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Based on record review and interview the facility staff failed to ensure that the patient or the patient's representative was informed of the patient rights on admission in 8 of 10 medical records reviewed (Patients #1, 2, 3, 4, 5, 6, 8, 10); failed to inform patients of their Medicare discharge rights upon admission in 4 of 5 Medicare-eligible patients (Patients #3, 8, 9, 10); and failed to inform patients of their Medicare discharge rights at discharge in 3 of 5 Medicare- eligible patients (Patients #3, 9, 10) out of a total universe of 10 medical records reviewed.

Findings:

Review of facility policy PR-033-16 "General Consent to Treat" last reviewed 11/7/2016 revealed under "Purpose To inform patients of their rights and responsibilities as a patient at Beaver Dam Community Hospitals, Inc. ("BDCH") and to comply with Conditions of Medicare Payment, Medicare Conditions of Participation, and state laws and regulations." "Policy B. The "Hospital Services Agreement" form serves as validation of notification and consent for a variety of regulatory requirement, therefore, a signature from all patients (not only Medicare beneficiaries) registered for BDCH hospital services, including all inpatient, outpatient and recurring services, will be obtained in accordance with this policy and procedure." "D. 2. Inpatient Hospital Services and Patients Admitted as "Observation". A patient's signature, including date and time, on the "Hospital Services Agreement" form for inpatient admissions and "Observation" status services must be obtained at the time of registration for each admission..." "Procedure B. IF an outpatient/observation admission is converted to an inpatient admission, the "Hospital Services Agreement" must be obtained again at the time the patient is admitted as an inpatient."

Patient #1
Review of Patient #1's medical record on 12/17/2020 revealed admission on 10/20/2020 for COVID-related pneumonia. Review of the "Treatment Consent" revealed a "verbal consent" with Patient #1's last name missing and no time on the form. This was confirmed per interview with Director E on 12/17/2020 at 4:11 PM.

Patient #2
Review of Patient #2's medical record on 12/17/2020 revealed admission on 11/06/2020 for COVID-19. Review of the "Treatment Consent" revealed a "verbal consent" with no date or time on the form. This was confirmed per interview with Director E on 12/17/2020 at 4:11 PM.

Patient #3
Review of Patient #3's medical record on 12/17/2020 revealed admission on 10/17/2020 for COVID-19. Review of the "Treatment Consent" revealed a "verbal consent" with no time on the form. There was no Important Message from Medicare (IMM) form in the record. Patient #3 was discharged on 11/14/2020. There was no second notice prior to discharge found in the medical record. This was confirmed per interview with Director E on 12/17/2020 at 4:11 PM.

Patient #4
Review of Patient #4's medical record on 12/17/2020 revealed admission on 11/26/2020 for bilateral pulmonary embolus (blood clots in the lung) and pneumonia. Review of the "Treatment Consent" revealed a "telephone consent" with no date or time on the form. This was confirmed per interview with RN J on 12/17/2020 at 12:55 PM.

Patient #5
Review of Patient #5's medical record on 12/17/2020 revealed an admission on 12/13/2020 for shortness of breath. Review of the "Treatment Consent" revealed a "verbal consent" with no date or time on the form. This was confirmed per interview with RN J on 12/17/2020 at 1:20 PM.

Patient #6
Review of Patient #6's medical record on 12/17/2020 revealed an admission on 10/16/2020 for Covid pneumonia. Review of the "Treatment Consent" revealed a "telephone consent" with no time or patients last name on the form. This was confirmed per interview with RN J on 12/17/2020 at 1:55 PM.

Patient #8
Review of Patient #8's medical record on 12/17/2020 revealed a current inpatient with admission on 12/5/2020 for shortness of breath. Review of the "Treatment Consent" revealed a signature indicated as "wife" with no time or witness signature on the form. This was confirmed per interview with RN J on 12/17/2020 at 3:35 PM. There was no Important Message from Medicare (IMM) form in the record of this 82 year old. This was confirmed per interview with Manager H on 12/17/2020 at 4:55 PM.

Patient #9
Review of Patient #10's medical record on 12/17/2020 revealed an admission for dementia and sepsis (infection) on 11/17/2020 and a discharge on 11/24/2020. The record revealed an activated Durable Power of Attorney. Review of the "Treatment Consent" revealed a "verbal consent" from the non-decisional patient with no time on the form. This was confirmed per interview with RN J on 12/17/2020 at 2:55 PM. The medical record record revealed an Important Message from Medicare form dated 11/18/2020. There was no second notice prior to discharge.

Patient #10
Review of Patient #10's medical record on 12/17/2020 revealed an admission to an observation bed status on 11/18/2020 for weakness and confusion. There was no "Treatment Consent" in the medical record. The record revealed the patient was changed to an inpatient status on 11/22/2020. There was no Important Message from Medicare form in the record when the status changed to inpatient or a second notice prior to discharge. This was confirmed per interview with RN J on 12/17/2020 at 3:30 PM.

