HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure conditions of admission [COA- a legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits, and acceptance of financial responsibility for medical services] was provided to patients and/or their legal representative for five of 30 sampled patients (Patient 30, Patient 26, Patient 23, Patient 8, and Patient 10). This failure resulted in Patient 30's legal representative being uninformed of Patient 30's medical status and course of treatment, and Patient 26, Patient 23, Patient 8, and Patient 10 being uninformed of their patient rights in agreement for care services during their hospitalization.

Findings:

During a concurrent observation and interview on 8/5/24 at 9:15 a.m., with Emergency Department Supervisor Registered Nurse (EDS), in the doorway of Patient 30's room, Patient 30 was in bed with continuous electroencephalogram (EEG- test that measures electrical activity in the brain) monitoring and swallow evaluation testing. EDS stated Patient 30 had a conservatorship (A designated court appointed person that makes decisions for medical care on behalf of a person not capable of making their own decisions) and was brought in for a medical evaluation of seizures (uncontrolled abnormal communication between brain cells and the body).

During a concurrent interview and record review on 8/5/24 at 1:16 p.m., with EDS, Patient 30's medical record admission section (MRAS), dated 8/2/24 was reviewed. There was no documentation in the MRAS that Patient 30's conservator was contacted regarding Patient 30's medical status, treatment, and admission to the hospital. EDS stated Patient 30's conservator should have been contacted regarding Patient 30's medical status and course of treatment.

During a concurrent interview and record review on 8/6/24 at 10:23 a.m., with Director Informatics Registered Nurse (DIRN), Patient 26's MRAS, dated 8/5/24 was reviewed. The MRAS indicated Patient 26 was brought to the Emergency Department (ED) on 8/5/24. DIRN stated there was no COA documentation to provide for Patient 26. DIRN stated the expectation was that Patient 26 was informed of her rights of admission. DIRN stated Patient 26's COA should have been done.

During a concurrent interview and record review on 8/6/24 at 10:48 a.m., with DIRN, Patient 23's MRAS, dated 6/1/24 was reviewed. The MRAS indicated Patient 23 was brought into the ED on 6/1/24. MIRN stated she was unable to find documentation of a COA for Patient 23. MIRN stated "there is not one [COA]" for Patient 23 and there should be.


42610


During a concurrent interview and record review on 8/6/24 at 10:24 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 8's MRAS, dated 6/3/24 was reviewed. The MRAS indicated, Patient 8 did not receive the COA. RNIM confirmed Patient 8 did not receive a COA.


49419


During a concurrent interview and record review on 8/6/24 at 1:45 p.m. with Manager of Emergency Department Admitting (MEDA), Patient 10's COA, dated 6/3/24 was reviewed. The COA indicated, Patient 10 signed his COA at 4:42 p.m. and left discharged at 4:50 p.m. (8 minutes). MEDA stated the expectation was for Patient 10's COA to be completed when he was admitted on 8/6/24 at 3:08 p.m. for treatment and not when he was discharged.

During an interview on 8/6/24 at 1:46 p.m. with Director of Licensing and Accreditation Registered Nurse (DLARN). DLARN stated Patient 10 "Did not receive [COA] timely."

During a review of the facility's P&P titled, "[Facility] Rules and Regulations," dated 2/28/12, the P&P indicated, "SECTION C. GENERAL CONDUCT OF CARE- 1. A Condition of Admission form, signed by or on behalf of every patient admitted to the medical center, must be obtained at the time of admission."

Based on interview and record review, the hospital failed to ensure the "Advance Health Care Directive" policy and procedure (P&P) was followed for two of 30 sampled patients (Patient 26 and Patient 8). This failure resulted in violation of patient rights to make medical care decisions and formulate an Advance Directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

Findings:

During a concurrent interview and record review on 8/6/24 at 10:01 a.m. with Director Informatics Registered Nurse (DIRN), Patient 26's "Care Preference Advance Directive (CPAD)," dated 8/6/24 was reviewed. The CPAD indicated Patient 26 was not offered the opportunity to formulate an Advance Directive. DIRN stated offering Patient 26 to formulate an Advance Directive included documenting not able to obtain. DIRN stated Patient 26's CPAD section was incomplete and there is no documentation to provide that Patient 26 was offered to formulate and Advance Directive.


42610

During a concurrent interview and record review on 8/6/24 at 10:24 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 8's "Medical Record (MR)," dated 6/3/24 was reviewed. The MR indicated, Patient 8 was not asked if he had an Advance Directive. RNIM stated there was no documentation Patient 7 was asked about an Advanced Directive or offered assistance to formulate an Advanced Directed.

