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Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient's representative) was informed of their rights, in advance of furnishing or discontinuing patient care whenever possible. This deficient practice was evidenced by:
1) failing to ensure the notice of rights was met by the failure to notify patients (or their representatives) of unanticipated outcomes impacting patient care in 1 (#1) of 1 (#1) patients reviewed with unanticipated outcomes;
2) failing to have evidence that 2 (#2 and #3) of 3 (#1-#3) patients reviewed were informed of their rights.
Findings:

1) Failing to ensure the notice of rights was met by the failure to notify patients (or their representatives) of unanticipated outcomes impacting patient care in 1 (#1) of 1 (#1) patients reviewed with unanticipated outcomes.
Review of hospital document approved on July 2023, titled Performance Improvement and Patient Safety Plan 2023, revealed, in part: XVIII. Disclosure of Unanticipated Outcomes, in part: A. Patients and when appropriate, families are informed about the outcomes of care, including unanticipated outcomes, or when the outcomes differ significantly from the anticipated outcome. B. The patient/family will be informed of the error and the data know to date, the actual and/or potential impact of the error on the patient, and the subsequent care that should be provided. C. It is the responsibility of the attending physician or his designee to inform or ensure disclosure to the patient and/or family. D. Procedures used in communicating with families the organization's role and commitment to meet the patient's right to have unexpected outcomes or adverse events explained to them in an appropriate, timely fashion include, in part: 1. Patient's rights statements.

Review of hospital document dated 09/30/2023 at 6:10 a.m., titled Hospital Abuse/Neglect Initial Report revealed, in part: Patient #1 with multiple medical comorbidities that presented to facility with dark diarrhea found to be anemic with supratherapeutic INR. Also, in acute on chronic hypoxic and hypercapnic respiratory failure with a large right sided pleural effusion. Patient was on a orogastric tube (OG) and intubated. On 9/30/2023 at around 6:20 a.m. S4RN went in to give medication to patient while S3RT was at bedside drawing arterial blood gas. It was noted that patient had ants coming from mouth, ears and nose and coming from OG tube and surrounding endotracheal tube (ETT). Patient was on tube feeding. The tube feeds were stopped, OG tube immediately discontinued, complete bed bath and linen change done; ETT holder changed out per Respiratory Therapist; mouth and nose cleaned out with swabs and water thoroughly until no ants were seen. S4RN stated that she had been in room all night and there were no ants to be seen in room or on patient during shift. Attending notified and called to bedside to assess, House Supervisor and Charge nurse called to bedside. Prior MD was contacted to ask if he had seen any ants on patients during his last round at around 5:30 a.m. Per MD no ants present on last end of shift rounding or during night that was noticed by provider. The patient was immediately moved to another room. Further review of self-report failed to reveal family was notified of events.

Review of Patient #1's electronic medical record navigated by S12QM, revealed the next of kin included her husband, son and daughter. Further review failed to reveal evidence that a family member was notified of events that occurred on the morning of 09/30/2023.

In an interview on 10/05/2023 at 1:15 p.m., S12QM confirmed Patient #1's medical record failed to reveal evidence that the hospital communicated with Patient #1's family explaining to them the unexpected outcomes/adverse events that occurred on 09/30/2023 in an appropriate and timely fashion.

In an interview on 10/05/2023 at 2:03 p.m., S1RN stated they notified risk management about the events that occurred on 09/30/2023 and they said they would handle notifying the family.

2) Failing to have documented evidence that 2 (#2 and #3) of 3 (#1-#3) patients reviewed were informed of their rights
Review of hospital policy #PAS 0015, titled "Patient Rights and Responsibilities", revealed, in part: Policy, in part: It is the practice of LCMC to inform each patient or when appropriate, the patient's representative as allowed by law, of the patient's rights. Procedure, in part: Once a patient has been registered, the patient receives a copy of the Patient Rights and Responsibilities and signs an acknowledgement of receipt of the Patient Rights and Responsibilities information.

Patient #2
Review of Patient #2's electronic medical record navigated by S12QM, revealed an admit date of 09/15/2023 with discharge due to expiration on 09/25/2023. Further review failed to reveal evidence that Patient #2 or patient representative was informed of their rights, in advance of furnishing or discontinuing patient care.

In an interview on 10/05/2023 at 12:20 p.m., S12QM confirmed that there was no evidence that Patient #2 or patient representative was informed of their rights, in advance of furnishing or discontinuing patient care.

Patient #3
Review of Patient #3's electronic medical record navigated by S12QM, revealed an admit date of 09/26/2023 with discharge on 09/30/2023. Further review failed to reveal evidence that Patient #3 or patient representative was informed of their rights, in advance of furnishing or discontinuing patient care.

In an interview on 10/05/2023 at 12:45 p.m., S12QM confirmed that there was no evidence that Patient #3 or patient representative was informed of their rights, in advance of furnishing or discontinuing patient care.

Based on record review and interview, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by failing to have documented evidence of a signed informed consent for treatment for 3 (#1-#3) of 3 (#1-#3) patients reviewed for signed written informed consent for treatment.
Findings:

Review of hospital policy #PAS 0015, titled "Patient Rights and Responsibilities", revealed, in part: Procedure, in part: Your rights, in part: You or your representative (as allowed by state law) have the right to give written informed consent before any non-emergency procedure begins. You, your family, and friends with your permission, have the right to participate in decisions about your care...

Review of hospital policy #CS-1280, revised 07/27/2021, titled "Initial Patient Assessment and Reassessment" revealed, in part: Policy, in part: V. Interdisciplinary Variables, in part: B. the following variables influence and direct the process of patient assessment and reassessment for all disciplines, in part: 1. Desire/consent for treatment.

Review of Patient #1's electronic medical record navigated by S12QM, revealed DOB: 07/03/1954; Admit: 09/26/2023; Discharge: Plan for terminal extubation 10/06/2023. Further review of Patient #1's medical record failed to reveal a signed consent for treatment.

Review of Patient #2's electronic medical record navigated by S12QM, revealed DOB: 07/05/2001; Admit: 09/15/202; Discharge: Expired 09/25/2023. Further review of Patient #2's medical record failed to reveal a signed consent for treatment.

Review of Patient #3's electronic medical record navigated by S12QM, revealed a 62 year-old male. Admit: 09/26/202; Discharge: 09/30/2023 Further review of Patient #3's medical record failed to reveal a signed consent for treatment.

In an interview on 10/05/2023 at 2:19 p.m., S12QM confirmed that the medical records of Patient #1, Patient #2, and Patient #3 failed to reveal signed consents for treatment. S12QM stated that every patient should have a signed consent for treatment on admission.