HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure discharge planning staff properly obtained consent on the "Patient Choice List for Discharge Needs" as required per facility policies. This deficient practice was identified in four (4) of ten (10) records reviewed (patients #1, 2, 3 and 4). This failure has the potential to adversely affect all patients' rights to make informed decisions regarding their care.

Findings include:

1. Review of the facility policy titled "Discharge Plan", effective date 11/09/11, revealed the policy states, in part: "If the patient is unable to return home but requires extended home services, such as home health, the social worker, case worker, or other qualified personnel involved in the discharge planning process will provide the patient/designee(s) a list of home health agencies from which to choose...The social worker, case manager, or other qualified personnel will document on a designated choice list which agency the patient/designee(s) has chosen and obtain consent to make the referral to the selected agency. This transaction is evidenced by verbal consent or signature of the patient/designee(s) on the choice list."

2. Review of the facility policy titled "Informed Consent", last revised 9/19/11, revealed the policy states, in part: "Purpose: To insure uniformity and consistency throughout the hospital for obtaining and documenting an informed consent...Scope: Hospital - Wide...Written Consent: The patient/other consenter signs the Consent Form and Hospital personnel may witness the patient's signature on the consent form. If the patient is unable to write her/his name, an X in place of the signature is binding when properly witnessed (two witnesses)...Oral Consent: Oral consent may be accepted only if a patient is physically unable to sign the consent form. This consent is witnessed by two individuals...The reason that the patient is unable to sign the consent form must be indicated on the form...Telephone or FAX Consent: If the patient is unable to consent (minor, mentally incompetent, other) and the person legally responsible for providing consent for the patient is unable to come to the Hospital to sign the consent form, telephone or FAX consent is permissible. The person giving permission will be required to reiterate permission in person as soon as possible...The telephone consent should be witnessed by two individuals (at least one RN) on extension of the same line..."

3. Review of the facility policy titled "Home or Outpatient Infusion Referrals", effective date 7/17/14, revealed the policy states, in part: "If the patient is currently receiving infusion services, then the agency providing the care will be contacted and given the orders for care. The only exception to this would be a patient who voluntarily requests the agency to be changed...All patients not receiving infusion services or those desiring a change will be given a written list of home infusion agencies in their area. The list of agencies is on a form labeled 'Patient Choices for Discharge Needs'...If the patient is disoriented or physically/mentally unable to make a decision then his or her representative or care provider (i.e. personal care home residents), will be contacted and asked for the agency of choice. If the patient or representative is unable to sign the form (i.e. illness, unavailable etc.), the nurse, care manager, or social worker may take a verbal or phone consent and have a witness who must also sign."

4. Review of patient #1's medical record revealed the Patient Choice List for Discharge Needs had "verbal via phone conversation" written in the Patient/Representative signature section of the form. Further review revealed the form was not witnessed by a second person and there was no documentation as to why the patient could not sign the form as required per facility policies.

5. Review of patient #2's medical record revealed the Patient Choice List for Discharge Needs had "per pt" written in the Patient/Representative signature section of the form. Further review revealed the form was not witnessed by a second person and there was no documentation as to why the patient could not sign the form as required per facility policies.

6. Review of patient #3's medical record revealed the Patient Choice List for Discharge Needs had "Verbal - (Medical Power of Attorney name)" written in the Patient/Representative signature section of the form. Further review revealed the form was witnessed by a second person; however, the form was not signed by the Medical Power of Attorney as soon as possible as required per facility policies.

7. Review of patient #4's medical record revealed the Patient Choice List for Discharge Needs had "per pt consent" written in the Patient/Representative signature section of the form. Further review revealed the form was not witnessed by a second person and there was no documentation as to why the patient could not sign the form as required per facility policies.

8. The above findings were reviewed and discussed with the Director of Case Management and Social Services on 1/24/17 at 9:05 a.m. and she concurred with the findings.

9. The above findings were also reviewed and discussed with the Community Chief Executive Officer on 1/24/17 at 10:45 a.m. and he concurred with the findings.