HospitalInspections.org

As indicated in A0131, patient #1 presented to the Emergency Department on January 17, 2014 with complaint of chest pain. The patient had a physician certification related to substitute decision making medical condition and treatment limitations was signed by physicians in August 2013 indicating that she lacked capacity to make medical decisions. Further she had a State of West Virginia Medical Power of Attorney dated August 23, 2013, naming a primary and secondary representative.

During the patient's stay the hospital staff had patient #1 sign consents for an endoscopy and for anesthesia. However, when it came to the patient's express wishes to not be returned to the nursing home, the patient and her representative both believed she lacked capacity to make that decision. Once medically cleared, patient #1 was chemically restrained with 1 mg of Haldol and discharged back to the nursing home against her will. In addition, as indicated in A 0154 the patient was given medication prior to her transfer without documentation regarding her behaviors, treatment, and condition at discharge.

Based on staff interviews, policies and procedures, and review of 1 of 16 medical records the hospital failed to ensure that patient #1's right to participate in her care and make decisions regarding discharge plans. The hospital honored the physician certificate of capacity dated August 2013 that indicated the patient lacked capacity to make decisions about her medical care and did not re-evaluate the patient for capacity during her January 2014 admission. However, the hospital allowed the patient to consent to and refuse treatment during her hospital stay when she supposedly lacked capacity to determine her post discharge placement . The hospital failed to recognize the patient's lack of capacity for some medical decisions but not all.

The patient was admitted to a monitored bed and cardiology consulted for complaint of chest pain. The cardiac enzymes remained negative. The patient declined further testing such as stress test.

The patient was positive for urinary tract infection, E-coli. She was started on antibiotic and completed the therapy. At one point the patient complained of something sticking in her throat and question of diverticulum on the CT scan. She had an upper endoscopy on 1/21/14 which revealed esophagitis but no other findings. Once the patient was medically cleared she was informed she would be returning to the nursing home. Patient #1 did inform the hospital that she did not want to return to the nursing home. The medical record review revealed the patient was calm, cooperative and fairly oriented to person, place, and time.

On 1/17/14 at approximately 6:48 PM her daughter #1 signed the consent for treatment, observation status form, and Important Message from Medicare. The patient was admitted to unit 4 South observation unit on 1/17/14 at 11:58 PM. The patient was transferred to 2 East on 1/18/2014 at approximately 6:00 PM. The medical record review revealed that on 1/19/14 at 4:53 PM case management performed an assessment which stated that patient #1 had been a resident at the nursing home for the past three years. The patient's main support appears to be her daughter #1 who stated she was the patient's power of attorney but there was no POA paperwork on the chart. In addition to the daughter #1, there is another daughter #2 , a son, an estranged husband and boyfriend as noted in the medical record.

The social worker/case manager met with the patient explained her role as a social worker. The patient stated she lives at the nursing home but would like to live with daughter #2 but daughter #1 will not allow daughter #2 to visit. Per the social worker the patient appeared confused so she contacted daughter #1 who stated the patient needed to return to the nursing home as soon as possible. Daughter #1 stated patient #1 has had mental illness for years and was deemed incompetent three years ago. (The note stated that the social worker explained to daughter#1 that the patient's competency can vary with time and she may need to be certified by two physicians. The social worker commented within the note that daughter #1 became frustrated stating that patient #1 symptoms are related to her anxiety and that any further testing was not needed. Daughter #1 stated that her sister daughter #2 is schizophrenic and cannot care for the patient. The patient is reported estranged from her husband and has an abusive boyfriend with whom she maintains phone contact. Daughter #1 shared that her son, the patient's grandson passed away last August, and since that time the patient has been involved in witchcraft. The social worker discussed the situation with nursing and she is aware that a psychiatric consult may be needed pending further discussion with the physicians. The social worker noted she would contact the nursing home social worker during the next business day to inquire about the POA paperwork/their background with the patient /patient family. The Advance Directive scanned into the hospital system states that the primary health care agent is granddaughter #1 who daughter #2's child and she was placed at that time as daughter #1 was overwhelmed with other responsibilities in her family. The note also revealed that physician recommended a Barium Swallow examination.

On 1/20/14 at 8:45 AM the social worker/case manager received a call from the 2E clerk who reports a family member (daughter #1) is on the floor early this morning presenting copies of the POA paperwork. The paperwork note granddaughter #1 as the primary and daughter #1 as the secondary. The social worker contacted the listed numbers for the primary POA without success but left a voice message. The social worker did seek supervision concerning incapacity forms, there appears to be no known time limit unless specified, and therefore the social worker met with the patient to inform her that the incapacity form signed 8/22/13 would likely be honored. The social worker documented she will attempt to contact the primary POA however if she is unable to be reached the social worker will work with daughter #1, secondary towards needs and discharge plans. The social worker/case manager documented receipt of incapacity forms and POA paperwork. She had received contact from the primary POA granddaughter #1 who reports consensus with daughter #1 being primary decision maker and she is in agreement and regular contact with daughter #1. The social worker advised regarding notary letter deferring decisions to the secondary POA for future needs and explained the legal obligation to attempt contact with the primary POA. The social worker than met with daughter #1 the secondary POA who would like the patient returned to the LTC facility as soon as possible as environmental issues can increase her mental health issues.