In interview with Case Manager Supervisor Q on 12/17/2020 at 3:30 PM, when asked about the missing IMM initial and second notices Q stated, "We must have missed that one (Patient #8) but I can tell you that we have never gotten 2 IMM's. I have worked here for 1 1/2 years and I have never given a notice prior to discharge." When asked about the consent obtained from a patient with dementia, Case Manager Supervisor Q replied, "We aren't going into patient's rooms because of Covid but we probably shouldn't have gotten consent from her."

During an interview with Director E on 12/17/2020 at 4:48 PM regarding Patient #3's IMM forms, E stated, "No, we could not find a Medicare form for that patient. It said in the chart that one was given, but we didn't find a copy."

Based on record review and interview, facility staff failed to inform patients' support person of a change in condition, per faciilty policy, for 1 of 10 inpatients (Patient #1) out of a total universe of 10 medical records reviewed.

Findings include:

Review of facility policy #PR-012-17 titled, "Patient Rights," last approved 06/19/2018 revealed, "...B. All patients and their support person/responsible person being admitted to an inpatient...department...have the right to the following...3. Will be well-informed about their illness: obtain from healthcare provider relevant, current, and understandable information concerning diagnosis, treatment, and prognosis, except when treatment is urgent discuss and request information related to specific procedures and/or treatment, the risk involved, length of recuperation and the medically reasonable alternatives and their accompanying risks and benefits...9. Will be involved in making decisions about their plan of care prior to and during the course of treatment...23. Be informed about outcomes of care, treatment and services, including unanticipated outcomes..."

Patient #1 was admitted to the facility on 10/20/2020 for COVID-related pneumonia.

On 11/08/2020, medical record review revealed Patient #1 became increasingly agitated and confused throughout the day, and escalated to a point where police were notified and Patient #1 was given sedation medications.

On 11/08/2020 at 6:00 PM, "Neurological" assessment revealed, "Patient was very agitated and wanted to leave the hospital. hospitalist (sic) was notified and stated that [#1] needed to walk out if [he/she] was going to go home. Patient was unable to do so, so we were given new orders to give haldol (a medication to treat psychosis or agitation) q10min (every 10 minutes) until patient was sedated. patient (sic) was also hypoglycemic (low blood sugar) so protocol was started for that as well."

On 11/08/2020 at 6:49 PM, "Interval Note" revealed, "Called by nurse who states that the patient continues to be belligerent despite haldol 5mg IV (intravenous) q 5 minutes as ordered verbally by [Hospitalist O]. Patient has reportedly received 3 of such doses. Have been informed that our security personnel is actually the maintenance man this evening. [City] police have been alerted and will be responding..."

On 11/08/2020 at 7:30 PM, "Neurological" assessment revealed, "Patient was very agitated and aggressive towards staff...wanted to go home to be with [spouse]...Hospitalist was notified and present at this time...Haldol was given at 1825 (6:25 PM), 1835 (6:35 PM), and 1845 (6:45 PM). Patient was finally calmed down and asleep. [He/She] is safe and stable and has a 1:1 (1 to 1) sitter to make sure that [he/she] stays safe and doesn't try to get out of bed. Hospitalist was present the entire time."

There was no evidence that Patient #1's spouse was notified of these activities or updated on Patient #1's escalation in behavior.

During an interview with Manager H on 12/17/2020 at 3:29 PM, when asked about the circumstances surrounding Patient #1 on 11/08/2020, H stated, "[#1] became more aggressive, and security - no one was able to calm [him/her] down. The police showed up - they were just here for presence, they didn't do anything. The following Monday at around 7:30 AM, the [spouse] called and was very upset that [he/she] wasn't notified, especially because [he/she] was called Friday night to come and sit with the patient. I went and spoke with the patient for a while and reassured [him/her] that [he/she] wasn't in any type of trouble, that there is such a thing as hospital psychosis." When asked if staff would be expected to notify family of a condition change such as Patient #1 on 11/08/2020, H stated, "Maybe not right away, when everything was going on. But I would have expected that yes, we should have contacted [#1's spouse]."

Based on record review and interview, facility staff failed to implement a process to ensure patients' home medications were reviewed for necessity and renewed or cancelled across all levels of care for 1 of 10 inpatients (Patient #1) with home medications out of a total universe of 10 medical records reviewed.

