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Tag No.: A0130
Based on medical record review, document review, and staff interviews, the facility failed to allow the patient's Healthcare Surrogate to participate in patient's plan of care, in one (1) of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.
Findings include:
A medical record review was conducted for patient #1. The patient arrived at this facility as a diversion transfer from another Psychiatric Facility for discharge placement on 08/28/23. The transfer paperwork included documentation of the patient's lack of capacity to make healthcare decisions, and appointed a Healthcare Surrogate (HCS) as a primary family member, including their address, email address, and telephone number. A "Geri-Psych [Geriatric Psychiatric] Diagnostic Evaluation'' was conducted on 08/28/23 at 11:48 a.m. by Employee (Emp) #2 and states in part, "... Per referral patient was becoming increasingly violent, attempting to stab staff, attempting to elope, etc ... Patient was interviewed on the unit. Patient is alert and oriented to person and knows [patient #1] is in WV [West Virginia]. Patient is cooperative with interview and in no acute distress. Patient reports that [patient #1] thought [patient #1] was in a nursing home, but has no idea why [patient #1] is here. Reports [patient #1]'s [grandchild] stated [patient #1] could come live with [grandchild] if [patient #1] signed [patient #1]'s 6 (six) acres over to [grandchild] ... Psychiatric history: one (1) admission to [Psychiatric facility], no previous history, Medical history: hyperlipidemia, valve replacement, hypertension, insomnia, GERD (Gastroesophageal Reflux Disorder), BPH (Benign Prostatic Hyperplasia], ... fund of knowledge is poor for the level of education based on communication and interview, as well as education history. IQ [intelligence quotient] is estimated to be poor based on level of education, fund of knowledge, and language skills. Patient does display limited insight into their mental health symptoms and can identify importance of treatment and medication compliance. Assessment of strengths: 1. Patient is cooperative with the interview. 2. Patient is currently compliant with medications. 3. Patient is stabilized on current medications. Assessment of liabilities: 1. Chronic medical conditions 2. Poor use of coping skills 3. Placement, Review of symptoms ... Psych: no suicidal ideations or homicidal ideations. Memory impairment. Mental Status Examination: Appearance: appears stated age, normal weight, appropriately dressed with adequate hygiene, Behavior: cooperative, pleasant, appropriate behavior, Motor activity: appropriate eye contact, no abnormal movement, ambulates with unsteady gait, Orientation: alert and oriented to person, Speech: clear with normal rate, rhythm and volume. Thought process: consistent with dementia, Thought content: appropriate, Attention and concentration: patient is alert and able to answer questions. Memory: recent: impaired, remote: impaired, Insight/judgment: poor as patient does not display insight into their mental health symptoms as well as cannot identify the importance of medication compliance to promote stability ... Assessment and plan of treatment: ... Staff will provide therapeutic milieu and group activities. Will monitor stabilization of mood, thoughts, and behaviors. Will assess each shift for suicidal thoughts. Pharmacological therapy will be adjusted and ordered if the patient becomes aggressive, psychotic, or anxious. A treatment plan with goals will be created which patient will be expected to work towards goals until discharge. Family will be contacted to be obtained collateral information and to coordinate plan of care. Discharge planning will be initiated now as the patient is deemed to no longer be a threat to themselves or others. Patient is said to be stabilized and ready to discharge. For the treatment of dementia, moderate, with other behavioral disturbances, active: Continue Depakote DR [delayed release] 250 mg [two hundred fifty milligrams] in a.m. and 500 (five hundred) mg DR QHS [at bedtime] memantine 10 (ten) mg BID (twice a day)."
The Admission Consents were verbally signed by the HCS on 08/28/23 at 3:20 p.m.
The "Master Plan of Care" was established on 08/28/23 at 1:00 p.m. and includes a presenting problem of "Neurocognitive Deficit" and focus of treatment "Cognitive Impairment."
