HospitalInspections.org

Based on review of records and interview, the facility failed to follow its own policy on ensuring the documentation of a witness when the patient is unable or unwilling to sign for receipt of patient rights for 3 out of 3 patient charts reviewed (Patient #2, #3, and #4).

Findings included:

Review of policy Title: "Patient's Rights, Policy No: CS004", Date Revised/Reviewed: 06/2018, conducted on 2-21-2019, revealed as follows:

"PROCEDURE:

Prior to admission, each individual shall be provided with a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language in simple non-technical language. If a patient has a legal guardian, the legal guardian will be given the patient's Bill of Rights form. If a family member, legal guardian, or friend is available, he or she shall be asked to be present during the explanation. This shall be done with both voluntary and involuntary patients.
...

The individual and/or guardian shall be requested to sign and date an acknowledgement of receipt of the Patient's Bill of Rights. The staff member who explains the rights shall also sign and date the acknowledgement receipt. This signed form shall be filed in the patient's medical record.

When the individual receiving services is unable or unwilling to sign the document which confirms that they have received a copy of the patient rights, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably by a family member, legal guardian or friend (if available) or by another staff member."



Review of Patient #2's chart was made on the morning of 2-21-2019. The patient had been admitted on 12-7-2018 and discharged on 12-18-2018. A 3-page form titled, Consent for Treatment & Conditions of Admission was found on the chart. The form contained patient acknowledgement statement concerning:
Consent for Treatment
Consent for Admission
Physician Coverage
Patient Rights and Responsibilities (to include acknowledgement that rights had been explained and a copy of the handbook given to the patient)
Patient/Family Grievance Procedure
Consent for Emergency Treatment
Patient Searches
Use of Photography and Surveillance Equipment
Confidentiality Statement
Loss of Personal Property/Money
Responsibility for Destruction of Property
Advanced Directives
Guarantee of Payment
Assignment of Insurance Benefits
Physician and Professional Services Billing

Each of the above subjects had a line next to it for the Patient/Guardian Initials. The last page had a line for the Patient Signature, the Guarantor/Guardian Signature, and a Witness Signature. There was no line for the staff member who was explaining these topics to sign.

Someone had written "pt too psychotic 12-7-18 LM" at the top of each form. At the bottom of each form,
someone had written "12/8/18 too (a symbol with an undefined meaning was written) to sign AR". There was no other documentation in the chart of attempts to explain to the patient her rights throughout her stay.

Review of Patient #3's chart contained a copy of the same 3-page Consent for Treatment & Conditions of Admission form. Someone had written the following at the bottom of each of the 3 pages:

"too disorganized 12/7/18
12/8/18 1209 too (a symbol with an undefined meaning was written) to sign AR
12-15-18 1800 too (a symbol with an undefined meaning was written) to sign AR"

Review of Patient #4's chart contained a copy of the same 3-page Consent for Treatment & Conditions of Admission form. Someone had written at the top of each page, "Pt too psychotic to sign JBM 12/11/18". The bottom of the pages contained:
"pt too psychotic JB 12/20/18
12-27-18 Pt too (a symbol with an undefined meaning was written) to sign AR
12-27-18 Pt too psychotic TR"

On the afternoon of 2-21-2019, an interview was conducted with Staff #10 in the admissions area of the hospital. Staff #10 stated that when the patient was not going to sign the form, staff would put the date, time, reason, and initial the form. Staff #10 confirmed that staff did not sign the forms or have a witness sign the form to acknowledge that the patient rights had been explained to the patient and that the patient was unable/unwilling to sign.

Based on observation and interview the facility failed to ensure that the maintenance of the facility and environment were maintained in a manner to assure the safety and well-being of patients in 3 (Stabilization Care Unit, New Freedom Unit, Dietary unit, and Progressive Care Unit) of 4 areas observed.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

During an observation tour on 2/21/2019 after 9:15 AM with Staff #1 and Staff #2 the following was observed:


STABILIZATION CARE UNIT

1. Observation of the ceiling, in the Common area across from the nurse's station, revealed bulging/sagging tiles that were stained with a brown colored substance that appeared to be water stains.

2. Multiple ceiling tiles were noted to be recessing into the ceiling exposing the metal frame.

3. The molding at the bottom of the wall next to the nurse's station was peeled away from the wall leaving a gap between the wall and the molding.


NEW FREEDOM UNIT

1. In the pre-assessment waiting room the wall next to the window was noted to have chipped paint and exposed sheetrock.

2. The door into patient room #124 exposed the bare wood beneath the painted surface. The porous material could not be adequately sanitized to prevent cross contamination between patients.



DIETARY ROOM

1. The hard vinyl molding around the base of wall, next to the window, was separated from the wall about 2 feet in length. This left a large gap between the wall and the molding strip exposing the sheetrock.

2.The table next to the wall had caused chipped paint and exposed the sheetrock.

Based on observation and interview, the facility failed to maintain a sanitary environment to ensure patient safety in 4 (Stabilization Care Unit, New Freedom Unit, Progressive Care Unit, and Dietary Unit) of 4 areas observed.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:


During an observation tour on 2/21/2019 after 9:15 AM with Staff #1 and Staff #2 the following was observed:



Stabilization Care Unit (SCU)
1. Observation of the Common Room revealed the patient chairs were heavily soiled in dirt, dust, and debris between the vinyl covering of the cushion and the plastic frame.


2. Stored in the patient Treatment room was a metal cabinet used to store medical supplies for patient care. On the top shelf, was an open multi-use package of sponges (4X4's). The sponges were used for multiple patients increasing the risk of cross contamination of infectious diseases between patients.

An interview was conducted with Staff #1 on 2/21/2019 after 9:15 AM. Staff #1 was asked if the sponges were used for multiple patients and how did they ensure there was no cross-contamination between patients. Staff #1 said the single packs of sponges should be used and the multi-pack of sponges should not be left open or used for multiple patients.


New Freedom Unit (NFU)
1. In the clean linen room was a metal rack used to store clean linen for patients. The rack was uncovered. There was no splash guard on the bottom shelf to protect the clean linen from contaminants when the floor was being cleaned. Staff #2 was asked if the linen cart is normally stored uncovered. Staff #2 stated, "It usually stays covered so I don't know".

3. The light covers in the hallway were harboring insects in between the light bulbs and light covers.




PCU
1.The sink in the medication room was soiled with dirt, dust, and dried brown liquid.

2. The Preventive Maintenance on the medication refrigerator was due 6/2018. Staff #2 was asked if he was aware that the preventative maintenance was past due on the refrigerator. Staff #2 stated, "I was not aware that the PM had not been completed."

3.The refrigerator used for patient nutrition had red and orange colored spills on the inside at the bottom. The shelves were soiled with dust and dirt.


Dining Unit
1. The drain under the serving unit was heavily soiled with dirt, dust, debris, and dried liquids. The corner of the wall, near the window, was noted to have chipped paint and exposing sheetrock. The baseboard was peeled away leaving a large gap between the wall and baseboard that was covered in dirt, dust, and debris.