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Based on observation, interview, and record review, the facility failed to provide the standardized notice, titled "Important Message from Medicare (IM - describes Medicare beneficiaries' rights to receive necessary care, their financial responsibility, rights to appeal to discharge, and how to appeal a hospital discharge)" within two days of admission to three of 23 sampled patients with Medicare benefits (Patient 4, 17, and 22) and/or their legal representatives when:

1. For Patient 4, the IM notice was provided three days after admission;

2. For Patient 22, the IM notice was provided eight days after admission; and

3. For Patient 17, the IM notice was provided three days after admission.

This failure had the potential for Medicare beneficiary patients and/or their legal representatives to not understand their rights as a hospital inpatient which could result to their inability to effectively make decisions regarding their treatment or care.

Findings:

1. Review of Patient 4's admission records indicated Patient 4 was admitted on 1/29/25 at 6:04 PM.

During an interview on 2/5/25 at 9:34 AM, Case Management Supervisor (CMS) 1 stated the IM is given to patients admitted to the hospital with Medicare benefits "within the first two days" of admission "to ensure patients are aware of appeal rights, in case they disagree with the decision for discharge."

During a concurrent interview and record review on 2/5/25 at 11:35 AM with Patient Advocate (PA) 1, Patient 4's IM, dated 2/1/25, with no time recorded, indicated on the signature line, "telephone consent." The IM did not indicate who provided the telephone consent. PA 1 stated, "Sometimes if unable to go to the patient, we call to get their consent." PA 1 verified Patient 4's IM was given three days after admission, adding it should have been provided "by the 31st (referring to 1/31/25)."

2. Review of Patient 22's admission records indicated Patient 22 was admitted on 12/16/24 at 1:15 AM.

During a concurrent interview and record review on 2/5/25 at 11:56 AM with PA 1, Patient 22's IM was reviewed. Patient 22's IM, dated 12/24/24 at 10:45 AM, indicated on the signature line, "verbal given by (Patient 22's family member)." PA 1 verified the IM was not given until eight days after admission.




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3. In an interview on 2/5/25, at 11:13 AM, with PA 1, PA 1 stated, when patients checked in the Registration on admission, the staff would have the patients sign the letter called "Important Message from Medicare" within "48 hours" of admission. The PA 1 stated, the staff would go over the patient's rights and their rights to "appeal" on discharge and if patient was unable to sign, the staff would reach out to the family or the person assigned as DPOA (Durable Power of Attorney, a legal document that allows someone to manage your finances and property if you are unable to do so).

Review of the History and Physical (H&P), dated 1/20/25 at 5:43 PM indicated, Patient 17 presented with the chief complaint of abdominal pain and the Physical Examination section of the H & P indicated, patient was awake, alert and oriented x 3, admitted for "Bowel perforation (a hole in the wall of the small or large intestine) on 1/20/25.

In concurrent record review and interview on 2/5/25, at 11:15 AM, with PA 1, the facility's document titled, "Important Message from Medicare," was reviewed. PA 1 stated, Patient 1 was admitted on 1/20/25, the IM, dated 1/23/25 at 2:26 PM was not signed by the patient, instead there was a written word "Verbal" on the line that asked for "Signature of patient or representative", it was "three (3) days" after admission, it should be signed by the patient within 48 hours of admission.

Review of the facility's Policy and Procedure titled, "Registration Accountability Policy" with the Effective date of 6/4/24 indicated, "Procedure: ... C. In addition ... 1. ... 5. Upon inpatient admission of a Medicare beneficiary patient, patient must be provided a copy of Notice called "An Important Message from Medicare about Your Rights". Staff are responsible for obtaining patient's or patient representative's signature to acknowledge receipt of notification upon admission. ... ."

Based on interview and record review the facility failed to ensure patients participated in the development of their Plan of Care (a written plan of care outlining individual patient's mental and physical needs for recovery) for one of 30 sampled patients (Patient 27) when, the Care Plan for Pain was not developed to address the pain issue.
This deficient practice had the potential to violate patient's right to participate in the development, implementation and re-evaluation of all aspects of the plan of care related to her pain.


Findings:


Review of undated "ADT (Admission, Discharge, Transfer) Event" indicated, Patient 27 was admitted to the facility on 2/2/25 at 9:35 PM.