A "Discharge Summary Note" on 09/28/23 at 9:18 a.m. by emp #3 states in part, "... Hospital Course: ... A treatment plan with problem areas and goals was created at admission. The patient encouraged to work towards goals during hospitalization. Throughout hospitalization, patient was compliant with medications and treatment recommendations. Patient did not exhibit any violent, aggressive or threatening behaviors. Patient was never sexually inappropriate. Medications were reconciled and continued. Patient tolerated medications and no adjustments were needed during hospitalization. Patient was on regular diet with minced, moist, ground foods. During hospitalization, the patient was encouraged to participate in group activities and therapy. The patient denied suicidal and homicidal ideations throughout the course of hospitalization. The patient denied any auditory or visual hallucinations. Patient was cooperative with medication and care provided. Patient was determined to be stabilized on current medication. Patient maximized benefit of inpatient hospitalization. The patient was educated on the benefits and the importance of medication compliance. Patient has no current side effects from medications. A list of medications and doses were provided along with recommended follow-ups. Consults: active APS case related to misuse of financial funds ([patient #1's HCS] and [HCS spouse]) ... Mental status examination: orientation: alert and oriented to person, place, time, and situation, Thought process: concrete with brief periods of confusion, Memory: recent: intact, remote: intact. Abstraction: fair. Follow up appointments: follow up with provider at facility ..."
The patient was discharged on 09/28/23 via Ambulance to an Assisted Living Facility approximately two hundred eleven (211) miles from patient #1's previous residence and HCS. The discharge summary note was sent with the patient, as well as the paperwork from the previous psychiatric facility, which contained information about the patient's HCS. The patient's demographic sheet was sent with the patient, which included an emergency contact listed as the patient's HCS.
A "General Notes" on 10/10/23 at 10:48 a.m. by emp #1 states, "On October 10th, 2023 at approximately 10:30 a.m., program director received call from [patient #1's HCS] requesting information about discharge of patient. During this time, this writer explained that the information cannot be provided due to the request of the patient upon discharge. Patient had capacity and requested specifically that [HCS] and family would not be aware of [patient #1] placement. There's an active APS investigation due to misappropriation of funds. [HCS] stated [HCS] would seek other routes to gain information. Call was witnessed by [emp #6]."
May it be noted, there was no documentation in patient #1's medical record in which the patient regained capacity.
There was no documentation the patient's HCS was revoked or changed. There was no documentation the patient's HCS was notified of the discharge plan, or the location patient #1 discharged to.
A review of the policy, titled "Advance Directives/Health Care Surrogate," reviewed 01/23. The policy states, in pertinent part, ... Definition: This procedure deals specifically with the three legally recognized forms of written advanced directives in West Virginia; the living will, the medical power of attorney, and the POST [Physician Orders for Scope of Treatment] form ... Procedure: ... 4. Admission Personnel will instruct the patient or family to bring the advanced directive to the hospital as soon as possible if they did not bring it with them and they wish to be honored ... 15. When a patient who lacks decision making capacity has not executed a living will or a medical private attorney, a healthcare surrogate shall be selected for that patient to participate in decision-making."
A review of the policy, titled "Patient Rights and Responsibilities," revised 09/23. The policy states, in pertinent part, "... Rights as a patient: The patient has the right to: ... 27. Formulate Advance directives and to have Hospital staff and practitioners who provide care in the hospital comply with these directives ... 29. Appoint a surrogate to make Healthcare decisions on his/her behalf to the extent permitted by law ..."
An interview was conducted with employee (emp) #1 on 10/16/23 at 9:10 a.m. Regarding patient #1, emp #1 states, "After the patient left, I did speak with the MPOA. There's an open APS case. The patient has capacity and requested to not give the MPOA any information. Also the MPOA didn't have a privacy code at that time."
An interview was conducted with emp #5 on 10/17/23 at 8:39 a.m. Regarding patient #1, emp #5 states in part, "We were trying to get the patient placed. We found out [patient #1] didn't have any money in [patient #1]'s account that [patient #1] thought, I contacted APS. I did the APS intake over the phone and they felt they should have an open case. They assigned someone to meet with [patient #1]. After they came and spoke with [patient #1], they told me it was going to be an open case and they were going to look into it further. [Patient #1] didn't say anything about contacting the police and I didn't contact the police. I got a letter in the mail stating that they had an open case and would be evaluating it. We didn't receive anything in writing not to contact the medical power of attorney. The patient did not have capacity at that point when [patient #1] made those accusations. My understanding was that the patient got capacity back at discharge ... The only other family member [patient #1] talked about was a grand[child]. I'm not sure if the discharge planner talked to anyone else."
