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Based on record review and interview, the facility failed to obtain informed consent for 1 of 2 incapacitated patients (Patient #1) in a sample of 10 records reviewed; resulting in failure to protect and promote Patient Rights.

Findings include:

The facility staff failed to recognize the type of Advance Directive (Health Care Power of Attorney), allowing the patient's representative (activated Health Care Power of Attorney) the right to make informed decisions regarding a procedure that was performed. See A-0131.

Based on record review and interview, the facility failed to obtain informed consent for 1 of 2 incapacitated patients (Patient #1) in a sample of 10 records reviewed; resulting in failure to protect and promote Patient Rights.

Findings include:

The facility policy, titled "Consent to Treatment", last updated 12/24/2019, revealed: "...D. The word 'patient' includes both inpatients and outpatients and, in appropriate circumstances, is deemed to mean the patient's parent, legal guardian, health care agent or other person authorized or empowered to make health care decisions on the patient's behalf. A. Obtaining Consents 1. Except in emergency situations, or as otherwise provided in this policy, it is the responsibility of the physician performing the treatment or procedure to obtain the patient's informed consent prior to providing treatment or performing a procedure...6) For patients who have an activated HCPOA or court appointed guardians, the consent documentation may be completed over the phone with another staff member on the line as a witness. (See CPM.0022-Advanced Directive)."

The facility policy, titled "Advanced Directive", #CPM.0022 last updated 04/15/2020, revealed: "...A. Advance Directive: An advance directive is a written instruction recognized under state law that relates to the provision of health care to an individual when the individual is incapacitated...Wisconsin law recognizes the following types of advance directives: (1) a power of attorney for health care...B. Power of Attorney for Health Care: A power of attorney for health care is a designation by an individual of a health care agent to make health care decisions on the individual's behalf if the individual becomes incapacitated. To be valid, a power of attorney for health care must be in writing and signed and dated in the presence of two witnesses...6. "Incapacity" is the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her health care decisions..."

The facility policy, titled "PATIENT RIGHTS AND RESPONSIBILITIES ADVANCED DIRECTIVES", last updated 04/2021, revealed: "Patient Rights...8. You have the opportunity to make healthcare decisions in collaboration with your health team members. You may also assign representatives to be involved in your care and designate your visitors. 9. Except in emergencies, consent for treatment will be obtained from you, or those legally authorized to act for you, before participating in research and before any diagnostic and/or surgical procedures are performed..."
Patient #1 was admitted to the facility's Inpatient Medical unit on 10/25/2021 for back pain and had "T3-pelvic decompression and fusion" (back surgery) on 10/29/2021, then was admitted to the facility's Inpatient Rehab unit on 11/12/2021. Patient #1 was diagnosed with a UTI (urinary tract infection) on 11/18/2021, then was admitted back to the facility's Inpatient Medical unit on 11/22/2021 with Sepsis (infection throughout the body); Patient #1 was still admitted on Inpatient Medical unit at time of survey (02/01/2022-02/03/2022). Patient has diagnoses that include "Delirium secondary to other medical condition and Hx (history) of Unspecified Depression and Anxiety."

Patient #1's Psychiatric Assessment, completed by Psychiatry Resident Physician RR on 12/06/2021 at 12:10 PM, revealed..."Psychiatry has been asked to evaluate patient for altered mental status. Patient presents with with severe delirium, hypoactive...As patient presents acutely altered and unable to participate in any meaningful interview-would recommend activation of HCPOA (Health Care Power of Attorney) as patient is not even able to communicate consistently with providers."

A review of Patient #1's medical record revealed that a "ACTIVATION OF POWER OF ATTORNEY FOR HEALTH CARE Statement of Incapacity" form for Patient #1 was signed and certified by two Physicians (Physician KK and Physician LL) on 12/07/2021, and Patient #1's daughter (Complainant A) listed as Patient #1's "Primary Healthcare Agent Name." The form also indicates Patient #1 as "Incapacitated: (use for Durable Power of Attorney for Health Care) means the inability to receive and evaluate information effectively or to communicate such decisions to an extent that the individual lacks the capacity to manage their own health care decisions."

A review of Patient #1's medical record revealed that a "Consent for Procedure" form was signed and initialed by Patient #1 on 01/15/2022 at 10:15 AM for procedure: "PEG tube [feeding tube] placement, possible open or laproscopic gastrostomy [opening into the stomach]"; there was a signature by Authorized Provider (Physician JJ) on 01/15/2022 at 10:15 AM, there was no signature by Patient #1's activated HCPOA on form and no documentation in chart that Patient #1's HCPOA was contacted for verbal consent.

A review of Patient #1's medical record revealed that a Op (Operative) Note dated 01/16/2022 at 6:00 PM by Surgeon MM stated "...[He/she] agrees to proceed with PEG tube placement to facilitate [his/her] recovery. The risks, benefits and alternatives were discussed with the patient who consented to undergo the procedure." It was noted that Patient was under "General Anesthesia" for this procedure and "tolerated procedure well and was transported back to the floor in stable condition."

