HospitalInspections.org

Based on record review, document review and staff interview it was determined the facility failed to uphold the right of patients to participate in the development of the plan of care via representative, if necessary, for one (1) out of thirty (30) patients (patient #1). This failure has the potential to place all patients at risk for violation of their rights to participate in their plan of care.

Findings include:

1. A review of patient #1's clinical record revealed the attending physician co-signed a history and physical on 6/22/19 at 7:10 p.m. stating in part: "Chronic cognitive impairment." A review of the history and physical revealed the attending physician noted, according to his contact with the Commission on Aging, the Department of Health and Human Resources (DHHR) had responsibility for him.

A review of the clinical record revealed the attending physician consulted a psychiatrist on 7/2/19 to establish mental capacity. A review of the psychiatrist's report dated 7/3/19 revealed it stated in part: "He is unable to state what medical problems he has and unable to state what medicines that he is taking. He is not able to explain the risks and benefits of compliance versus noncompliance with treatment."

A review of patient #1's clinical record revealed on 7/2/19 at 12:42 p.m. the case manager noted in part: "As per earlier conversation with the Cath Lab, the DHHR representative offers that the DHHR was the patient's surrogate several years ago in reference to a colonoscopy. The DHHR representative offers that the agency has not had any further contact with any type of agency in reference to a consent for treatments since the colonoscopy and therefore, the agency withdrew the surrogacy. The DHHR representative offers the agency would be glad to open a new referral." A review of patient #1's clinical record revealed on 7/3/19 at 12:24 p.m. the case manager noted, "Received notification from [primary nurse] that the [psychiatrist] states that the patient lacks capacity to make medical decisions for treatment. Copy of surrogacy papers and supporting documentation faxed to DHHR representative, DHHR to get surrogacy set up..." A review of patient #1's clinical record revealed on 7/3/19 at 1:24 p.m. the case manager noted in part: "Received call back from DHHR representative with DHHR offering that she received the faxed information. She is going to send a worker to the site to see the patient and complete the surrogacy. She offers that the office of DHHR is closed Thursday and Friday (7/4 and 7/5) and will not be available until Monday." A review of patient #1's clinical record revealed the DHHR did not complete an onsite visit and assume surrogacy prior to his discharge.

A review of patient #1's clinical record revealed on 7/3/19 at 6:10 p.m. Licensed Practical Nurse (LPN) #1 noted in part: "Patient discharged this evening, DHHR will follow-up with patient on Monday." The note further states in part, "...Commission on Aging called and message left regarding discharge..." A review of patient #1's clinical record revealed on 7/3/19 at 6:17 p.m. he was discharged via ambulance to his home.

2. An interview was conducted with the psychiatrist on 7/30/19 at 10:00 a.m. He revealed patient #1 did not have the capacity to make informed medical decisions and poor medical decisions would result. He revealed patient #1 could not understand his medications and his side effects. He revealed family or someone would need to be involved in this situation as a safety net when discharged. The psychiatrist further stated he felt patient #1 would have difficulty following discharge instructions.

An interview was conducted with LPN #1 on 7/31/19 at 7:55 a.m. She revealed the DHHR did not see patient #1 prior to discharge. She revealed she gave discharge instructions to patient #1 with no surrogate present.

3. A review of a document titled Patient Handbook, no revision date, issued to all patients on admission lists patient rights. Under those rights the document states in part: "You have a right to make decisions about your care and refuse treatment permitted by law and be informed of the medical actions."

4. A review of policy and procedure titled Patient Rights and Responsibilities, 2.04, approved 11/2017, states in part: "The Patent/Parent/Guardian/Patient Representative (when appropriate) is entitled to...obtain complete and current information concerning diagnosis, treatment and known prognosis and plans for discharge and follow-up care."

A review of policy and procedure titled Discharge Planning, reviewed 11/17, states in part: "6. Evaluation of the patient's home situation, as well as an assessment of the resources available and the ability of those who will care for the patient at home, will be completed through discussion with the patient and family.." 7. The patient/family will be assisted in development of a realistic post-hospital plan of care that allows for the patient to be discharged safely."

An interview was conducted with the Assistant Chief Nursing Officer on 7/31/19 at 9:50 a.m. He concurred a patient who lacks capacity to weigh the risks and benefits of medical care and cannot understand their medications and their side effects should not be discharged without post-discharge services.

Based on record review and staff interview it was determined the facility failed to update one (1) out of thirty (30) patient's plan of care when the patient had a change of diagnosis impacting nursing care (patient #1). This failure has the potential for all patients to be cared for without a current plan of care.

Findings include:

1. A review patient #1's clinical record revealed the attending physician consulted a psychiatrist on 7/2/19 to establish mental capacity. A review of the psychiatrist's report dated 7/3/19 revealed it stated in part: "He is unable to state what medical problems he has and unable to state what medicines that he is taking. He is not able to explain the risks and benefits of compliance versus noncompliance with treatment."

