HospitalInspections.org

Based on document review, policy review, and interviews, the Acute Care Hospital (ACH)'s administrative staff failed to ensure hospital staff informed patients or their legal representative of their rights as a patient for 2 of 11 sampled patients (Patients #5 and #10) who presented to the ACH from 1/23/24 to 11/21/24.

This deficient practice placed all incapacitated patients who received care at the ACH, including incapacitated patients, at risk of not having their rights as a patient amply protected and promoted.

Findings include:

1. Review of the policy titled "Patient Rights and Responsibilities Policy" last reviewed January 2022 revealed in part:

a. "[The hospital] will provide information to patients advising them of their rights and responsibilities."

b. "In the case of a patient who is incapacitated, when an individual presents to the hospital with an advance directive, medical power of attorney or similar document [such as legal guardian] executed by the patient and designating an individual to make medical decisions for the patient when incapacitated, then the hospital must, when presented with the document, provide the required notice of its policies to the designated representative."

c. "When a patient is incapacitated or otherwise unable to communicate his or her wishes, there is no written advance directive on file or presented, and an individual asserts that he or she is the patient's spouse, domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a minor child), or other family member and thus is the patient's representative, the hospital is expected to accept this assertion, without demanding supporting documentation, and provide the required notice to the individual."

2. During an interview on 12/02/24 at 12:39 PM, Staff OO (Patient Access Director) reported that registration staff had a responsibility to ensure patients or their representative received the Patient Rights and Responsibilities information. Staff OO reported, in the case of an incapacitated patient, registration staff would initially wait to see if the patient's family arrived. If no family arrived, then staff would look into the electronic medical record system to see if the patient had a power of attorney (POA). If the patient did not have a POA, then staff would contact the legal next of kin. Staff OO reported that registration staff would document any contact or contact attempts with the patient's family or legal representative.

3. Review of Patient #5 (P5)'s 8/22/24 medical record revealed the following:

a. P5 presented to the ACH on 8/22/24 for increased lethargy (lack of energy) and weakness. P5 had a history of dementia and resided in a nursing home.

b. On 8/22/24 at 2:59 PM the emergency department (ED) physician documented they spoke with a family member, and they provided the phone number of the family member in their note.

c. On 8/22/24 at 5:02 PM Staff PP Physician documented in the History and Physical (H&P) that P5 could not provide their own medical history and did not have family at their bedside at this time.

d. Review of the medical record did not reveal evidence of registration staff informing the family member of the patient's rights.

e. During an interview on 12/02/24 at 12:39 PM with Staff OO (Patient Access Director), Staff OO acknowledged that registration staff did not document any attempts to contact P5's legal representative to provide information regarding the patient's rights.

f. On 8/24/24 at 10:11 AM, hospital staff discharged P5 back to their nursing facility.

4. Review of the medical record Patient #10 (P10)'s 9/11/24 medical record revealed the following:

a. P10 presented to the Acute Care Hospital on 9/11/24 after ingesting a foreign body. P10 had a history of schizophrenia and resided in a care facility.

b. Review of documentation sent with the patient from the care facility to the hospital showed that P10 had a legal guardian and noted the contact information for the guardian.

c. Review of the medical record did not reveal evidence of hospital staff informing the legal guardian of the patient's rights.

d. During an interview on 12/02/24 at 12:39 PM, Staff OO (Patient Access Director) Staff OO acknowledged that registration staff did not document any attempts to contact P10's legal representative to provide notice of the patient's rights.

e. On 9/14/24, hospital staff discharged P10 back to their care facility.