HospitalInspections.org

Based on Pt. medical record review, family and staff interviews, and facility pt. rights review, the facility failed to notify and obtain informed consent from family of the hospitalization and treatment in a timely manor for 1 of 1 Dementia pts. who was admitted without family knowledge from a total sample of 10 pts. sampled (Pt. #1). The facility failed to review all family members for potential contact for consent for treatment. This has the potential to affect all pts. who are admitted without family's knowledge or presence.

Findings include:

Facility pt. rights states that pts. and their legal representative, and their family have the right to participate in planning care or treatment as well as changes in the pt's care and treatment.


Per medical record review of Pt. #1 beginning on the afternoon of 9/24/12, the following was noted:

Pt. #1 came into the E.D. via ambulance on 8/24/12 at 1:48 p.m. The initial physician note states that staff are "contacting family".

Per interview with CBRF staff H at 10:47 a.m. on 10/3/12 and interview with CBRF staff I beginning at 2:10 p.m. on 10/3/12 a form entitled, "Emergency Medical Information" was sent with Pt. #1 when the ambulance took Pt. #1 to the ED on 8/24/12. Review of this form on the morning of 8/3/12 revealed the following : Primary Contact listed as Daughter K with home and cell phone numbers and secondary contact as #1's Son with a home phone number.

The history and physical note of 8/24/12 documented by Dr. B states that B will discuss Pt. #1's case with #1's son who is POA. There is no other family member mentioned for possible contact if POA not available.

The POA documents in #1's medical record list Pt. #1's son as POA for health care and Daughter K as POA for finances. The document states if unable to reach Son POA, contact Daughter K. The POA document was activated on 6/8/12.


Per review of form entitled, "Service Terms" with staff initials of "KD", the form says attempted contact with Son/POA at 2:10 p.m. and 5:50 p.m. on 8/24/12 as POA not present. There is no evidence to indicate that the staff attempted to reach K when Pt. #1's Son was not reached. At 12:00 p.m. on 8/25/12 initials of staff " KK" documents another attempt to contact POA (Son). There is no documentation that staff attempted to contact K due to inability to contact #1's Son.

Per review of the morning progress note documented on 8/26/12 by Dr. B, it states, "Unfortunately I am still not able to get a hold of son." There is no mention of trying to contact K.

Per review of form entitled "Consent for Blood Transfusion", at 3:57 p.m. on 8/26/12, telephone consent was received for the transfusion from Pt. #1's Son.

Per e-mail from Administrative Officer C on 9/25/12, Dr. B is out of the country and not available for interview until the week of 10/8/12.

Per telephone interview with K beginning at 12:40 p.m. on 10/9/12, K said that K and #1's son were not aware of Pt. #1's admission to the hospital until on 8/26/12 when K had a message on the answering machine to call the hospital for permission to give Pt. #1 a blood transfusion. According to K Pt. #1's son could not be reached via phone as there was a problem with the phone line, but added that no one from the CBRF or the hospital notified K that Pt. #1 was seen in the ED and admitted to the hospital until 3 days after #1 was admitted. Per K, the hospital had K's home and cell number to notify if needed.

Per telephone interview with Dr. B beginning at 12:05 p.m. on 10/11/12, B verified that B had attempted to reach Pt. #1's son for notification of treatment, but had not attempted to reach K.

Per exit interview beginning at 2:30 p.m. on 10/11/12, Nurse Administrator D, Dr. A, and Associate Administrative Officer C verified that the hospital had 3 telephone numbers listed for K and just the 1 for Pt. #1's son and verified that there was no evidence to support that hospital staff attempted to notify K when #1's Son could not be reached. A, C, and D confirmed that K should have been contacted since #1's Son could not be reached for consent for treatments.

Based on medical record review, facility policy reviews, and family and staff interviews, the facility failed to document pertinent information in 1 of 10 pts. records sampled (Pt. #1) in regard to family notification of treatment and method of transfer upon discharge.

Findings include:

Per review of Pt. #1's medical record beginning on the afternoon of 9/24/12, the following was noted:

Pt. #1 was admitted to the hospital through the E.D. on 8/24/12. A form entitled, Consent for Blood Transfusion states that telephone consent was obtained by Pt. #1's Son/POA at 3:57 p.m. on 8/26/12.

Per facility policy entitled, "Consent for Surgery or Procedure with Universal Precautions" states that for telephone consents, "The conversation should be summarized in the patient's medical record."

There is no documentation in Pt. #1's medical record of the phone conversation regarding the need and consent for blood transfusion.

Per telephone interview with Pt. #1's Daughter K beginning at 12:40 p.m. on 10/9/12, K stated that on 8/26/12 a telephone message was left on K's answering machine to contact the hospital. Per K, it was in regard to a blood transfusion. Per K, K contacted the hospital and spoke with a nurse, but there is not documentation in the nursing notes of this telephone discussion.

Per review of Pt. #1's nursing notes, there is no documentation of how and who transferred Pt. #1 out of bed for transfer to the nursing home upon discharge on 8/31/12.

Per review of physician progress notes from the nursing home that #1 was transferred to, the following was noted: 9/5/12 Dr. B documented that this was an admission review and documented, "Was found to have a left hip intertrochanteric fracture either when she was in the hospital or when she was transferred here."

Per telephone interview with RN E beginning at 9:00 a.m. on 10/3/12, E was not involved in the transfer of Pt. #1 upon discharge, but stated that CNA F and G probably did the transfer of Pt. #1 out of bed and into a wheel chair when discharged on 8/31/12. Per E, E did not notice a deformity of #1's hip when did dressing changes on the morning of 8/31/12 prior to #1's discharge.

Per telephone interview with CNA F beginning at 3:43 p.m. on 10/3/12, F could not recall being involved in transferring #1 out of bed upon the 8/31/12 discharge. Per F, does not think Pt. #1 could bear weight or stand for a transfer.

Per telephone interview with CNA G beginning at 8:30 a.m. on 10/5/12, G was unable to recall who helped G with the transfer of Pt. #1 prior to discharge to the nursing home on 8/31/12. According to G, Pt. #1 was a 2 person transfer as could not bear weight due to sores on heels. G could not recall any left leg deformity of Pt. #1 during #1's hospital stay.

Nurse Administrator D confirmed the above findings during the exit interview beginning at 2:30 p.m. on 10/11/12. D verified that documentation of the transfer upon #1's discharge was pertinent information that should have been included in #1's medical record.