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A. Based on review of the medical record, document review and staff interviews it was revealed the patient representative did not have the right to participate in the care of patient #1. The facility failed to ensure the patient representative was involved in placement upon discharge from the facility. This failure was identified in one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients/patient representative's rights to participate in the care of the patient while at the facility.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 10/23/21 with a diagnosis of metabolic encephalopathy secondary to a urinary tract infection. Patient had altered mental status. A health care surrogate form was completed on 6/23/21 due to the patient was found to lack capacity. Patient #1 has a history of dementia. Patient #1 was transported from a local nursing facility due to altered mental status and lethargy for two (2) to three (3) days. Case management documented the patient is to return to the nursing home. No documentation of a freedom of choice form was noted in the medical record indicating the surrogate wanted the patient to return to the same nursing facility. Nursing documented the health care surrogate was notified of the discharge on 11/3/21, the day of discharge.

2. An interview was conducted with Registered Nurse (RN) #2 on 12/7/21 at 12:45 p.m. RN #2 stated if a patient comes from a nursing home, the case manager will talk to the family to see if it is their wish for the patient to return to the same facility or same agency. They complete a patient choice form. RN #2 stated they will try to locate the form in case it has not been scanned in the medical record.

3. An interview was conducted with RN #2 on 12/7/21 at approximately 1:15 p.m. RN #2 stated there is no patient choice form in the medical record for patient #1. RN #2 stated a patient choice form should have been in the medical record.

4. A review of the policy titled "Advance Directives," approved 01/2020, stated in part: "When a patient who is incapacitated has executed an advance directive designating a particular individual to make medical decisions for him/her when incapacitated, the hospital must, when presented with the document, provide the designated individual the information required to make informed decisions about the patient's care."

5. An interview was conducted with the Director of Risk Management/Patient Safety on 12/7/21 at 3:03 p.m. The director concurred the patient's representative was not given the opportunity to complete the patient choice form prior to discharge.


B. Based on a review of the medical record, staff interviews and document review it was revealed the facility failed to provide care in a safe setting. The facility failed to ensure all labs in the emergency department (ED) were drawn as per policy. This failure was identified in one (1) of ten (10) medical records reviewed (patient #7). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #7 revealed they arrived at the ED on 10/6/21 at 5:35 p.m. via Emergency Medical Services (EMS) with a diagnosis of cardiac arrest. They arrived at the ED with a pulse and had been intubated by EMS. A medical screening exam was initiated at 5:43 p.m. Labs were ordered at 5:57 p.m. On 10/6/21 at 10:26 p.m. the ED physician's discharge summary stated, "Significant delay in lab work." The ED physician was unable to assess lab work prior to discharge. Patient #7 was admitted to the intensive care unit (ICU). Labs were documented as collected at 10:14 p.m. Labs were received at the lab at 10:40 p.m. Glucose level was eight hundred and fifteen (815), results were reported at 11:16 p.m.

2. An interview was conducted with the Interim Director of the ED on 12/7/21 at 2:07 p.m. When asked about the labs for patient #7 being completed in the ED, the interim director stated once a lab is drawn by the ED nurse, then it is put in a lab basket to be taken to the lab. The interim director stated, "I could not imagine the labs not going to the lab immediately." The interim director stated the lab basket is to be taken to the labs every thirty (30) minutes. The interim director stated it is the expectation for labs to go immediately to the lab for someone who came to the ED in cardiac arrest.

3. A review of the policy titled "Pathology & Laboratory Testing Guidelines and Laboratory Testing Methodologies," approved 03/2021, stated in part: "a. STAT - These tests are entered into the computer system at priority "S" and means a critical situation exists. The lab will collect the specimen within 15 minutes ...."

4. An interview was conducted with the Director of Risk Management/Patient Safety on 12/7/21 at 3:03 p.m. The director concurred the labs were not completed in a timely manner for patient #7.

Based on document review, staff interviews and review of the medical record for patient #1 it was revealed the facility failed to provide an appropriate discharge planning evaluation for post-hospital care. This failure was identified in one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed they were admitted on 10/23/21 with a diagnosis of metabolic encephalopathy secondary to a urinary tract infection. Patient had altered mental status. A health care surrogate form was completed on 6/23/21 due to the patient was found to lack capacity. The patient has a history of dementia. Patient #1 was transported from a local nursing facility due to altered mental status and lethargy for two (2) to three (3) days. Case management documented the patient is to return to the nursing home. No documentation of a freedom of choice form was noted in the medical record indicating the surrogate wanted the patient to return to the same nursing facility. Nursing documented the health care surrogate was notified of the discharge on 11/3/21, the day of discharge.

2. An interview was conducted with the Director of the Critical Care Step Down Unit (CCSD) and Licensed Practical Nurse (LPN) #1 on 12/7/21 at 8:46 a.m. The director stated LPN #1 knows more about the discharge process. LPN #1 okayed the director of the CCSD unit to be in on the interview. When asked about discharges (d/c) on the unit, LPN #1 stated the nurses and case managers (CM) talk to the family. The physician puts in a referral to CM to follow up with the family to ensure it is the nursing home they want the patient to return to. LPN #1 stated families are called the day of d/c, after the order is received. If it is a new placement or changing placement for a patient, then the CM will call the family.

3. An interview was conducted with Registered Nurse (RN) #2 on 12/7/21 at 12:45 p.m. RN #2 stated if a patient comes from a nursing home, the CM will talk to the family to see if it is their wish for the patient to return to the same facility or same agency. They complete a patient choice form. RN #2 stated they will try to locate the form in case it has not been scanned in the medical record.

4. An interview was conducted with RN #2 on 12/7/21 at approximately 1:15 p.m. RN #2 stated there is no patient choice form in the medical record for patient #1. RN #2 stated a patient choice form should have been in the medical record.

5. A review of the policy titled "Discharge Planning," approved date 04/2021, stated in part: "Discharge needs (i.e.. home health, DME, community services) will be arranged by the case manager/social workers keeping patient choice...... The patient or family will be given the "Patient Information and Choice Letter" as well as a list of providers for their decision on which provider to use."

6. An interview was conducted with the Director of Risk Management/Patient Safety on 12/7/21 at 3:03 p.m. The director concurred no patient choice form was completed for patient #1.