Review of the admission History and Physical (H&P) dated 2/2/25 indicated, Patient 1 was brought in by the ambulance from home to the Emergency Room (ER, area in the hospital staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries that require life-saving interventions) with the complaint of "worsening abdominal pain", and was prescribed OxyContin (strong pain medication) following a biopsy (a procedure to remove a piece of tissue or a sample of cells from the body) two days ago in another hospital. The Assessment/ Plan section of the H&P indicated, the diagnoses that included pancreatic mass (lump in the pancreas that can be cancerous or noncancerous) status post biopsy, "now with abdominal pain", uncontrolled diabetes mellitus (high blood sugar), and chronic pain syndrome.

In a concurrent record review and interview on 2/5/25, at 2:14 PM, with the Nurse Manager (NM 1) in the presence of the Director of Risk Management (DRM), the Pain Assessment Flowsheet dated 2/2/25, was reviewed. The Pain Assessment Flowsheet indicated, on 2/2/25 at 9:42 PM, the Numeric Pain Scale (NPS, is a tool for the self-reporting of pain level for use in cognitively functioning verbal adults, as define in the facility policy. The NPS of 0/10 means no pain and the NPS of 10/10 is severe pain) was 2/10 on 2/2/25 at 9:42 PM and the NPS was 8/10 on 2/2/25 at 11:22 PM. Further review of the Pain Assessment Flowsheet indicated the following: the type of pain was "acute pain", pain location was "abdomen", pain description was "aching", pain frequency was "constant", and the pain onset was "ongoing". The NM 1 stated, patient had pancreatic mass with recent biopsy and was given pain medication in the ER prior to the admission in the Nursing Unit. The NPS on admission was assessed as 2/10 at 9:42 PM, the NPS went up to 8/10 at 11:22 PM, and Dilaudid (opioid medication that treats severe pain) was administered to the patient for pain control.

Record review of the Medication Administration Record (MAR) dated 2/2/25 indicated, "Hydromorphone (Dilaudid) Inj (injectable) 0.25 mg (milligrams)" was administered on 2/2/25 at 11:22 PM.

In a concurrent record review and interview on 2/5/25, at 2:17 PM, with the NM 1 in the presence of the DRM, NM 1 searched the list of Care Plans and stated, "I don't see" the Care Plan for pain. The NM 1 stated, the staff should develop Care Plan for pain because patient came in with pancreatic mass and ongoing pain, it's "patient's rights" and the patient has the "right to be humanly be free from pain."

Review of the facility's Policy and Procedure (P&P) titled, Pain Management Procedure, with the last revised date of 2/22/24 indicated, "Policy: It is the policy ... to respect the patient's right to pain management ... Procedure, ... B. Pain Management Plan, 1. The patient experiencing pain should have a pain treatment plan developed ... 3. The pain management plan maybe documented in the care plan and/or interdisciplinary. C. Pain Intervention, 1. Pain is treated in accordance with the plan based on an assessment. ... ."

Review of the facility's P&P titled "Policy on Patient Rights" with the last effective date of 4/20/23 indicated, "Procedure: ... Patient Rights: ... 9. Appropriate assessment and management of your pain, ... and to participate in pain management decisions. ... ."

Based on interviews and record reviews the facility failed to ensure patients were provided information to formulate their Advance Directive (AD, an individual's health care instruction or power-of-attorney for health care, as define in the facility policy) upon admission for two patients (Patients 15 and 27) when:
1. For Patient 15, there was no documented evidence the copy of the Advance Directive (AD) was placed in the medical record.
2. For Patient 27, the AD section on the Flowsheet was not completed.
These deficient practices resulted in the potential for patient's inability to exercise their rights to make decisions concerning their medical care including the right to accept or refuse medical care.


Findings:


1. Review of the undated "ADT (Admission Discharge Transfer) Event" indicated, Patient 15 was admitted to the facility on 1/29/25.

In an interview on 2/5/25, at 1:42 PM, with the Nurse Manager (NM 1) in the presence of the Director of Risk Management (DRM), NM 1 explained, the staff would ask whether the patient has Advance Directive (AD) or not on admission and they would mark the question with a "yes" or "no" answer on the Flowsheet. The NM 1 stated, if the patient has a signed Advance Health Care Directives (AHCD) or signed "POLST (stands for Physician Orders for Life-Sustaining Treatment, it is a medical form that documents a patient's wishes regarding end-of-life care)" in the past, it would be scanned and placed in the medical record.

In a concurrent record review and interview on 2/5/25, at 1:45 PM, with the NM 1 in the presence of the DRM, the "Advance Directive (Medical Healthcare)" section of the Flowsheet dated 1/29/25 for Patient 15, was reviewed. The AD section of the Flowsheet indicated, the box for the AD was marked "yes", the box that stated, AD information given was marked, "yes", and the box that stated, patient request assistance was marked, "no". The NM 1 searched the entire Electronic Health Record (EHR) and stated, "I don't see" the AD on file and did not see a signed copy of POLST on file.