An interview was conducted with emp #6 on 10/17/23 at 9:09 a.m. Regarding patient #1, emp #6 states in part, "... I explained to the family the financials needed for placement. I don't remember how soon after the APS was filed that they stopped talking to family but they did shortly thereafter. I did not reach out to any family members afterwards, since it was handed off to APS. I do feel that [patient #1] can pay [patient #1]'s bills and take care of [patient #1] self. If [patient #1] had to be on [patient #1] own, [patient #1] would be okay. [Patient #1] was going to Assisted Living due to [patient #1] age and [patient #1] chose that. [Patient #1] explained since [patient #1] was getting older and needed a little bit of assistance. [Patient #1] never mentioned to me [patient #1] wanted to go home alone. I believe we can do a medical power of attorney here and I'm not sure why we didn't do a new one. It had been a rough road this whole stay trying to get information from the family for this patient. As soon as APS was involved, I figured that they were going to take over and they were going to be [patient #1]'s advocate so we no longer had to reach out to the family. From my understanding the patient's capacity was officially restored at discharge."
An interview was conducted with emp #2 on 10/17/23 at 9:31 a.m. Regarding patient #1, emp #2 states, "When a patient comes to us, diverted from [other psychiatric facility], we get the recent history and physical and notes from [other psychiatric facility]. If we feel we need any additional information, we reach out and get that information. Only a psychiatrist can do capacity or physician, not a nurse practitioner. [Emp #7] is involved in teams two (2) times a week and cosigns all the notes. [Emp #7] could have seen the patient but I'm not sure if [emp #7] did. The patient brought to our attention when [patient #1] first got here, that [patient #1] had concerns a family member was taking [patient #1]'s money. [Patient #1] set up [patient #1]'s account so [patient #1's HCS] would only have access to [patient #1] money upon death, is what [patient #1] told us. I did not know that [patient #1's primary geriatric specialist] called in to give information. I did not know the patient was previously in a locked unit. The patient, while [patient #1] was here, was alert and oriented times three (3) and was consistent with conversations and concerns. Case management was working with [patient #1] on [patient #1]'s discharge plan. I wasn't aware that the patient did not want anyone to know where [patient #1] was upon discharge. I knew they contacted APS about misappropriation of funds. I was not involved in that situation. The patient was very forward thinking and goal directed. This was the first time that I've been aware of ever discharging someone without the medical power of attorney or healthcare surrogate knowing. If there is an issue with the healthcare surrogate, case management can always appoint a new health care surrogate if needed."
An interview was conducted with emp #4 on 10/17/23 at 10:08 a.m. Regarding patient #1, emp #4 states in part, "When [patient #1] got here, [patient #1] wasn't going to meet any deficits for a nursing home. We were trying to find out [patient #1]'s financials and get Assisted Living placement. [Patient #1] could take care of [patient #1]'s self and mentally [patient #1] seemed with it enough. I don't think the family wanted [patient #1] at home. We quit giving the medical power of attorney any information. I didn't feel comfortable after APS was involved, so I just quit giving any information to them. The [HCS] was nasty to us when we tried to get financial information and it was not a very trusting situation. Once APS is involved, I assumed we shouldn't give any information. It was passed on to me from [emp #5] that APS said not to give any information. The patient did tell us multiple times and [patient #1] was very verbal about telling us [patient #1] did not want to give any information to [HCS]. Since APS was involved, I felt we shouldn't give any information. I felt we were doing the right thing at the time. I guess we could have appointed a new health care surrogate but I have never done that before. I was under the impression [patient #1] had the capacity to make [patient #1] own decisions. I did not have any previous documentation that the patient couldn't make any decisions..."