The social worker met with the patient who reports she is unhappy with living in the nursing home and wants to go live with her daughter #2.. Patient ' s daughter #2 is reportedly unsuitable to manage care for herself or the patient. The patient denied POA paperwork and reported she had an attorney. Per the note the patient was encouraged to work with the facility on ongoing needs towards resolution of safe discharge planning. It was documented the patient does not seem to have sense of reality about health needs and care needs. The patient is focusing on marrying boyfriend. The boyfriend is a support according to the patient. The social worker did contact the physician to discuss the case. The physician reports on-going treatment for urinary tract infection and additional testing for chest pain. He reports possible discharge within 24 hours. The patient was made aware of the time frame. The social worker discussed incapacity with the physician who is also the patient's physician at the LTC facility. He reports that the patient does not have capacity for decision making and that he is familiar with the patient. The social worker requested that physician document incapacity and nursing home concerns in notes.
The patient was deemed to lacked capacity to make her health care decisions but on 1/21/14 the patient was allowed to sign paper work for a endoscopy and anesthesia following complaints of difficulty swallowing. The patient had the procedure without difficulty.

On 1/22/14 the patient was medically cleared by cardiology for discharge and arrangements made for transfer to the nursing home. The patient per the social worker was having difficulty with returning to the nursing home and escalated while on the telephone with daughter #2. The social worker reviewed with patient the need to return to the nursing home and supported her to pursue legal avenues but that the paperwork for incapacity from August of 2013 was being honored. The patient is not showing the ability to make sound decisions and lack sense of reality. The patient is also demonstrating loss of time, talking about events that are not current, lacks awareness of previous discussions or staff which have been present. The power of attorney was contacted and patient to return to the nursing home. The patient is gaining compliance and successful in transport back to nursing home. The power of attorney was notified for support at the facility due to transition concerns.


The patient clearly informed the hospital that she did not want to return to the nursing home and the medical record revealed some assessments where the patient appears to be alert and oriented x3 and able to participate in education and treatment. The notes by social worker revealed there were questions regarding reality based thought process. Although the hospital determined that the certificates had no time limit, in fact they cannot be used for all future treatments as the patient's capacity can change. The hospital allowed the patient to consent to some decisions but not others . If the patient lacked capacity to determine her post discharge plan but had capacity to consent to an endoscopy and anesthesia .

Based on the medical record review it was noted on 1/22/14 the patient escalated while on phone with daughter #2 resulting in the administration of medication to calm the patient .

The medical record review revealed that an order for Haldol 1mg IM was obtained at 11:31 AM and per the medication administration record given at 11:34 AM at right deltoid. There is no documentation in the medical record regarding the patient's specific behaviors requiring the administration of the medication or chemical restraint except to say she escalated. On 1/22/14 at 11:40 AM the patient was discharged. No documentation could be found regarding reassessment of the patient following administration of the medication. The hospital failed to meet the regulatory standards as evident by failure to document justification for use of chemical restraint for patient #1.

Based on review of the medical record, it was determined that patient #1 received Haldol 1 mg IM at 11:34 AM and was discharged 6 minutes later at 11:40 AM. The patient was described as being upset because she was being sent back to the nursing home. There was no description of her behavior justifying the restraint and no re-assessment of the patient's condition after receiving the medication. The Haldol was used to restrict the patient's movement and interaction with her environment in order to calm patient prior to discharge. No assessment was performed of the effectiveness of the drug or potential side-effects since the patient was not monitored but discharged back to the nursing home.

Based on hospital policy and review of patient #1's medical record, it is revealed that no face-to-face was written for patient #1 after receiving chemical restraint of Haldol 1mg IM at 11:34 AM on 1/22/14. The order was obtained at 11:31 AM and the patient discharged at 11:40 AM. There was no documented assessment of the patient after administration of the medication and no documented face-to-face.

Based on staff interviews, policies and procedures, and review of 1 of 16 medical records the hospital failed to ensure that patient #1's right to participate in her care and make decisions regarding discharge plans. The hospital honored the physician certificate of capacity dated August 2013 that indicated the patient lacked capacity to make decisions about her medical care and did not re-evaluate the patient for capacity during her January 2014 admission. However, the hospital allowed the patient to consent to and refuse treatment during her hospital stay when she supposedly lacked capacity to determine her post discharge placement . The hospital failed to recognize the patient's lack of capacity for some medical decisions but not all.

The patient was admitted to a monitored bed and cardiology consulted for complaint of chest pain. The cardiac enzymes remained negative. The patient declined further testing such as stress test.

The patient was positive for urinary tract infection, E-coli. She was started on antibiotic and completed the therapy. At one point the patient complained of something sticking in her throat and question of diverticulum on the CT scan. She had an upper endoscopy on 1/21/14 which revealed esophagitis but no other findings. Once the patient was medically cleared she was informed she would be returning to the nursing home. Patient #1 did inform the hospital that she did not want to return to the nursing home. The medical record review revealed the patient was calm, cooperative and fairly oriented to person, place, and time.