2. Review of the undated ADT Event indicated, Patient 27 was admitted to the facility on 2/2/25 at 9:35 PM.

In a concurrent record review and interview on 2/5/25, at 1:57 PM with the NM 1 in the presence of the DRM, the Flowsheet on Advance Directive dated 2/2/25, was reviewed. The NM 1 searched the "Advance Directives, Medical Healthcare" section of the Flowsheet and stated, "I can't find the Advance Directives." The NM 1 stated, the Licensed Nurse (LN) should be completing the information that was asked on the AD such as: Does patient has AD on file? Did the patient request assistance with the AD? Was AD information given? The NM 1 stated, the Flowsheet on AD did not have an answer to the questions asked, it was not completed by the LN on admission. After searching the entire EHR, the NM verified, there was no documentation the staff spoke to patient /or surrogate to determine whether the patient has AD or not and there was no signed AD Health Care Directive or POLST on file. When asked why AD was important to verify when patients were admitted, the NM 1 stated, it was important to be able to follow patient's wishes when providing medical care.

Review of the facility's Policy and Procedure (P&P) titled, Advance Healthcare Directive Policy, with the last revised date of 8/2/23 indicated, "Policy: ... When a patient has an advance directive the staff will ask for and make an effort to secure a copy to be included in the patient's medical record so that the patient's wishes are known and the patient's agent is identified. ... Procedure: A. Department Responsibilities: Inpatient Setting, 1. The nurse/social worker will fill out the Advance Directive portion of the Electronic Health Record (EHR). ... ."

Review of the facility's P&P titled "Patient Rights", with the effective date of 4/20/23 indicated, "Purpose: The purpose of this policy is to provide guidance and mechanism by which Patient Rights are protected and exercised ... Procedure: ... Patient Rights: ... 10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment ... ."

Based on interviews and record review the facility failed to ensure the use of restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely and is not a normal part of treatment, as per facility policy) was discontinued at the earliest possible time for one of 30 sampled patients (Patient 1) when, the bilateral (means both) mittens (a type of restraint, which are soft, padded gloves worn on one or both hands to prevent patients from harming themselves or others, or from disrupting medical treatment), applied for "pulling lines/tubes", were not discontinued when the patient developed altered level of consciousness (change in the person's level of alertness and arousal), became "unresponsive (no reaction to stimulation, such as touch, sound, or activity)" and "obtunded (difficult to arouse)" following a Rapid Response Team (RRT, a group of healthcare professionals, typically including nurse(s) and a physician, who are called to a patient's bedside when their condition is rapidly deteriorating) interventions on 1/24/25 at 12:18 PM. The bilateral mittens were re-started/re-applied on 1/24/25 at 3:00 PM and continued until 1/25/25 at 5:00 AM. The patient was placed on "Comfort Care (type of medical care that focuses on relieving pain and other symptoms for patients who are near the end of their life)" and passed away on 1/25/25 at 12:52 PM.

This deficient practice had resulted in the potential to negatively affect the patient's physical and emotional well-being as well as the patient's dignity and safety.


Findings:


In a concurrent record review and interview on 1/30/25, at 1:20 PM, with the Nurse Manager (NM 1) in the presence of the Clinical Effectiveness Consultant (CEC 1), the undated "ADT (Admission Discharge Transfer) Event" was reviewed. The NM 1 stated, Patient 1 was admitted on 1/1/25 at 6:47 PM.

Review of the Admission History & Physical (H &P), dated 1/1/25 indicated, patient presented with the chief complaint of "slurred speech" and right sided weakness. The Assessment/Plan section of the H &P indicated, the diagnoses that included right sided hemiparesis (weakness or an inability to move on the right side of the body), dysarthria (speech disorder), and dysphagia (swallowing difficulties) presumed secondary to "CVA (cerebrovascular accident means stroke)", hypertension (abnormally high blood pressure), and carotid artery disease (arteries in the neck become blocked or narrowed).

In a concurrent record review and interview on 1/30/25, at 2:01 PM, the NM 1 and 2, in the presence of the CEC 1, NM 1 stated, restraints were used due to non-violent behavior, four types of restraints were used on the patient, and discontinued at different times such as: bilateral mittens and bilateral soft wrist restraint (medical device where soft, fabric-like restraints are applied to both wrists of a patient, limiting their arm movement due to "pulling lines/tube" and a "vest" (a sleeveless garment that's placed over a patient's clothing to prevent them from falling or climbing out of bed or a chair) and raising the four (4) bed side rails up, due to patient "climbing out of the bed".