A telephone interview was conducted with emp #3 on 10/17/23 at 10:53 a.m. Regarding patient #1, emp #3 states, "We don't have the scope here to give or take away a patient's capacity. I couldn't tell you if [patient #1] capacity was ever given back. Usually the process is, if a patient is on diversion from [Other Psychiatric facility], the capacity was only temporarily removed and it automatically gets returned upon discharge. [Patient #1] would have still had [patient #1]'s financial competency, just the medical capacity is taken away. This patient was alert and oriented and fully understood the situation [patient #1] was in. When a patient comes from [other psychiatric facility] we only get what they send us. I was aware [patient #1] came from a nursing home but not aware where exactly [patient #1] came from and what the circumstances were. [Patient #1] diagnosis was passed on to me as neurocognitive disorder, not dementia. We did not request any records from previous providers. I was told that the geriatric specialist did call to tell us [patient #1] didn't have capacity, but we would not get any information from [geriatric specialist] because a patient's status can change as they follow different providers. If [patient #1] would have had permanent capacity taken away, they would have had to send us official documentation from the previous facility and we did not get anything. I was not involved in the APS case. I just knew that they made an APS referral. I did not speak with the patient about the APS case. The patient said multiple times that [patient #1] didn't want anything to do with [HCS] and that the [HCS]was just after [patient #1]'s money. I did not address this thought in any way, and I did not further investigate, I can't say whether it's true or not true. I knew that it was listed as a goal from the previous facility for the patient to not verbalize that the [HCS] was taking [patient #1] money. When the patient came here, we create new goals and that was not a goal here. Because the patients are considered stabilized, ready for discharge when they arrive here, and we create new goals for the patient to focus on. I couldn't tell you exactly what was addressed in this patient's therapy. Case management decides what the best discharge plan is and so I don't know why [patient #1] didn't go home, why [patient #1] didn't return to family, or what the circumstances were for discharge."
An interview was conducted with emp #7 on 10/17/23 at 12:25 p.m. Regarding patient #1, emp #7 states, "I am the psychiatrist and I work with three (3) nurse practitioners underneath me. We have a team's meeting on Tuesday and Thursday and I participate via telephone. They can call me anytime with a case discussion. There is a diversion program for the geriatric patients sent here from [other psychiatric facility]. [Other psychiatric facility] helps pay for the patient to stay here until they get placed. For the patient's capacity, there would be a daily assessment to establish if the patient was alert and oriented or not. If the capacity was formally taken away and there was an official document then it would be formally given back. If there was no official document then just the assessment by the nurse practitioner saying the patient was alert and oriented would be sufficient. We would only obtain outside records from previous hospital stays or providers if it was pertinent. I was not made aware that [patient #1 geriatric specialist] had called to try to give information on this patient. If I would have known, I would have investigated it further. If the previous records would have played a part in the current diagnosis, I would have been interested to see what they said. Dementia and Alzheimer's doesn't usually get better. Dementia patients are usually paranoid about finances and family taking all their belongings. I never saw this patient in person. Regardless of age, if this patient was alert and oriented we'd have to abide by [patient #1] request to not contact [patient #1] medical power of attorney. Usually we would tell a patient they should change the medical power of attorney if there was an issue, but I'm not sure if that happened or not. I have trust in my providers and I would have to doubt that all three (3) providers would say [patient #1] was alert and oriented and with it if [patient #1] wasn't."
An interview was conducted with emp #1 on 10/18/23 at 9:37 a.m. Regarding patient #1, emp #1 states, "I don't oversee the providers. The provider explained that the patient's capacity is automatically restored on discharge, and I trusted in what they said. Normally a Healthcare Surrogate would be involved in the patient's care the whole time. This is the first time something like this has happened. I trusted if the patient was alert and oriented that we would respect [patient #1]'s wishes not to tell [patient #1]'s family were [patient #1] was discharged to."
Tag No.: A0808
Based on medical record review, document review, and staff interviews, the facility failed to discuss discharge planning, and provide the final discharge plan with the patient's Healthcare Surrogate, in one (1) of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.
