critical Access Hospital (CAH) failed to ensure the competency for 4 of 4 nursing staff (Staff C, D, E and F). This deficient practice has the potential for all patients to receive incompetent care that may lead to harm or other adverse outcomes.

Findings Include:

Review of Kansas Regulation §28-34-8(a)(d)(3) showed, "Administrative Services - Staff Development. Education programs. Orientation and in-service training programs shall be provided to allow personal to improve and maintain skills and to learn of new health care developments."

Review of the CAH's document titled "Job Description, Position Title: Director of Nursing Service," dated March 2009, showed, . . . "The director of nursing will . . . identify existing nursing staff for educational needs, facilitates use of appropriate, available resources to meet the needs on a continued basis . . . assists and develops unit specific competency exams for nursing personnel. Assist the education department in yearly in-services for nursing personnel . . . develops and conducts written evaluations for nursing skills on a yearly basis."

Review of the CAH's document titled, "RN [Registered Nurse] Orientation Handbook," revised December 2021, showed "evaluations will be completed by your department manager at 90 days of employment . . . please turn in your orientation manual at this time . . . the preceptor is to initial each competency with their initials. Initialing the skills completed, indicates that the new employee can locate equipment, demonstrates correct set-up and usage of equipment, provides appropriate nursing interventions, describes troubleshooting techniques, and proves proper documentation techniques. The new employee and the preceptor(s) are expected to sign the competency packet off to indicate that the orientee has successfully completed all areas of the competencies . . . This is a legal document that will be added to the new personnel's file."

Review of Staff C, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire.

Review of Staff D, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire.

Review of Staff E, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire.

Review of Staff F, RN's personnel file showed that it did not have evidence of a completed "RN Orientation Handbook," that included nurse competencies done upon hire.

During an interview on 01/05/23 at 2:55 PM, Staff H, Program Director (PD), stated that the hospital had not done compentencies in a few years.

During an interview on 01/06/23 at 9:10 AM, Staff B, Director of Nursing/Risk Manager, Quality Assurance (DON/RMQA) stated that there is no policy on nursing competencies or ongoing training.

During an interview on 01/06/23 at 12:35 PM, Staff I, Human Resource Director (HRD), stated that when nurses are hired, they go to orientation and then to the floor to their preceptors for competency completion. Staff I stated that the documentation does not always make it back to HR for filing in the staff's personnel file. Staff I stated that none of the sampled nurses have documentation to show competencies were completed.

During an interview on 01/06/23 at 12:48 PM, Staff B, DON/RMQA, stated that trainings that are completed during nurse meetings are not documented in personnel files.

Based on state regulation review, policy review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure care was provided in accordance with a patient's needs to protect the privacy for 1 of 4 patients reviewed (Patient 4). This deficient practice has the potential to cause harm and other adverse outcomes.


Findings Include:


Review of Kansas Regulation §28-34-3(b)(a) showed "The governing body shall ensure that the facility establishes policies and procedures which support the rights of all inpatients and outpatients. At a minimum, each facility shall ensure that each patient has the right to respectful care" . . .


Review of the CAH's policy titled, "Patient Rights," dated 01/04/13, showed, "The use and reference to 'patient' includes the patient/parent/guardian/surrogate/legal representative, as appropriate to the individual situation . . . you [the patient] or your legal representative have the right to . . . considerate dignified and respectful care . . . be informed by his/her [the patient's] physician or a delegate of his/her physician of the continuing healthcare requirements following his/her discharge from the hospital. Be involved in formulating the plan of care . . .Have all patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient."


Patient 4

Review of Patient 4's discharged medical record showed that Patient 4 was admitted to the senior behavioral health unit (SBHU)on 10/16/22 at 3:40 PM with increased behaviors at home, increased aggression, refusing cares, erratic sleep patterns, urinating in sink and trash can, increased insomnia (inability to fall asleep or stay asleep), confusion, and refusing medications.

Patient 4 was discharged from the senior behavioral health unit and transferred to the med-surge floor on 10/25/22 at 5:30 PM. Patient 4 has been diagnosed with unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life) with agitation, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior), Chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), benign prostatic hyperplasia (BPH, a condition in which the flow of urine is blocked due to the enlargement of the prostate gland), basal cell carcinoma (cancer) of nose, and Tachy brady (the alternation of fast and slow heart rates).

Review of "Progress Note," dated 10/21/22 at 11:33 PM, showed Staff L, Registered Nurse (RN), documented "2200 [10:00 PM] catheter placed . . . arm board and it's wrapped due to fidgeting with the IV tubing . . . catheter tubing is secured by a stat lock and tape. He has brief placed and pants to hopefully keep him from pulling on the catheter tubing. His [Patient 4] bed was then placed in the hallway to monitor him." The hospital failed ensure care was provided in accordance with a patient's needs to protect Patient 4's privacy .