On 1/17/14 at approximately 6:48 PM her daughter #1 signed the consent for treatment, observation status form, and Important Message from Medicare. The patient was admitted to unit 4 South observation unit on 1/17/14 at 11:58 PM. The patient was transferred to 2 East on 1/18/2014 at approximately 6:00 PM. The medical record review revealed that on 1/19/14 at 4:53 PM case management performed an assessment which stated that patient #1 had been a resident at the nursing home for the past three years. The patient's main support appears to be her daughter #1 who stated she was the patient's power of attorney but there was no POA paperwork on the chart. In addition to the daughter #1, there is another daughter #2 , a son, an estranged husband and boyfriend as noted in the medical record.

The social worker/case manager met with the patient explained her role as a social worker. The patient stated she lives at the nursing home but would like to live with daughter #2 but daughter #1 will not allow daughter #2 to visit. Per the social worker the patient appeared confused so she contacted daughter #1 who stated the patient needed to return to the nursing home as soon as possible. Daughter #1 stated patient #1 has had mental illness for years and was deemed incompetent three years ago. (The note stated that the social worker explained to daughter#1 that the patient's competency can vary with time and she may need to be certified by two physicians. The social worker commented within the note that daughter #1 became frustrated stating that patient #1 symptoms are related to her anxiety and that any further testing was not needed. Daughter #1 stated that her sister daughter #2 is schizophrenic and cannot care for the patient. The patient is reported estranged from her husband and has an abusive boyfriend with whom she maintains phone contact. Daughter #1 shared that her son, the patient's grandson passed away last August, and since that time the patient has been involved in witchcraft. The social worker discussed the situation with nursing and she is aware that a psychiatric consult may be needed pending further discussion with the physicians. The social worker noted she would contact the nursing home social worker during the next business day to inquire about the POA paperwork/their background with the patient /patient family. The Advance Directive scanned into the hospital system states that the primary health care agent is granddaughter #1 who daughter #2's child and she was placed at that time as daughter #1 was overwhelmed with other responsibilities in her family. The note also revealed that physician recommended a Barium Swallow examination.

On 1/20/14 at 8:45 AM the social worker/case manager received a call from the 2E clerk who reports a family member (daughter #1) is on the floor early this morning presenting copies of the POA paperwork. The paperwork note granddaughter #1 as the primary and daughter #1 as the secondary. The social worker contacted the listed numbers for the primary POA without success but left a voice message. The social worker did seek supervision concerning incapacity forms, there appears to be no known time limit unless specified, and therefore the social worker met with the patient to inform her that the incapacity form signed 8/22/13 would likely be honored. The social worker documented she will attempt to contact the primary POA however if she is unable to be reached the social worker will work with daughter #1, secondary towards needs and discharge plans. The social worker/case manager documented receipt of incapacity forms and POA paperwork. She had received contact from the primary POA granddaughter #1 who reports consensus with daughter #1 being primary decision maker and she is in agreement and regular contact with daughter #1. The social worker advised regarding notary letter deferring decisions to the secondary POA for future needs and explained the legal obligation to attempt contact with the primary POA. The social worker than met with daughter #1 the secondary POA who would like the patient returned to the LTC facility as soon as possible as environmental issues can increase her mental health issues.

The social worker met with the patient who reports she is unhappy with living in the nursing home and wants to go live with her daughter #2.. Patient ' s daughter #2 is reportedly unsuitable to manage care for herself or the patient. The patient denied POA paperwork and reported she had an attorney. Per the note the patient was encouraged to work with the facility on ongoing needs towards resolution of safe discharge planning. It was documented the patient does not seem to have sense of reality about health needs and care needs. The patient is focusing on marrying boyfriend. The boyfriend is a support according to the patient. The social worker did contact the physician to discuss the case. The physician reports on-going treatment for urinary tract infection and additional testing for chest pain. He reports possible discharge within 24 hours. The patient was made aware of the time frame. The social worker discussed incapacity with the physician who is also the patient's physician at the LTC facility. He reports that the patient does not have capacity for decision making and that he is familiar with the patient. The social worker requested that physician document incapacity and nursing home concerns in notes.
The patient was deemed to lacked capacity to make her health care decisions but on 1/21/14 the patient was allowed to sign paper work for a endoscopy and anesthesia following complaints of difficulty swallowing. The patient had the procedure without difficulty.

On 1/22/14 the patient was medically cleared by cardiology for discharge and arrangements made for transfer to the nursing home. The patient per the social worker was having difficulty with returning to the nursing home and escalated while on the telephone with daughter #2. The social worker reviewed with patient the need to return to the nursing home and supported her to pursue legal avenues but that the paperwork for incapacity from August of 2013 was being honored. The patient is not showing the ability to make sound decisions and lack sense of reality. The patient is also demonstrating loss of time, talking about events that are not current, lacks awareness of previous discussions or staff which have been present. The power of attorney was contacted and patient to return to the nursing home. The patient is gaining compliance and successful in transport back to nursing home.