Findings include:
A medical record review was conducted for patient #1. The patient arrived at this facility as a diversion transfer from another Psychiatric Facility for discharge placement on 08/28/23. The transfer paperwork included documentation of the patient's lack of capacity to make healthcare decisions, and appointed a Healthcare Surrogate (HCS) as a primary family member, including their address, email address, and telephone number. A "Geri-Psych [Geriatric Psychiatric] Diagnostic Evaluation'' was conducted on 08/28/23 at 11:48 a.m. by Employee (Emp) #2 and states in part, "... Per referral patient was becoming increasingly violent, attempting to stab staff, attempting to elope, etc ... Patient was interviewed on the unit. Patient is alert and oriented to person and knows [patient #1] is in WV [West Virginia]. Patient is cooperative with interview and in no acute distress. Patient reports that [patient #1] thought [patient #1] was in a nursing home, but has no idea why [patient #1] is here. Reports [patient #1]'s [grandchild] stated [patient #1] could come live with [grandchild] if [patient #1] signed [patient #1]'s 6 (six) acres over to [grandchild] ... Psychiatric history: one (1) admission to [Psychiatric facility], no previous history, Medical history: hyperlipidemia, valve replacement, hypertension, insomnia, GERD (Gastroesophageal Reflux Disorder), BPH (Benign Prostatic Hyperplasia], ... fund of knowledge is poor for the level of education based on communication and interview, as well as education history. IQ [intelligence quotient] is estimated to be poor based on level of education, fund of knowledge, and language skills. Patient does display limited insight into their mental health symptoms and can identify importance of treatment and medication compliance. Assessment of strengths: 1. Patient is cooperative with the interview. 2. Patient is currently compliant with medications. 3. Patient is stabilized on current medications. Assessment of liabilities: 1. Chronic medical conditions 2.Poor use of coping skills 3. Placement, Review of symptoms ... Psych: no suicidal ideations or homicidal ideations. Memory impairment. Mental Status Examination: Appearance: appears stated age, normal weight, appropriately dressed with adequate hygiene, Behavior: cooperative, pleasant, appropriate behavior, Motor activity: appropriate eye contact, no abnormal movement, ambulates with unsteady gait, Orientation: alert and oriented to person, Speech: clear with normal rate, rhythm and volume. Thought process: consistent with dementia, Thought content: appropriate, Attention and concentration: patient is alert and able to answer questions. Memory: recent: impaired, remote: impaired, Insight/judgment: poor as patient does not display insight into their mental health symptoms as well as cannot identify the importance of medication compliance to promote stability ... Assessment and plan of treatment: ... Staff will provide therapeutic milieu and group activities. Will monitor stabilization of mood, thoughts, and behaviors. Will assess each shift for suicidal thoughts. Pharmacological therapy will be adjusted and ordered if the patient becomes aggressive, psychotic, or anxious. A treatment plan with goals will be created which patient will be expected to work towards goals until discharge. Family will be contacted to be obtained collateral information and to coordinate plan of care. Discharge planning will be initiated now as the patient is deemed to no longer be a threat to themselves or others. Patient is said to be stabilized and ready to discharge. For the treatment of dementia, moderate, with other behavioral disturbances, active: Continue Depakote DR [delayed release] 250 mg [two hundred fifty milligrams] in a.m. and 500 (five hundred) mg DR QHS [at bedtime] memantine 10 (ten) mg BID (twice a day)."
The Admission Consents were verbally signed by the HCS on 08/28/23 at 3:20 p.m.
A "General Notes" on 09/14/23 at 2:45 p.m. by emp #4 states ..."[Patient #1] signed a paper so we can obtain [patient #1]'s financial documents to start looking for placement. [APS worker] at APS [Adult Protective Services] contacted about possible misuse of patient funds."
A "General Notes" on 09/14/23 at 2:51 p.m. by emp #5 states, "Due to concerns about the possible mishandling of patient's monies, a referral was made to adult protective services, Case number 328-862, [APS worker name] was the worker."
A "General Notes" on 09/14/23 at 3:30 p.m. by emp #6 states, "This writer spoke to [patient #1's HCS] about the financial statements received by [patient #1] financial institution regarding money being transferred out of [patient #1] account when [patient #1] has been in the hospital at [Other Psych Facility] and now at Laurel Place. [HCS] stated [HCS] was not aware of the money. APS was contacted for suspected misappropriation of funds. [APS worker] at APS was contacted; Case number 328-862."
