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Based on document review and interviews, the facility failed to ensure patients' representatives were notified, informed and involved with the patients' health status, care planning and treatment, including discharge, to meet the patient's healthcare needs in one of two observation patient records reviewed (Patient #2).

Findings include:

Facility policies:

The Patient Rights policy read, patient rights and responsibilities are established and honored to assure basic protections for health, safety, and mutual satisfaction of the patient/family/legal representative, the hospital, physician, and staff. The patient has the right to participate in decisions about their care. The patient has a right to name a decision-maker for the times when you may not be able to make decisions for yourself and to have a family member, or representative of your choice, and your own physician, notified of your admission to the hospital promptly upon request.

1. Facility staff did not ensure a patient's representative was notified and involved in the patient's care plan.

According to the facility's Patient Rights policy, patients have the right to have a family member notified of admission to the hospital.

a. Review of Patient #2's medical record, from 10/16/19 through discharge on 10/17/19, showed no evidence the patient's family member was notified and involved in his care plan. The patient was admitted to the hospital with altered mental status. This was in contrast to the Patient Rights listed in the policy above.

i. According to the emergency department (ED) provider notes, dated 10/16/19, Patient #2 presented to the ED with a chief complaint of altered mental status. The ED physician documented the patient was a very difficult historian and had a known history of schizophrenia and seizure disorder. The physical exam noted the patient was alert and oriented to person and place, but was questionable with the situation because the patient could not state why he was in the emergency department. The physician also documented the patient was disoriented with time.

ii. On 10/16/19 at 2:47 p.m., Licensed Clinical Social Worker (Social Worker) #2 conducted a psychiatric evaluation for Patient #2. She documented the patient was confused, disorganized and very difficult to get a history from. Patient #2's psychiatric history included schizoaffective disorder and dementia. Further review of the notes, showed the social worker found the patient had a supportive brother according to another facility's records reviewed. Her Clinical Impression notes read, Patient #2's assessment was challenging as the patient had both severe mental illness and dementia and at the time could not contribute much to his history.

Although, SW #2 identified the patient had a supportive brother, there was no evidence in either the ED provider notes or the social worker notes, the patient's brother was contacted.

iii. On 10/16/19 at 1:16 p.m., an emergency department registered nurse (RN #6) documented a neurological assessment note which read the patient had an unknown baseline orientation and lived with a brother. Review of the patient's demographics information showed a brother listed as an emergency contact with a contact phone number. There was no evidence the nurse called the brother.

Patient #2 was admitted to the hospital for observation monitoring.

b. There was no evidence in the medical record either Physician #3 or the admitting nurse practitioner attempted to notify the family of the patient's admission and discuss the patient's treatment plan. However, both documented the patient was confused.

Physician #3 documented a History and Physical attestation on 10/16/19 at 4:28 p.m. The physician noted Patient #2 reported confusion, drowsiness, partial orientation and illogical in response to questions.

According to the nurse practitioner's History and Physical, dated 10/16/19 at 5:05 p.m., Patient #2 presented to the hospital with altered mental status, including disorientation with time. She noted the patient was an atrocious historian and had dementia.

c. Review of nursing notes and flowsheets documented during the patient's admission, revealed two registered nurses (RN #4 and RN #5), on 10/16/19 and 10/17/19, wrote "family/other" was present or had been informed of admission. However, there was no evidence as to who was present or notified.

d. Review of therapy notes showed lack of family involvement in the patient's evaluations of his post hospital care needs.

i. According to the physical therapist (PT) note, dated 10/17/19 at 10:19 a.m., it was unclear if the patient had assistance at home. Additionally, because of poor insight and balance deficits, PT recommended 24 hour care at home. There was no evidence in the PT note which indicated family was involved in the patient's care plan, which included discharge.

ii. Review of the occupational therapist (OT) note, dated 10/17/19, the same day was conducted. The OT note showed the patient completed a test with a score of 6/30 which indicated possible dementia and the patient would benefit from continued services to address deficits with cognition, insight and safety awareness that impact basic activities of daily living. There was no evidence in the OT evaluation family was involved in the care plan.

Patient #2 was discharged home via a taxi from the facility on 10/17/19 at 4:29 p.m. Review of both the Discharge summary and nurse's Discharge Note, dated 10/17/19, showed no evidence family, who was listed as a contact and noted in Social Worker #2's note to be involved in the patient's prior care, was notified of the patient's discharge and possible post care needs.

e. Multiple staff who provided care to Patient #2 were interviewed and were unable to explain why family was not notified and involved in Patient #2's care plan while admitted to the hospital.

i. On 2/4/20 at 12:32 p.m., Patient #2's discharging physician was interviewed (Physician #7). He said he vaguely remembered the patient and reviewed what he wrote in his discharge note. Physician #7 stated he did not remember talking with family and did not know if the patient had family.

ii. On 2/4/20 at 1:49 p.m., ED RN #6 reviewed the patient's record and stated she could not see in the record where someone was contacted. She stated her process was to document the conversation, as well as the number called. RN #6 stated she remembered the patient and he was possibly staying with his brother.

iii. On 2/5/20 at 7:11 a.m., RN #4 was interviewed and stated she remembered Patient #2's name and the patient was provided a taxi ride home when he was discharged. RN #4 stated she did not remember talking with any family members about the patient's care.

iv. On 2/5/20 at 10:51 a.m., Physician #3 was interviewed and reviewed Patient #2's medical record. He said typically physicians would try to reach family on admission or speak to who was present in the room. Physician #3 stated on admission, Patient #2 reported only to be oriented to his name. He said in that type of situation, the presumption would be the patient lacked capacity for more involved decision making. However, Physician #3 said he did not see in the medical record where a formal decision capacity tool was performed.

Physician #3 stated family should have been notified in Patient #2's case. He said the purpose of family notification was to get corroborating information about the patient, as well as involvement with care decisions. Physician #3 stated the day Patient #2 was admitted was a busy day and he presumed with psychiatry involved, family notification would have been taken of.

Based on interviews and document reviews, the facility failed to adhere to death reporting requirements for the Centers for Medicare and Medicaid Services (CMS). The death of a patient who expired within 24 hours after being restrained by a vest, was not reported to CMS in one of two patients required to be reported according to the regulation (Patient #5)

Findings include:

1. The Director of Risk Management (Director #9) did not contact CMS, to report a patient's death within 24 hours of being restrained, as required by CMS.

a. Review of Patient #5's medical record revealed Patient #5 was placed in a strap fastening vest on 1/9/20 for inability to comply with safety measures. According to the restraint flowsheets, the patient was restrained until 1/10/20 at 2:30 p.m. According to an After Death Checklist, Patient #5 died on 1/11/20 at 10:55 a.m. which was within 24 hours after the patient's restraint was removed. There was no evidence in the medical record which showed CMS was notified of the patient's death according to the regulation.

b. Review of the Restraint Death Log for 2020, showed no evidence the facility reported the Patient #5's death to CMS, according to the regulation requirements.

c. On 2/10/20 at 1:31 p.m., Director #9 and the Director of Quality (Director #10) were interviewed. Director #9 stated she was responsible for the Restraint Death Logs. She said something happened with her process that failed and she missed the reporting of Patient #5's death.