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Based on review of 7 open medical records and 6 closed medical records, it was determined the hospital failed 1) verify patient #1's reported decision-maker as a medical Power of Attorney (POA), or determine a surrogate decision-making hierarchy among relatives; and 2) certify patient #1 lacked capacity to make informed decisions prior to referring to the POA or surrogate.

Patient #1 was an 85+ year old with a history of dementia who was admitted to the hospital for continued treatment of upper respiratory infections. Per record review, patient was alert during most of the admission but not always oriented. Patient #1's grandchild was listed as patient's POA on the form titled "Patient Designated Contact. Authorization to Release Information Form." There was no Medical Power or Attorney, or Advance Directive found in the record to verify this. Per the same form, under "Secondary Contact Person" there was a list of 5 names with the statement identifying the five as "(children)."

No certification for incapacity was completed until patient's 8th day of admission, post surveyor review of record on unit. Patient #1's grandchild had signed patient #1's forms for "An Important Message from Medicare About Your Rights" and the "Consent to Treatment." Per provider progress note on day of admission at 2252, the provider stated "d/w (discussed with) family and change of code status to DNR." The provider failed to document who the "family" was.

In summary, no verifiable POA, Advance Directive, or Health Care Agent was found in the patient's record. The hospital failed to verify a medical POA or certify an incapacity to make health care decisions prior to decisions regarding his/her care were made by a Grandchild. Also, despite the fact that patient #1 had lived with the Grandchild prior to this hospitalization, the hospital failed to follow the process of determining the hierarchy of surrogate decision-making, where patient #1 was known to have 5 children.

Based on review of 7 open medical records and 6 closed medical records, including two restraint records, it was determined the hospital failed to renew a non-violent restraint order for patient #7.

Per hospital policy "Patient Restraints" (last revised 12/2017) section III "Nonviolent, Non-Self-Destructive Behavior Restraint (Medical Restraint)" subsection D. 4, it stated, "A new order must be rewritten by the provider every twenty-four (24) hours ..."

Patient #1 was an 85+ year old on a medical/telemetry unit. Patient #1 was justifiably placed on non-violent, medical restraints on day of admission. Patient #1 did not have a renewal order for the third day of admission though nursing flow documentation revealed patient #1 remained in restraints. The previous order was at 20:34 on the second day of admission and the next order was on the fourth day of admission at 19:57, almost 48 hours later. Therefore, patient #1 was restrained without a physician order for an approximate 24 hour period.

Based on review of 7 open medical records and 6 closed medical records, including two restraint records, it was determined the hospital failed to monitor a non-violent restraint patient per policy.

Per hospital policy "Patient Restraints" (last revised 12/2017) section III "Nonviolent, Non-Self-Destructive Behavior Restraint (Medical Restraint)" subsection D. 1, it stated, "A nurse must re-assess the patient for the same or similar behavior and determine if the patient still posed a safety risk as follows: a) Adult's behavior every (2) two hours." The policy also mentioned every two hour monitoring under subsection E. "Care of the Patient in Non-violent, Non-Self Destructive Behavior (Medial Restraint)."

Patient #1 was placed in non-violent restraints at 13:00 in the emergency department. Monitoring every 2 hours was not documented until 1650 per restraint flow sheet.

Patient #1 was in non-violent restraints for six consecutive days. The restraint flow sheet had several instances where the two hour monitoring was over by several minutes and 4 instances that were 3 hours over the required timeframe.

Based on a review of seven open and six closed medical records, it was determined that Patient #9 (Pt# 9) did not receive a face-to-face assessment by a physician within one hour of initiation of an order for violent 4-point restraints.

Pt# 9 arrived in the Emergency Department exhibiting acute psychotic behavior, was resistant to care and became combative. A physician order for 4-point violent restraints was entered at 0525 hrs. Pt# 9 remained in 4-point restraints from 0520hr until 0615hr. After review of the medical record, no evidence was found the physician conducted a face-to-face that addressed all 4 components of a face-to-face within one hour of initiation of the violent restraint episode. The face-to-face lacked: the patient's immediate situation, the patient's reaction to the intervention, the patient's current medical and behavioral condition and the need to continue or terminate the restraint or seclusion.

Based on review of 7 open medical records and 6 closed medical records, it was determined the hospital failed to provide the necessary durable medical equipment for Patient #8 upon discharge.

Patient #8 was a 65+ year old who was admitted to the hospital for management of an acute episode of chronic lung disease. Upon discharge, patient required a nebulizer (drug delivery device) to use two prescribed medications. There was no evidence in the medical record of an order for a nebulizer or mention of acquiring one in the record. Patient #8 was discharged from the hospital without the needed nebulizer.