During record review on 02/01/2022 at 2:16 PM, Patient Safety Specialist R confirmed that Patient #1's "Consent for Procedure" form (dated 01/15/2022) for "PEG tube placement, possible open or laproscopic gastrostomy" procedure should have been signed by Patient #1's activated HCPOA prior to the procedure.

During an interview on 02/02/2022 at 1:30 PM, Assistant Nurse Manager Z stated, "When it comes to decision-making, such as the 'PEG procedure' ordered for Patient #1, the activated POA needs to be called for permission." When asked if there were any calls made to Patient #1's activated HCPOA regarding the PEG procedure, Assistant Nurse Manager Z stated "Not that I can see in the chart." Assistant Nurse Manager Z confirmed that the signature and initials on the "Consent for Procedure" form (dated 01/15/2022) for "PEG tube placement, possible open or laproscopic gastrostomy" procedure were Patient #1's signature and initials.

During an interview with Registered Nurse AA on 02/02/2022 at 2:10 PM, when asked if Patient #1 has an activated HCPOA, Registered Nurse AA stated "Yes." When asked if he/she would call the activated HCPOA if Patient #1 had a PEG procedure ordered, Registered Nurse AA stated "I would delegate to the Physician to call the POA and to get permission for that kind of procedure."

Based on record review and interview the facility failed to ensure the completion and documentation of reassessment of pain per facility policy in 1 of 5 (Patient #6) Emergency Department medical records reviewed in a total universe of 10 records reviewed.

Findings include:

The facility document, titled "Standards of Practice in the Emergency Department", dated 7/25/2017, revealed: "The Standards of Practice in the Emergency Department include those elements that reflect the delivery of care by Emergency Department Registered Nurses. Each standard is accompanied by competency statements that provide key action elements of that standard. The Standards of Practice are: 1. Assessment-The Emergency Department (ED) Registered Nurse (RN) collects comprehensive data pertinent to the health care consumer's health and/or situation. Initial Assessment...completes a pain assessment on all patients during the initial assessment as well as with any reassessments. If pain is present the following will be documented: pain scale used, pain rating, tolerable pain goal, pain location, quality, interventions...Administration of Medication Considerations. Documents a full set of vital signs, including a pain reassessment if applicable, within 15-30 minutes after an intervention (e.g. IM (intramuscular) injection, IV (intravenous) push medications, fluid bolus) and based on treatment. Time frame is dependent on the medication being administered..PO (by mouth) medication should be every 30 minutes to 60 minutes after intervention (e.g. Tylenol) Reassessment of pain will occur within or at about one hour of intervention (s)."

The facility policy, titled "Pain Management" last reviewed 6/12/2020, revealed: "A. Pain assessment will be based on the patient's clinical presentation. Appropriate follow up and treatment will be done based on the needs of the patient and appropriate for the care setting...J. The Emergency Department Registered Nurse documents ongoing pain assessments and reassessments for every patient receiving pain treatment of any kind based on the needs of the patient and appropriate for the care setting."

Patient #6 Emergency Department (ED) timeline, dated 11/20/2021, revealed: "5:49 PM Triage Note: Patient ambulatory to triage with [spouse] with cc (chief complaint) right side of face/tongue swelling. Has rectal cancer and lung cancer with hx (history) brain radiation. No obvious swelling noted with assessment, pt (patient) moving tongue back and forth in mouth while try to assess. Pt was reporting today his/her right ear hearing aid felt tight. [Spouse] gave pt 1 mg decadron (steroid) at 5:00 PM. Pt states didn't much help, (sic) [spouse] states tongue looks less swollen...Pt took tylenol 1000 mg and 800 mg ibuprofen at 5:30 PM. Pain/Comfort/Sleep: Number: Pain Rating (0-10): Rest 5; Activity: 5; Pain location: head; Pain side: right. At 9:30 PM the physician treated Patient #6 with bupivacaine with epinephrine (local anesthetic) greater occipital nerve block (sic) for headache. Pain is not reassessed until 11/21/2021 at 12:50 AM: Pain reassessed. Acceptable pain level: 2, Number: Rest 4. At 4:30 AM Fentanyl (narcotic pain medication) 50 mcg-given via IV for pain rating 7/10. At 5:31 AM Patient denies pain."

During record review on 2/2/2022 at 3:00 PM, Patient safety specialist N, confirmed that Patient #6 received a nerve block on 11/20/2021 at 9:30 PM and pain was reassessed on 11/21/2021 at 12:50 AM. (3 hours and 20 minutes after intervention)

During an interview on 2/2/2022 at 3:30 PM, ED CNS (clinical nurse specialist) M stated, I would expect the nurse to do a pain reassessment after a patient received a nerve block for pain.