HospitalInspections.org

Based on record review and interview the facility failed to ensure that each patient or patient's representative is informed of the patient's rights in 5 of 10 medical records (Patient #'s 1, 4, 5, 9 & 10) and that "An Important Message from Medicare" was reviewed and signed by patient or patient's representative within 2 days of admission per facility policy in 1 of 10 medical records (Patient #1) in a total universe of 10.

Findings include:

Review of policy titled "Informed Consent/Refusal" revealed "PURPOSE: To provide a process that allows patients to participate fully in the decision of their care and treatment; to provide guidelines for obtaining informed consent; to identify who may provide consent related to the care and treatment of a patient; and to comply with state and federal regulations and accreditation standards related to informed consent processes. E. Who May Give Consent: 2. Incapacitated Adult Patients: a. Guardians. If a patient is deemed to be incompetent by a Court of Law, the patient is then incapable of providing consent and the Court will order a legal guardianship. In such situations, consent will be obtained from the patient's guardians. F. Process for Obtaining Informed Consent: 3. Telephone Consent: In limited situations where the individual with the authority to consent can only be reached by phone, and where the delay in treatment could jeopardize the health of the patient, telephone consent may be obtained. The attending provider must speak to the third party giving authorization for treatment because he or she is in the best position to inform the third party of the risks, benefits, and alternatives of treatment and to answer questions about the patient's condition. A witness must verify with the third party that they are indeed providing informed consent. When telephone consent is received, the following items are noted in the patient's medical record: a. Date and time of the call; b. Name of the person providing consent; c. Relationship to the patient of the person giving consent; d. Signature of the provider and of the witness."

Review of policy titled "Patient Rights and Responsibilities" revealed "I. POLICY: Sacred Heart recognizes the patient's right to make decisions regarding his or her medical care, including the decision to discontinue treatment, to the extent permitted by law and hospital policy. Sacred Heart will endeavor to assist the patient in the exercise of his or her rights (consistent with the law) and will inform the patient of any responsibilities incumbent upon him or her in the exercise of those rights. II. PURPOSE: To provide a statement of patient rights and responsibilities for Sacred Heart Hospital consistent with the philosophy of the Hospital Sisters Health System, the Ethical and Religious Directives for Catholic Health Care Services, the American Hospital Association's Advisory on a Patient's Bill of Rights, and in compliance with Joint Commission standards. GUIDELINES/PROCEDURES: A. The patient is encouraged to be well informed and to participate in treatment decisions, and is supported to communicate openly with physician(s) and other healthcare professionals. B. During the admission process, the patient or the patient's legally authorized guardian is informed and given a copy of the "Patient Rights and Responsibilities" brochure. C. Any hospital staff member or medical staff member who identifies or is made aware of a potential violation of a patient's rights will immediately report it to their immediate supervisor, department director or the house supervisor. The incident or situation will be thoroughly investigated by the appropriate authority in order to ascertain whether a rights violation has occurred and corrective action will be taken."

Review of facility "CONSENT FOR TREATMENT" document revealed "I have been given or offered Sacred Heart Hospital's Patient Rights and Responsibilities brochure which includes information about advanced directives."

Examples of consent to treat:

Review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 4/12/2019 from his/her group home with a urinary tract infection and dehydration. Long standing medical history of Dandy Walker Syndrome (congenital malformation of the brain) was non verbal entire life and had recently been diagnosed with terminal, non-treatable brain cancer. Patient #1 was unable to make decisions or needs known and had a (non related) legal guardian appointed. There was no documented consent for treatment in Patient #1's medical record.

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F stated, "I don't see the consent in the medical record."

Review of Patient # 4's medical record revealed Patient #4 was admitted to the facility on 5/3/2019 and discharged on 5/8/2019 after a cerebral vascular accident (stroke). There was no documented consent for treatment in Patient #4's medical record.

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F stated, "I don't see the consent in the medical record."