A "Geri-Psych Progress Note" on 09/15/23 at 8:37 a.m. by emp #3 states in part, "... Treatment Plan ... Family will be contacted to obtain collateral information into coordinate plan of care ..."
"Treatment Team Documentation" was completed on 09/20/23 at 10:25 a.m. Emp #2 was present. No documentation was noted of patient #1 HCS participating, or emp #7.
A "General Notes" on 09/27/23 at 3:47 p.m. by emp #4 states, "Received a call around 15:30 [3:30 p.m.] from a [Geriatric Specialist] stating I would like to speak with someone about [patient #1], [Geriatric Specialist] was unable to tell this nurse the passcode, so explained that I cannot discuss anything further with [Geriatric Specialist]. [Geriatric Specialist] continued to say [patient #1]'s grand [child] wanted me to call and explain how [patient #1] is, [patient #1] has dementia and is confused. I thanked [Geriatric Specialist] and ended the call."
A "Discharge Summary Note" on 09/28/23 at 9:18 a.m. by emp #3 states in part, "... Hospital Course: ... A treatment plan with problem areas and goals was created at admission. The patient was encouraged to work towards goals during hospitalization. Throughout hospitalization, patient was compliant with medications and treatment recommendations. Patient did not exhibit any violent, aggressive or threatening behaviors. Patient was never sexually inappropriate. Medications were reconciled and continued. Patient tolerated medications and no adjustments were needed during hospitalization. Patient was on regular diet with minced, moist, ground foods. During hospitalization, the patient was encouraged to participate in group activities and therapy. The patient denied suicidal and homicidal ideations throughout the course of hospitalization. The patient denied any auditory or visual hallucinations. The patient was cooperative with medication and care provided. The patient was determined to be stabilized on current medication. The patient maximized benefit of inpatient hospitalization. The patient was educated on the benefits and the importance of medication compliance. The patient has no current side effects from medications. A list of medications and doses were provided along with recommended follow-ups. Consults: active APS case related to misuse of financial funds ([patient #1's HCS] and [HCS spouse]) ... Mental status examination: orientation: alert and oriented to person, place, time, and situation, Thought process: concrete with brief periods of confusion, Memory: recent: intact, remote: intact. Abstraction: fair. Follow up appointments: follow up with provider at facility ..."
The patient was discharged on 09/28/23 via Ambulance to an Assisted Living Facility approximately two hundred eleven (211) miles from patient #1's previous residence and HCS. The discharge summary note was sent with the patient, as well as the paperwork from the previous psychiatric facility, which contained information about the patient's HCS. The patient's demographic sheet was sent with the patient, which included an emergency contact listed as the patient's HCS.
A "General Notes" with unknown entry date and time, signed on 10/10/23 at 11:13 a.m. by emp #5 states, "Patient was discharged to [Name of Assisted Living Facility] in [County] on 9/28/2023. APS informed of transfer via email."
A "General Notes" on 10/10/23 at 10:48 a.m. by emp #1 states, "On October 10th, 2023 at approximately 10:30 a.m., program director received call from [patient #1's HCS] requesting information about discharge of patient. During this time, this writer explained that the information cannot be provided due to the request of the patient upon discharge. Patient had capacity and requested specifically that [HCS] and family would not be aware of [patient #1] placement. There's an active APS investigation due to misappropriation of funds. [HCS] stated [HCS] would seek other routes to gain information. Call was witnessed by [emp #6]."
May it be noted, there was no documentation in patient #1's medical record in which the patient regained capacity. There was no documentation the patient's HCS was revoked or changed. There was no documentation the patient's HCS was notified of the discharge plan, or the location patient #1 discharged to. There was no documentation in the discharge paperwork of follow up aftercare with any specialists including cardiologists, neurologists, or psychiatrists. The patient's Advance Directive, including the Medical Power of Attorney [MPOA] document, was not in the patient's medical record.