During an interview on 01/03/23 at 12:06 PM, Staff B, Director of Nursing/Risk Manager, Quality Assurance (DON/RMQA), stated that the hospital is in the process of updating all their nursing policies and that there are some that are old. She stated that she does not have a policy that addresses nursing care.

During an interview on 01/05/23 at 10:32 AM, Staff C, RN, stated that there is never a reason to have a patient sleep in the hallway.

During an interview on 01/05/23 at 11:45 AM, Staff G, Licensed Master's Social Worker (LMSW), stated that a patient may be placed in the hallway because of suicidal ideation, but usually they put them in the group room because there are windows to that room.

During an interview on 01/05/23 at 2:03 PM, Staff B, DON/RMQA, stated that a patient may be placed in the hallway at times if it is difficult to keep them in bed or if they are agitated. Staff B stated that they usually put the patient in the group room because there are windows, and the door can be shut. Staff B stated that moving a patient to the room closest to the nurse's station would be the best thing to do.

During an interview on 01/05/23 at 2:55 PM, Staff H, Program Director (PD) of the Senior Behavioral Health Unit, stated that there shouldn't be any patients in the hallway in a bed.

Based on document review, record review, and interview, the Critical Access Hospital (CAH) failed to obtain release of information authorization for 2 of 4 patients (Patient 1 and 4) reviewed. This deficient practice has the potential to cause harm or other adverse outcomes.

Findings Include:

Review of the CAH's document titled "Consent for Hospital Treatment," dated 09/29/20, showed "I wish to be treated at [the CAH] and consent to hospital care encompassing routine diagnostic procedures, clinical evaluation, and medical treatment by the attending physician, assistant(s) or designees as is necessary in their judgment. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatment or examination in the hospital. I authorize the hospital to take photographs of me or parts of my body for use in medical evaluation, education or research. I consent to the study and retention or disposal of tissue or parts which may be removed during the required operation or procedure." Further review showed that the document did not include consent to release information to other facilities for continuity of care.

Review of the CAH's document titled "Confidentiality Statement," dated 02/2018, showed "All patients have a right to privacy. State and Federal law dictates that medical treatment is confidential. Discussing any patient or information concerning their illness, treatment or contents of the medical record without specific written consent is a breach of confidentiality and an invasion of privacy. Be careful to respect the patient's rights at all times. All information concerning client of [the CAH] Senior Behavioral Health [SBH] Services is to be held in strict confidence and shared only with appropriate staff at [the CAH]."


Patient 1

Review of Patient 1's medical record showed that Patient 1 was admitted to SBH on 09/30/22 due to sexually inappropriate behaviors towards staff at his assisted living facility. Patient 1 has medical diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).

Review of Patient 1's "Durable Power of Attorney (DPOA)", dated 09/02/21 showed that he had an appointed representative for health care.

Review of Patient 1's "Progress Notes" dated 10/04/22 at 12:51 PM, Staff F, Registered Nurse (RN), documented that referral packets were faxed to five aftercare facilities .

The medical record failed to show Staff F documented evidence that a release of information was obtained from Patient 1 or his DPOA prior to sending his personal health information to the skilled nursing facilities (SNF).


Patient 4

Review of Patient 4's medical record showed that Patient 4 was admitted on 10/16/22 at 3:40 PM. Patient 4 was transferred to the med-surge floor on 10/25/22 at 5:30 PM. Patient 4 has been diagnosed with unspecified dementia with agitation, Alzheimer's disease. Patient 4 was admitted due to increased behaviors at home, increased aggression, refusing cares, erratic sleep patterns, urinating in sink and trash can, increased insomnia, confusion, and refusing medications.

Review of Patient 4's "Durable Power of Attorney (DPOA)", dated 08/26/09 showed that he had an appointed representative for health care.

Review of Patient 4's "Progress Note," dated 10/24/22 at 5:40 PM, Staff H, Program Director (PD) documented that twelve different facilities were contacted for Patient 4's care upon discharge.

Additionally, Staff H documented that Staff F, RN contacted an unknown number of facilities in two other cities.

The medical record failed to show Staff H documented evidence that a release of information was obtained from Patient 4 or the DPOA prior to sending Patient 4's personal health information to the facilities.


During an interview on 01/05/23 at 9:16 AM, Staff D, RN, stated that a release of information (ROI) must be completed for every facility or home health that a referral packet is sent.

During an interview on 01/05/23 at 10:32 AM, Staff C, RN, stated that a referral packet includes the patient's history and physical (H&P), physical and occupational therapy evaluations, labs, most updated physician notes and the discharge notes. Staff C stated that there are two different forms that can be used for the ROI and that a patient or a patient's representative must sign for each facility or party the information is going to.

During an interview on 01/05/23 at 2:55 PM, Staff H, PD, stated that they call facilities to determine if they have a bed available and then get consents signed to send a referral packet. If the consent is over the phone, there must be a second staff person witnessing the consent obtained. Staff H stated that a nurse's note is not consent.

