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Based on medical record review and staff interview it was determined the facility failed to ensure a consent to treat was obtained prior to providing care to the patient. This failure was identified in one (1) of ten (10) medical records reviewed (patient #2). This failure has the potential to adversely affect all patient/patient's representative who are not able to participate in the care received.

Findings include:

A review of the policy titled "Disclosure and Informed Consent/Consent to Treatment," effective 01/2020, stated in part: "If the patient comes in with no other authorized party and is unable to sign due to condition (unconscious/incapacitated state, competency, and or alertness) telephone consent may be obtained from MPOA ... 1. A member of the Patient Registration team will follow up daily on all Transfer, Direct Admissions, and/or Observation patients who were unable to sign consent at time of registration. Daily visits will be made to the patient while in-house in order to obtain the patient's physical signature. 2. If after 24 hours the patient is still unable to sign, and we have not been able to obtain telephone consent from an authorized party, the Case Management department must be notified."

A review of the medical record for patient #2 revealed the patient was seen in the Emergency Department (ED) on 2/11/22 at 10:54 a.m. Patient #2 was listed as a poor historian, with a history of dementia. ED diagnosis was super ventricular tachycardia, with a two hundred and seven (207) heart rate upon arrival at the ED. The ED nurse documented patient #2 as confused, and oriented only to person. The ED physician documented the patient as baseline dementia, and can answer some questions. The ED physician documented the patient as alert, pleasant and confused. The emergency medical services (EMS) run sheet listed the daughter as the medical power of attorney (MPOA). The MPOA's phone number was listed on the EMS run sheet. No documentation is noted in the medical record the ED physician contacted the family/MPOA upon decision to admit the patient to the telemetry floor. No consent to treat was noted in the medical record for the ED visit or the inpatient visit. Telemetry nursing staff documented the patient as confused, easily awakened, oriented to person. On 2/12/22 at 7:25 a.m., the nursing assessment documented the patient as oriented to person, and one (1) person assist. On 2/12/22 at 6:30 p.m., patient #2 is documented as incontinent. On 2/13/22 at 1:03 a.m., patient #2 is documented as incontinent, diapered changed. On 2/13/22 at 7:45 a.m., patient #2 is documented as confused, and on 2/13/22 at 10:10 p.m., patient #2 is documented as oriented to person. On 2/14/22 at 7:45 a.m., patient #2 is documented as oriented to person, verbal response confused. On 2/14/22 at 8:00 a.m., patient #2 is documented as confused, awake and alert. No documentation is noted in the medical record the MPOA was contacted, except for discharge and notification of admission. Nursing documented patient was provided care and dressed prior to discharge. No nursing documentation was noted in the medical record the MPOA had called the facility. Consent to treat was never obtained for patient #2. It is documented in the medical record the MPOA refused to sign the discharge paperwork due to no consent to treat was ever obtained for the patient.

An interview was conducted on 4/12/22 at 8:12 a.m. with staff members (SM) #1 and 2. When asked about the complaint, SM #1 stated, "We know about the patient due to the daughter complained to the nursing supervisor. During the ED visit, an attempt was made to call the family and the staff were hung up on twice. We didn't have any record of a medical power of attorney. If a patient comes into the facility confused, we go by our policy. We call the next of kin, or the MPOA, whichever is listed. We have a process for getting a consent signed. We did not have a consent signed by the MPOA." When asked if documentation was in the medical record about the attempt to call the family, SM's #1 and 2 stated they would check the chart and get back with me.

An interview was conducted with SM #3 on 4/12/22 at 10:48 a.m. When asked about consent to treat in the emergency department, SM #3 stated, "It is up to registration to get the consent to treat. If it is an emergency the patient would be considered as emergent." When asked if patient #2 was considered emergent, SM #3 stated, "Yes." When asked if the family was contacted after the emergency room treatment and admission to the hospital due to the patient was listed as confused, SM #3 stated, "I possibly did not talk to the family. I try to talk to the family about the admission, but I cannot find documentation where the family was called about admission to the hospital. When the patient came into the emergency room, I felt it was emergent, and I took care of the patient. Consent for treatment on the floor is another issue."

An interview was conducted with SM's #1 and 2 on 4/12/22 at 10:03 a.m. They stated no consent to treat or communication with the family was noted in the medical record for the patient.