A review of the policy, titled "Discharge Planning," reviewed 03/22. The policy states, in pertinent part, "... Procedure: ... F. The multidisciplinary team will respect the right of the patient/family to choose an alternative plan of care that is recommended by the team and will assist in assuring that basic continuity of care needs are met through referrals when appropriate. 1. Options will be presented to the patient and family which include options for continuity of medication management, this includes any vouchers available, community centers who help, and pharmaceutical assistance programs. G. With the patient's consent, relevant family members or significant others are included in the discharge Outpatient Care plan. 1. The treatment team informs family members of discharge plans, when appropriate, and documents accordingly ... I. An Aftercare plan will be completed on all patients and will specify appropriate referrals and appointments ... K. The Aftercare plan will be signed by members of the treatment team assigned to the patient's care and will be reviewed with a patient and/or family prior to discharge. 1. Information regarding available alternative services will be provided to the patient/family upon request. 2. The patient and/or family member will sign the Aftercare plan and will be provided with a copy upon discharge. 3. Information provided to include: a. Reason for discharge b. Physical/psychological status at discharge c. Summary of care/Treatment/Services provided d. Patient progress toward goals e. List of referrals and/or resources provided to the patient."
A review of the policy, titled "Advance Directives/Health Care Surrogate" reviewed 01/23. The policy states, in pertinent part, ... Definition: This procedure deals specifically with the three legally recognized forms of written advanced directives in West Virginia; the living will, the medical power of attorney, and the POST [Physician Orders for Scope of Treatment] form ... Procedure: ... 4. Admission Personnel will instruct the patient or family to bring the advanced directive to the hospital as soon as possible if they did not bring it with them and they wish to be honored ... 15. When a patient who lacks decision making capacity has not executed a living will or a medical private attorney, a healthcare surrogate shall be selected for that patient to participate in decision-making."
A review of the policy, titled "Patient Rights and Responsibilities" revised 09/23. The policy states, in pertinent part, "... Rights as a patient: The patient has the right to: ... 27. Formulate Advance directives and to have Hospital staff and practitioners who provide care in the hospital comply with these directives ... 29. Appoint a surrogate to make Healthcare decisions on his/her behalf to the extent permitted by law ..."
An interview was conducted with employee (emp) #1 on 10/16/23 at 9:10 a.m. Regarding patient #1, emp #1 states, "After the patient left, I did speak with the MPOA. There's an open APS case. The patient has capacity and requested to not give the MPOA any information. Also the MPOA didn't have a privacy code at that time."
An interview was conducted with emp #4 on 10/17/23 at 10:08 a.m. Regarding patient #1, emp #4 states, "When [patient #1] got here, [patient #1] wasn't going to meet any deficits for a nursing home. We were trying to find out [patient #1]'s financials and get Assisted Living placement. [Patient #1] could take care of [patient #1]'s self and mentally [patient #1] seemed with it enough. I don't think the family wanted [patient #1] at home. We quit giving the medical power of attorney any information. I didn't feel comfortable after APS was involved, so I just quit giving any information to them. The [HCS] was nasty to us when we tried to get financial information and it was not a very trusting situation. Once APS is involved, I assumed we shouldn't give any information. It was passed on to me from [emp #5] that APS said not to give any information. The patient did tell us multiple times and [patient #1] was very verbal about telling us [patient #1] did not want to give any information to [HCS]. Since APS was involved, I felt we shouldn't give any information. I felt we were doing the right thing at the time. I guess we could have appointed a new health care surrogate but I have never done that before. I was under the impression [patient #1] had the capacity to make [patient #1] own decisions. I did not have any previous documentation that the patient couldn't make any decisions. I took the phone call when [patient #1 geriatric specialist] called to give us information. I questioned if it was really a provider, as they don't usually call like that. I passed the information on to the provider and don't know if anything was done. After the patient left, a Cardiology office called to schedule a follow-up appointment. I didn't give them any information about the patient, but I did call the place where the patient now resides and gave [them] the information."
An interview was conducted with emp #1 on 10/18/23 at 9:37 a.m. Regarding patient #1, emp #1 states, "I don't oversee the providers. The provider explained that the patient's capacity is automatically restored on discharge, and I trusted in what they said. Normally a Healthcare Surrogate would be involved in the patient's care the whole time. This is the first time something like this has happened. I trusted if the patient was alert and oriented that we would respect [patient #1]'s wishes not to tell [patient #1]'s family were [patient #1] was discharged to."