During an interview on 01/06/23 at 9:10 AM, Staff B, DON/RMQA, stated that the Senior Behavioral Health (SBH) Unit has not been using the updated consent for admission and treatment form that outlines personal health information (PHI) will be shared with other facilities for the continuation of care.

Based on policy review, record review, and interview the CAH failed to ensure appropriate discharge education and information was provided to patient's appointed durable power of attorney (DPOA) upon discharge for 4 of 4 patients (Patient 1, 2, 3, and 4) reviewed. This deficient practice has the potential to affect all patients with DPOA's or guardians from receiving updated education, information, and required follow up care and may lead to harm or other adverse outcomes.


Findings Include:


Review of the CAH's policy titled, "P&P [policy and procedure] Discharge Planning/Overall Plan of Care [POC] Meeting," dated 12/12/07, showed, "It will be the responsibility of the discharge planner to facilitate communication between the patient/patient representative, the physician, the staff, and the interdisciplinary health care team members . . . Physicians and all staff will continue to make patients/patient representatives aware of the [POC] and discharge plans . . . to patients/patient representative so that each person receiving care will understand the continuity of their care ."

Review of the CAH's policy titled, "Discharge Planning," dated 07/24/14, showed "to provide guidelines in the initiation and continuation of discharge planning for the facilitation and promotion of continuity of care for each patient, family, and significant other(s) (if appropriate)."

Review of the CAH's policy titled, "Discharge of Patient," dated 08/07/08, showed "Explain discharge procedure to patient. Include the family . . . exit care discharge instructions will be filled out by the charge nurse. Home care instructions for activities, diet, medications, follow-up appointments, and agencies for referral are included . . . after the paperwork is completed, escort patient to family car . . . attach a copy . . . to the medical record."

Review of the CAH's policy titled, "Guardianship/Durable Power of Attorney Involvement," dated 12/19/22, showed, "A patient's DPOA or guardian is to be included throughout the treatment process. Changes in diagnosis, treatment, or progress will be communicated to the guardian. His/her involvement will be encouraged or required when approval is necessary to initiate and/or continue treatment and to release the patient's health information to a third party."


Patient 1

Review of Patient 1's discharged medical record showed that Patient 1 was admitted to the Senior Behavioral Health (SBH) unit on 09/30/22 at 5:00 PM, after displaying sexual aggression toward the staff at his assisted living facility (ALF). Patient 1 has an appointed DPOA .

Patient 1's medical record failed to show evidence that the DPOA was provided with Patient 1's discharge or aftercare instructions when Patient 1 left the CAH .


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted to the CAH on 12/30/22 at 1:07 PM for aspiration pneumonia (caused by breathing in something that results in infection, swelling, and fluid filled air spaces that make breathing difficult). Patient 2 has an appointed DPOA .

Review of Patient 2's medical record failed to show evidence that the DPOA was provided with Patient 2's discharge or aftercare instructions when Patient 2 left the CAH .


Patient 3

Review of Patient 3's medical record showed that Patient 3 was admitted on 09/29/22 at 10:10 PM, from her Long-Term Care Facility (LTC) for self-harming behaviors, spitting and throwing objects, refusing medications, or spitting them at staff, and stating "I wish I were dead." Patient 3 has an appointed DPOA .

Review of Patient 3's medical record failed to show evidence that the DPOA was provided with Patient 3's discharge or aftercare instructions when Patient 3 left the CAH .


Patient 4

Review of Patient 4's medical record showed that Patient 4 was admitted on 10/16/22 at 3:40 PM to SBH due to increased behaviors at home, increased aggression, refusing cares, erratic sleep patterns, insomnia, confusion, and refusing medications. Patient 4 was discharged and transferred to the med-surge floor on 10/25/22 at 5:30 PM .

Review of Patient 4's medical record failed to show evidence that the DPOA was provided with Patient 4's discharge or aftercare instructions when Patient 4 left the CAH .


During an interview on 01/05/23 at 9:16 AM, Staff D, RN, stated that the family is given education during the family meeting, so the facility the patient is discharged to gets the discharge education, not the DPOA. Staff D stated that the family meeting could occur days prior to the discharge of the patient. Staff D acknowledges that treatment and discharge plans can change during that time requiring the DPOA or family to receive further education or information. USE updated

During an interview on 01/05/23 at 9:16 AM, Staff D, RN, stated that DPOA's are provided the education and discharge instructions if you can get a hold of them. Staff D stated that you must document if you are unable to contact them. Staff D stated that if you provide the information over the phone, two staff sign as witness that the information was provided over the phone to the DPOA.

During an interview on 01/05/23 at 11:00 AM, Staff E, RN, stated that the discharge instructions are printed and given to the doctor and facility the patient is going to or given to the family. Staff E stated that sometimes just the driver will get it. Staff E stated that if the family is not present, sometimes a driver signs it for them (the patient) if the patient is unable or have family sign at the vehicle. Staff E stated that if the patient is alert and oriented then they can sign for the discharge information.