On 04/13/22 at 11:10 a.m. the Chief Operating Officer (COO) stated it is the responsibility of the nurses, physicians and registration to ensure a consent to treat is signed. The Director of Quality stated it is documented the staff attempted to call the patient's MPOA and was hung up on. The surveyor informed the COO and Director of Quality, the surveyor was unable to locate any documentation.

Based on document review and staff interview it was determined the facility failed to provide prompt resolution of patient grievances in a timely manner by not following their own policy for notification of the resolution to appropriate parties involved. This failure was identified in seven (7) of seven (7) grievances reviewed. This failure has the potential to adversely affect all patients.

Findings include:

A review of the policy titled "Patient Complaints and Grievances," effective 07/2021, stated in part: "Once the review/investigation by the PCR [Patient Care Representative] is completed, the Grievance Committee reviews the grievance for appropriate follow-up and ensure any needed action to resolve the grievance is taken ... A letter shall be drafted and sent to the patient or patient's legal representative(s) ... The letter shall be mailed within 7 days ..."

A review of the complaint log revealed a complaint was received by the Grievance Committee on 11/5/21. A letter of resolution was mailed to the patient/patient representative on 12/21/21, forty-seven (47) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 1/10/22. A letter of resolution was mailed to the patient/patient representative on 1/18/22, eight (8) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 1/11/22. A letter of resolution was mailed to the patient/patient representative on 1/19/22, eight (8) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 2/8/22. A letter of resolution was mailed to the patient/patient representative on 2/16/22, eight (8) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 2/1/22. A letter of resolution was mailed to the patient/patient representative on 2/10/22, nine (9) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 2/7/22. A letter of resolution was mailed to the patient/patient representative on 2/16/22, nine (9) days after the complaint/grievance was received.

A review of the complaint log revealed a complaint was received by the Grievance Committee on 3/22/22. No resolution was sent to the patient or patient's representative.

An interview was conducted with the Chief Executive Officer (CEO) on 4/13/22 at approximately 9:00 a.m. The CEO concurred the facility failed to follow the hospital policy for patient complaints and grievances.

Based on document review and staff interview it was determined the Quality Assessment/Performance Improvement (QA/PI) failed to track and trend quality indicators that access processes of care, hospital services and operations. The QA/PI failed to track and trend sanitation in the emergency department (ED). This failure has the potential to adversely affect all patients due to poor sanitation in the ED.

Findings include:

A review of the QA/PI meeting minutes for October 2021 through March 2022 revealed no documentation of tracking and trending of sanitation in the ED. The Director of Quality reviewed the meeting minutes with the surveyor.

An interview was conducted with staff member (SM) #13 on 4/13/22 at 10:00 a.m. When asked if the QA/PI program tracks and trends sanitation in the ED, SM #13 stated, "Quality and performance improvement does not track and trend sanitation in the ED. That is not what we do."

Based on document review, observation and staff interview it was determined the facility failed to provide infection control surveillance and prevention, including maintaining a clean and sanitary environment in the Emergency Department (ED) to avoid sources and transmission of infection. This failure has the potential to adversely affect all patients presenting to the ED for care.

Findings include:

A review of the policy titled "Environmental Services," effective 01/2020, stated in part: "Purpose: To provide the finest environment conditions possible for patient comfort as related to cleanliness, health and sanitation ... The bathroom should be adequately disinfected: to include floors ... Pick up trash with counter brush and dust pan and empty into waste receptacle."

A tour of the ED was conducted on 4/11/22 at 9:10 a.m. with the Director of Quality, Chief Nursing Officer, Director of the ED and the Clinical Coordinator. During the tour, ED Room #15 was observed to have hard plastic pieces of garbage lying on the floor, which were slick when stepped on. The Director of the ED concurred Room #15 was ready for patient use. In the prompt care area of the ED, dirty gloves and paper garbage was located beside the garbage can in a room that was ready for patient use, and a bathroom had black soap scum on the floor. During the tour, the Director of the ED concurred with the findings.

An interview was conducted with the Director of Quality on 4/12/22 at 11:15 a.m. The Director of Quality stated, "I agree with everything you saw in the ED on the tour."