During a review of the facility's P&P titled, "Advance Health Care Directive," dated 2/2024, the P&P indicated, "It is the policy of [Facility] to inform the patients of their right to accept or refuse treatment, their right to collaborate in developing goals of treatment, and the right to communicate those decisions, either verbally or in writing (Advance Health Care Directive) to their health care team."

Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, "Patient Safety Observation" for three of 30 sampled patients (Patient 29, Patient 27, and Patient 7). This failure had the potential for Patient 29, Patient 27, and Patient 7 to cause self harm.

Findings:

During a concurrent interview and record review on 8/5/24 at 3:38 p.m. with Emergency Department Supervisor Registered Nurse (EDS), Patient 29's "Observation Log (OL)," dated 8/5/24 was reviewed. The OL indicated Patient 29 was on a legal hold (5150- A 72 hour legal hold for assessment and evaluation for a person that is a danger to self or others) and had safety observation ordered. EDS stated there was no summary and/or comments entry for Patient 29 at times: 1:30 a.m., 1:45 a.m., and 2 a.m. EDS stated the OL's purpose was "for safety" of the patient. EDS stated there was no breakfast meal tray safety check done at 8 a.m. and no safe meal tray ordered for Patient 29. EDS stated the expectation for safety was for a safe meal tray ordered and the OL to be completed and no documentation meant "not done."

During a concurrent interview and record review on 8/5/24 at 4:05 p.m. with EDS, Patient 27's "OL," dated 8/4/24 was reviewed. The OL indicated Patient 27 was on a legal hold (5150) and had safety observation ordered. EDS stated there was no breakfast meal tray safety check done at 8 a.m.. EDS stated Patient 27's breakfast meal tray "should have been checked."

During an interview on 8/5/24 at 4:09 p.m. with EDS, EDS stated Patient 27 and Patient 29 were a danger to self harm. EDS stated Patient 27 and Patient 29 were both on legal holds for safety.

During an interview on 8/5/24 at 4:11 p.m. with EDS, EDS stated Patient 29 had a Columbia Suicide Severity Rating Scale (CSSRS- Risk stratification assessment for Suicide) score of 25 (a score of 6 or greater is high risk for suicide/self-harm).


42610

During a concurrent interview and record review on 8/6/24 at 10:04 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 7's OL, dated 6/3/24 was reviewed. The OL indicated, at 6:15 p.m. a meal tray was served to Patient 7. RNIM stated there was no documentation that a meal tray safety check was done.

During a review of Patients 7's "ED Triage (EDT-process of organizing emergency patient priority)," dated 6/3/24 the EDT indicated, "Psychiatric Hold: Yes. . . CSSRS Risk Level: High Risk."

During a review of Patient 7's "Physician Order (PO)," dated 6/3/24, the PO indicated, "Regular Diet. . . Tray, Safe Meal."

During a review of the facility's P&P titled, "Scope of Service-Emergency Department", dated January 2023, the P&P indicated, "The ED will provide and maintain a physical environment that is safe for all patients. . . Safety. . . b) The ED staff will follow established guidelines to ensure safe and efficient delivery of care. . . 4) Close Observation (a) Close observation is defined as constant visual access with ability to reach patient quickly enough to prevent any further injuries. (b) Patients requiring close observation include, but are not limited to, attempted suicide, §5150 hold."

During a review of the facility's P&P titled, "Patient Safety Observation (PSO)", dated July 2023, the P&P indicated, "PURPOSE: To establish guidelines for the use of patient safety observers, both in-person and virtual, to ensure the safety of patients at risk of harm to themselves. . . PROCEDURE. . . the use of a remote or in-person patient observer to support the safety needs of the patient in accordance with [Facility] policies and standards. . . Patient behavior, activity and safety will be observed and documented at least every 15 minutes and upon behavior change on Associated Form, #3115, In-Person Observation Log. . . Have been screened as a high risk for suicide utilizing the Columbia Suicide Severity Rating Scale (CSSRS)."

During a review of the facility's training Power Point titled, "PATIENT SAFETY OBSERVATION (PSO)", (undated), the PSO indicated, "PURPOSE. . To establish guidelines for the use of patient safety observers, both in-person and virtual to ensure the safety of patients at risk of harm to themselves or others. . . EVERY 15-MINUTE DOCUMENTATION IN-PERSON OBSERVATION LOG. . . Meal tray check for contraband. . . EVERY 15- MINUTE DOCUMENTATION (FORMFAST #3115) IN-PERSON OBSERVATION LOG. . . Meal tray check for contraband."