Review of Patient #5's medical record revealed Patient #5 was admitted to the facility on 5/27/2019 and discharged on 5/30/2019 after being septic (infection in blood stream) from Escherichia coli (E coli). There was a copy of a consent for treatment in Patient #5's medical record. Under "Signature of Patient" there was written in "verbal per LG" with a date of 5/28/2019. There was no documented legal guardian signature or signature of 2 staff as required with telephone consent being obtained.

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F stated when asked if consent was correctly filled out Chief Nursing Officer F stated, "No, there is no signature at all on it. If the legal guardian consent was obtained over the phone then two staff should have signed."

Review of Patient #9's medical record revealed Patient #9 was admitted to the facility on 3/25/2019 and discharged on 5/9/2019 for altered mental status. There was no documented consent for treatment in Patient #9's medical record.

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F was asked if consent was present in electronic medical record Chief Nursing Officer F stated "I don't see it."

Review of Patient #10's medical record revealed Patient #10 was admitted on 5/10/2019 and discharged on 5/13/2019 for hypoxia and ventilator acquired pneumonia. There was no documented consent for treatment in Patient #4's medical record.

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F was asked if consent was present in electronic medical record Chief Nursing Officer F stated "I don't see it."

Examples of Important Message from Medicare:

Review of facility policy titled "WWD IMPORTANT MESSAGE FROM MEDICARE (IM OR IMM) POLICY" revealed "1. Registration must make every effort to ensure that the beneficiary comprehends the contents of the notice before obtaining the beneficiary's signature. This includes explaining the notice to the beneficiary if necessary and providing an opportunity for the beneficiary to ask questions. Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission, and must obtain the signature of the beneficiary or his/her representative in the EMR (electronic medical record). Initial Notice: Hospital personnel must provide the IM at or near admission but no later than 2 calendar days from the day of admission or at preadmission, but not more than seven (7) calendar days before admission, and obtain the signature and signature date of the patient or representative to indicate receipt of notice. REPRESENTATIVE: A representative is defined broadly to include individuals authorized to act on behalf of the beneficiary; someone acting responsibly on behalf of an incapacitated or incompetent beneficiary; or someone requested by the beneficiary to as his or her agent. Notice Delivery to Beneficiary Representatives: If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary's rights as a hospital patient, including the right to appeal a discharge decision. The delivery of the initial IM or follow up IM notice should be in person. If the representative is not available for in person delivery, the notice may be made by telephone, but not by voicemail, with a copy of the notice mailed or faxed that same day. If the hospital is unable to reach the representative by telephone, the notice may be sent by certified mail/return receipt. The date of signature or refusal becomes the date of notification. ADMISSION PROCEDURE: 8. If the initial IM notice cannot be given at the point of admission for any reason, the notice will be issued to the patient and/or the patient's representative within 2 business days of admission by the Case Manager, Social work, Liaison or Registration. Medical Record Documentation: Hospitals will place a copy of the initial notice in the patient's medical record. Hospitals must document timely delivery of the follow-up copy of the IM in the patient records. The hospital should also document any attempted contact with beneficiary representatives, including telephone calls, messages and subsequent certified mail."

Review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 4/12/2019 from his/her group home with a urinary tract infection and dehydration. Long standing medical history of Dandy Walker Syndrome (congenital malformation of the brain) was non verbal entire life and had recently been diagnosed with terminal, non treatable brain cancer. Patient #1 was unable to make needs known or decisions and had a (non familial) legal guardian appointed. The "Important Message from Medicare" was documented as legal guardian signature received by staff on 4/15/2019 (3 days after admission).

Interview on 6/20/209 at 2:00 PM with Neurological Registered Nurse Manager H and Chief Nursing Officer F, Chief Nursing Officer F was asked if the Important Message from Medicare was completed per policy, Chief Nursing Officer F stated, "No, it was completed on third day after admission and it should have been completed on day two."