In a concurrent record review and interview on 2/5/25, at 10:05 AM, with the NM 1 and 2 in the presence of the Director of Risk Management (DRM) and the Quality Specialist (QS 1), the Flowsheet for Restraints dated 1/24/25 and 1/25/25, were reviewed. The Flow sheet dated 1/24/25 at 3:00 PM, indicated, Restraint Type: Mitts, Bilateral ... Start, ... Continued ... Restraint order Before Application: yes, ... Restraint Monitoring Q (every) 2 (two) Hours, Visual Check: patient asleep, ... ." The NM 2 stated, on 1/24/25 at 3:00 PM, the bilateral mittens were re-started and continued until 1/25/25.

Review of the Physician's Order, dated 1/24/25 at 3:12 PM indicated, "Type of restraint: Mitts (mittens) Bilateral, Reason(s) for restraint: pulling lines, pulling tubes".

In a concurrent record review and interview on 2/5/25, at 1:32 PM, with the NM 1 and 2 in the presence of the DRM and the QS 1, the Rapid Response Team (RRT) Documentation dated 1/24/25, was reviewed. The RRT Documentation dated 1/24/25 at 12:18 PM indicated, "RRT was called for AMS (altered mental status, means change in mental functioning) ... Assessment: ... unresponsive despite painful stimuli ... patient con't (continued) to be unresponsive. ... ." The NM 2 stated, Ativan (prescription medication that produces calming effect) IV (intravenously) was administered prior to the RRT being called on 1/24/25 at 12:18 PM and the RRT was called due to altered mental status and "unresponsive."

Review of the Medication Administration Record (MAR) dated 1/24/25 indicated, four (4) milligrams of Ativan (also known as Lorazepam) was administered intravenously at 11:59 AM on 1/24/25.

In a concurrent record review and an interview on 2/5/25, at 1:38 PM, with the NM 1 and 2, in the presence of the DRM and the QS 1, the RRT Documentation dated 1/24/25 at 4:50 PM and 1/25/25 at 3:15 AM were reviewed. The RRT Documentation dated 1/24/25 at 4:50 PM indicated, "RRT was called for prolonged ALOC (Altered Loss of Consciousness), obtundation (dulled or blunted sensitivity). Assessment: flexion (bending an arm or leg) to deep painful stimuli in BLE (bilateral lower extremity, means both legs), nothing in the upper extremity (both arms). ... ." The NM 2 stated, another RRT was called at 4:50 PM due to "prolonged altered mental status and "obtundation." Review of the RRT Documentation dated 1/25/25 at 3:15 AM indicated, "RRT called for altered level of consciousness and increase o2 (oxygen) requirement ... Assessment: Pt (Patient) obtunded ... not responding to pain or vigorous stimuli. ... ." The NM 2 stated, another RRT was called on 1/25/25 at 3:15 AM, due to altered loss of consciousness and prolonged oxygen requirement, from oxygen use at 2 liters (L)/ min (per minute) using nasal cannula to 15 L/min using a non-rebreather mask (NRB, a breathing device use to provide high concentrations of oxygen) and the patient was "intubated (tube is inserted through the mouth or nose into the trachea (windpipe), a form of life support)". The NM 2 further stated, the patient was transferred to the Intensive Care Unit (ICU, area in the hospital that provides specialized care for patients who are critically ill or injured) on 1/25/25 at 4:10 AM, was placed on Comfort Care, and passed away on 1/25/25 at 12:52 PM. When asked when the bilateral mittens should had been discontinued, the NM 1 stated, there was a change in the level of consciousness on 1/24/25 at 12:18 PM, the bilateral mittens should had been discontinued and not re-started at 3:00 PM on 1/24/25. The NM 2 stated, the bilateral mittens were discontinued on 1/25/25 at 5:00 AM.

Review of the Discharge Summary, dated 1/25/25 indicated, the Discharge Diagnoses that included, left temporal (side of the skull behind the ears) brain tumor due to glioblastoma (brain cancer), right sided weakness and expressive aphasia (difficulty in producing speech or forming words).

Review of the facility's Policy and Procedure titled, "Restraint Use and Management" with the last revised date of 8/18/22 indicated, "Procedure: (non-Violent and Violent). ... B. Orders for Restraints 1. Non-violent (Non-Self-Destructive) Restraint Orders: ... c. Implementation of a time-limited order for restraint does not require application of the restraint for the entire period. If the patient demonstrates reduction in the activity/behavior that led to the restraint, restraint or seclusion must be discontinued at the earliest possible time. Regardless of the length of time identified in the order. ... ."