During a review of the facility's P&P titled, "Safety Tray (ST)," dated 1/2023, the P&P indicated, "POLICIES: Safety trays are ordered for patients who are a threat to themselves or others. PROCEDURES. . . Containers, dishes, and cups used are non-plastic and disposable, typically either Styrofoam or paper. A disposable tray is used. . . No utensils or pre-approved disposable "safety" utensil(s) are provided. . . Food packaging not permitted includes plastic bottles, aluminum containers/cans or foil. . . Tray, Safe Meal. . . Paper tray, disposable plates, a specific paper spoon, straw, no plastic utensils. . . Order Required per Unit. . . YES."

Based on observation, interview and record review the facility failed to ensure a physician medical screening examination (MSE) was completed and documented prior to patient discharge for one of 30 sampled patients (Patient 29). This failure had the potential to result in a disruption in continuity of care.

Findings:

During a concurrent observation and interview on 8/5/24 at 9:27 a.m. with Emergency Department Supervisor Registered Nurse (EDS), Patient 29 was in the overflow area next to the nurses station. EDS stated "that's the line-of-sight observation" area.

During a concurrent interview and record review on 8/5/24 at 1:58 p.m. with EDS, Patient 29's Medical Record Documentation Section (MRDS), dated 8/5/24 was reviewed. EDS stated Patient 29 had "only RN [Registered Nurse]" MSE documented. EDS stated there was no physician MSE. EDS stated Patient 29 was discharged on 8/5/24 at 10:47 a.m., and a physician "MSE should be done meaning completed since patient already discharged." EDS stated all patients are supposed to have a completed physician MSE in order to determine severity of condition and suitable for discharge or transfer.

During a concurrent interview and record review on 8/7/24 at 11:25 a.m., with Emergency Department Attending Doctor (EDAD), Patient 29's MRDS, dated 8/5/24 was reviewed. EDAD stated the MSE was expected to be "completed prior to end of shift." EDAD stated the expectation with emergency circumstances including trauma and life-sustaining medical interventions would be "24 hours" for MSE completion. EDAD stated he was overseeing ED Residents care provided to Patient 29.

During a concurrent interview and record review on 8/7/24 at 11:35 a.m., with EDAD, Patient 29's electronic MRDS, dated 8/5/24 was reviewed. The MRDS indicated ED Resident (EDR) authentication of completion for Patient 29's MSE was on 8/7/24 at 11:34 a.m. EDAD stated, EDR's MSE for Patient 29 was "routed to me today[8/7/24]" awaiting his review, and co-signature. EDAD stated expectation was to "complete MSE by discharge."

During a concurrent interview and policy and procedure (P&P) review on 8/7/24 at 2:26 p.m. with ED Medical Director (EDMD), the P&P titled, "[Facility] Medical Staff Rules and Regulations," dated 2/28/12 was reviewed. The P&P indicated at the time a patient is discharged all notes must be completed. EDMD stated Patient 29's physician MSE "should have been completed" per the facility's Medical Staff Rules and Regulations.

During a review of the facility's P&P titled, "[Facility] Medical Staff Rules and Regulations," dated 2/28/12, indicated, "SECTION A. ADMISSION, TRANSFER AND DISCHARGE OF PATIENTS- 1. ADMISSION a. The medical staff will comply with all federal and state rules and regulations. . . and the policies and procedures of the hospital. Medical staff members will provide services, including but not limited to medical screening. . . 9. EMERGENCY DEPARTMENT-An appropriate medical record shall be kept for every patient receiving emergency services and be incorporated in the patient's medical record. . . 10. COMPLETION- a. Each patient's medical record shall be signed by the member of the medical staff who is responsible for its clinical accuracy. . . c. The patient's medical record shall be complete at the time of discharge, including progress notes, final diagnosis, and clinical summary. Records are considered complete when the responsible practitioners and health care professionals have dictated or written and authenticated all necessary reports and have authenticated all record entries."

During a review of the facility's P&P titled, "Legal Medical Record (LMR)," dated 4/2021, the P&P indicated, "c. content. . . all hospital records. . . must comply with the applicable hospitals' medical staff rules and regulations requirement for content and timely completion. . . 6. All LMR entries will be made as soon as possible after care is provided or observation is made. . . Responsibility for the medical record. . . b) The medical staff and other healthcare professionals are responsible for the documentation in the medical record within required and appropriate timeframe's to support patient care. . . d) Draft Document/Work in Progress 1) Electronic processes and workflow management require methods to manage work in progress. These work in progress documents are often available in the system as "draft documents" and are viewable."