HospitalInspections.org

Based on interview, record review, and policy review, the facility failed to ensure Patient #4's legal representative was informed of the patient's health status and was able to make informed decisions regarding care and treatment.

See A131

Based on interview, record review, and policy review, the facility failed to ensure a patient's legal representative was informed of the patient's health status and was able to make informed decisions regarding care and treatment. This affected one (Patient #4) of ten sampled patients.

Findings include:

Review of the medical record revealed Patient #4 was admitted to the hospital on 12/12/2023 and had diagnoses including major depressive disorder, unspecified anxiety, and neurocognitive disorder with Lewy bodies. The patient was discharged to an assisted living facility on 12/15/2023.

Review of document titled "Request for Voluntary Admission and Consent to Treat", dated 12/12/2023 at 4:30 PM revealed Patient #4 was unable to sign. The document was signed by Registered Nurse (RN) K with no second witness signature.

There were no documents in the medical record regarding consent to administer new medications or acknowledging the patient/legal representative was educated to medication changes including education to risk and benefits, side effects, and risk of involuntary movement.

Review of intake documents revealed a face sheet from Patient #4's assisted living facility revealed Patient #4's husband was listed as financial and health care power of attorney (POA) and contact information was provided for both the patient's husband and daughter.

Review of the Initial Nursing Assessment dated 12/12/2023 at 4:30 P.M. revealed RN K documented that Patient #4 had severe Lewy-body dementia, type II diabetes, and major depressive disorder. Patient #4 was brought to the hospital from an assisted living facility due to increasing violent behavior against staff and other patients. Patient #4 was calm and cooperative during the assessment, but was unable to answer questions as the patient exhibited tangential speech and word salad. Notes from the assisted living facility stated the patient needed constant redirection and had been becoming violent, towards staff (hitting, kicking, screaming). Ativan was needed to calm the patient during these episodes. Additionally, the patient's limitations were described as no insight into illness, difficulty communicating thoughts, lack of social skills, poor memory, unable to meet basic needs, self-care deficits, needs 24-hour care, and limited/no decision-making. There was no mention of a guardian or POA.

Review of daily nursing progress notes dated 12/13/2023 to 12/15/2023 revealed the patient had memory loss, remained disoriented to person, place, and time, and was unable to answer assessment questions unless yes or no due to limited verbal communication. RN L documented she did not think the patient understood the questions. There was no documentation in the progress notes regarding any contact between nursing staff and the patient's POA related to notification of changes in medications.

During a telephone interview on 01/29/24 at 4:45 P.M., Patient #4's POA/spouse stated he called the hospital on 12/12/23 and was unable to receive any information from the staff because he did not have a personal identification number (PIN) number. He was told they would have Patient #4 call him. He explained to the receptionist, unidentified, that Patient #4 had dementia and was unable to use the phone or give consent. The receptionist said they would have the nurse call him, but no one ever did. The spouse stated he had looked online and saw visitation hours listed on the hospital's website. The spouse went to the hospital on 12/13/23 in the evening after work around 5:30 P.M. and was told there had been no visitation since COVID. The spouse said he became upset and was not on his best behavior. They sent a nurse to speak with him, but the nurse cited HIPPA and would not tell the spouse anything. The spouse stated he did not have the POA documents with him because he had just come from work. The spouse denied ever meeting with Patient #4 earlier in the day on 12/13/23 with the Administrator, denied receiving any phone calls from Patient #4 during her stay at the hospital, and denied receiving any phone calls from any staff regarding Patient #4's treatment, medications, or plan of care during her stay at the hospital.

During an interview on 01/30/2023 at 8:41 A.M. the Administrator verified the hospital had received a face sheet from the facility before Patient #4 was admitted, which listed her spouse as the POA and gave contact information. It was the admitting nurse's responsibility to review the facility paperwork and make every effort to contact the POA for consent to treat. The Administrator verified there was nothing in the medical record which indicated the facility had ever contacted the Patient #4's POA to provide consent for admission, new medications, or to inform about the plan of care. The administrator stated it was the hospital's policy to identify, locate, and contact a surrogate decision-maker for any patient who was not competent to make their own medical decisions to obtain informed consent for all care and services.


Review of policy titled "Informed Consent", no date, revealed the individual providing treatment/care determined the individual's competence to understand information about proposed care, treatment, and services. The individual providing treatment identified, located, and contacted the surrogate decision maker, a person who was legally appointed to make decisions on behalf of the patient, when necessary. If no surrogate decision-maker was located within 24 hours, the provider determined possible surrogate decision makers in order of priority to the patient including legal guardian, spouse, adult child, parent, adult sibling, adult grandchild, or adult close friend. Once identified, the individual providing care provided the surrogate decision-maker a clear, concise explanation of the individual's condition and any proposed treatment, care, and/or services. The provider documented the consent of the surrogate decision maker in the patient's clinical record.