Findings include:

Review of facility policy #PC-313-19 titled, "Medication Reconciliation," last approved 02/11/2019 revealed, "...Purpose: The appropriate continuation of medication therapy after transfer of care (at all levels) has been identified nationally as a significant patient safety concern...Policy: Medication reconciliation is intended to maintain continuity of care for patients with regard to medication use. An accurate list of each patient's current medications including name, dosage, frequency and route will be compiled and reconciled with the practitioner's admission order(s)...Discrepancies will be brought to the attention of the prescriber and any resulting changes will be documented. Responsibility for this process will be multidisciplinary and require input from nursing and/or pharmacy and from medical staff...Procedure: 1. Inpatient Admission..a. When any patient is received to a...inpatient unit, the nurse, a pharmacist, or a pharmacy technician will obtain a medication history as part of the admission assessment...The home medication list must be saved and verified within 24 hours of admission. Staff will then notify the ordering practitioner to complete the admission medication reconciliation...c. The home medication list will be reviewed by a pharmacist. All discrepancies will be followed up with the practitioner. d. Upon transfer to different levels of care (to and from Surgery, to and from PACU, etc.) previous medications are discontinued...4. In cases where a patient's previous medication would obviously be contraindicated by the patient's current medical condition, it is not necessary for pharmacists to contact the prescriber to reconcile this discrepancy. 5. During the hospital stay the electronic M.A.R. (medication administration record) will serve as the current medication list..."

Patient #1 was admitted to the hospital on 10/20/2020 for COVID-related pneumonia. Patient #1's past medical history included chronic depression, hypertension (high blood pressure), osteoarthritis, Type 2 diabetes, and obesity.

The "Medication Reconciliation Order Report" was completed on 10/20/2020 at 4:03 PM. The report revealed, "...Antidepressants...Citalopram 40 milligram PO (by mouth) daily...Reason for Taking...depression...Continue..."

Review of medication orders in Patient #1's medical record revealed Patient #1's home anti-depressant medication, Citalopram, was ordered to be given daily, starting on 10/20/2020 at 5:00 PM.

Review of the "Medication Administration Record (MAR)" revealed that Patient #1 received the Citalopram daily, as ordered, from 10/20/2020 through 10/24/2020.

On 10/24/2020, Patient #1 was transferred to the Intensive Care Unit (ICU), intubated (breathing tube placed), and sedated.

Further review of the MAR revealed that on 10/25/2020, the Citalopram was not given due to "patient condition." Patient #1 did receive the Citalopram daily, as ordered, via an orogastric (a feeding tube inserted in the mouth, leading to the stomach) tube, from 10/26/2020 through 10/31/2020.

Review of the medication orders revealed on 10/31/2020, the Citalopram was discontinued. There was no reason for the discontinuation documented.

Patient #1 was extubated in the ICU on 11/02/2020, and transferred back to the general medical/surgical inpatient unit on 11/04/2020.

On 11/07/2020 at 5:33 PM, "Progress Note" revealed, "Very depressed...Nursing tells me that [he/she] has a (sic) antidepressant that needs to be resumed..."

Review of the medication orders revealed Patient #1's anti-depressant, "Citalopram 40 mg PO q day (once per day)" was re-ordered on 11/07/2020 at 5:37 PM, 7 days after it was originally discontinued.

Review of the MAR revealed Patient #1 received the Citalopram dose as ordered on 11/07/2020 at 6:30 PM, and then daily thereafter through discharge on 11/13/2020.

The anti-depressant was discontinued while Patient #1 was in the ICU, intubated and sedated. Upon extubation and subsequent transfer to the general nursing unit, the anti-depressant was not re-ordered until 5 days after Patient #1 was extubated and 3 days after transfer back to the general medical/surgical unit. Patient #1 was not administered his/her regular anti-depressant medication for 6 days out of a total stay of 24 days.

During a concurrent interview with Director E and Pharmacist P on 12/17/2020 at 1:25 PM, E stated, "We do not expect staff to do med recs if a patient is transferred to or from ICU - only if they go to surgery." P stated, "We don't do them if the patients goes to another level of care. Maybe we should?" When asked how long the effects of the anti-depressant stay within a patient's system, P stated, "It would be almost completely out of the system within a week. We don't normally want to quit that cold turkey, but there is not a real good non-oral option. I suppose they could have crushed it and administered it through [Patient #1]'s OG (orogastric feeding) tube while [he/she] was intubated. There is no specific documentation as to why it was discontinued on 10/31/20."

During an interview with Manager H on 12/17/2020 at 2:49 PM, when asked how staff are aware of patient's home medications when transferred between other departments of the hospital if medication reconciliations are only done at admission and discharge, H stated, "The nurses should be asking the doctors after the patient is extubated. If nurses are not familiar with the patient or didn't admit the patient and enter the home medications, I can see how it could be missed. It is not just one person's responsibility."

During an interview with Hospitalist O on 12/17/2020 at 3:29 PM, when asked about Patient #1's anti-depressant, O stated, "It was held because the patient was intubated in the ICU. It was overlooked when the patient was taken off the ventilator. I did apologize to the [spouse] that is was missed." When asked if Patient #1's agitation and confusion could have been caused as a result of the anti-depressant medication not being administered, O stated, "It could have."