A review of patient #1's clinical record revealed on 7/2/19 at 12:42 p.m. the case manager noted in part: "As per earlier conversation with the Cath Lab, the Department of Health and Human Resources (DHHR) representative offers that the DHHR was the patient's surrogate several years ago in reference to a colonoscopy." The DHHR representative offers that the agency has not had any further contact with any type of agency in reference to a consent for treatments since the colonoscopy and therefore, the agency withdrew the surrogacy. The DHHR representative offers the agency would be glad to open a new referral. A review of patient #1's clinical record revealed on 7/3/19 at 12:24 p.m. the case manager noted: "Received notification from [primary nurse] that the [psychiatrist] states that the patient lacks capacity to make medical decisions for treatment. Copy of surrogacy papers and supporting documentation faxed to DHHR representative, DHHR to get surrogacy set up..." A review of patient #1's clinical record revealed on 7/3/19 at 1:24 p.m. the case manager noted in part: "Received call back from DHHR representative with DHHR offering that she received the faxed information. She is going to send a worker to the site to see the patient and complete the surrogacy. She offers that the office of DHHR is closed Thursday and Friday (7/4 and 7/5) and will not be available until Monday."

A review of patient #1's clinical record revealed on 7/3/19 at 6:10 p.m. Licensed Practical Nurse (LPN) #1 noted in part: "Patient discharged this evening, DHHR will follow-up with patient on Monday." The note further states in part: "...Commission on Aging called and message left regarding discharge..." A review of patient #1's clinical record revealed on 7/3/19 at 6:17 p.m. he was discharged via ambulance to his home. A review of nurse's notes dated 7/3/19 revealed nursing did not change his plan of care after the psychiatrist's consult. Therefore he received discharge instructions on 7/3/19 without a surrogate present and was discharged home without post discharge services.

2. An interview was conducted with the psychiatrist 7/30/19 at 10:00 a.m. He revealed patient #1 did not have the capacity to make informed medical decisions and poor medical decisions would result. He revealed patient #1 could not understand his medications and his side effects. He revealed family or someone would need to be involved in this situation as a safety net when discharged.

An interview was conducted with LPN #1 on 7/31/19 at 7:55 a.m. She revealed she knew about the psychiatrist's evaluation which stated patient #1 was incapacitated but she thought his incapacity only related to his ability to consent to a cath lab procedure. She stated she did not change her plan of care to take into account patient #1 did not have the capacity to weigh the risks and benefits of all medical care.

Based on record review, document review and staff interview it was determined the facility failed to provide a current discharge evaluation for one (1) out of thirty (30) patients (patient #1). This failure has the potential to place all patients at risk for discharge without the capacity for self care.

Findings include:

1. A review of patient #1's clinical record revealed the attending physician co-signed a history and physical on 6/22/19 at 7:10 p.m. stating in part: "Chronic cognitive impairment." A review of the history and physical revealed the attending physician noted, according to his contact with the Commission on Aging, the Department of Health and Human Resources (DHHR) had responsibility for him.

A review of the clinical record revealed the attending physician consulted a psychiatrist on 7/2/19 to establish mental capacity. A review of the psychiatrist's report dated 7/3/19 revealed it stated in part: "He is unable to state what medical problems he has and unable to state what medicines that he is taking. He is not able to explain the risks and benefits of compliance versus noncompliance with treatment."

A review of patient #1's clinical record revealed on 7/2/19 at 12:42 p.m. the case manager noted in part: "As per earlier conversation with the Cath Lab, the DHHR representative offers that the DHHR was the patient's surrogate several years ago in reference to a colonoscopy." The DHHR representative offers that the agency has not had any further contact with any type of agency in reference to a consent for treatments since the colonoscopy and therefore, the agency withdrew the surrogacy. The DHHR representative offers the agency would be glad to open a new referral." A review of patient #1's clinical record revealed on 7/3/19 at 12:24 p.m. the case manager noted: "Received notification from [primary nurse] that the [psychiatrist] states that the patient lacks capacity to make medical decisions for treatment. Copy of surrogacy papers and supporting documentation faxed to DHHR representative. DHHR to get surrogacy set up..." A review of patient #1's clinical record revealed on 7/3/19 at 1:24 p.m. the case manager noted in part: "Received call back from DHHR representative with DHHR offering that she received the faxed information. She is going to send a worker to the site to see the patient and complete the surrogacy. She offers that the office of DHHR is closed Thursday and Friday (7/4 and 7/5) and will not be available until Monday." A review of patient #1's clinical record revealed the DHHR did not complete an onsite visit and assume surrogacy prior to his discharge.

A review of patient #1's clinical record revealed on 7/3/19 at 6:10 p.m. Licensed Practical Nurse (LPN) #1 noted in part: "Patient discharged this evening, DHHR will follow-up with patient on Monday." The note further states in part: "...Commission on Aging called and message left regarding discharge..." A review of patient #1's clinical record revealed on 7/3/19 at 6:17 p.m. he was discharged via ambulance to his home. A review of the clinical record reveals he was discharged without post hospital services. There is no note in the clinical record the Commission on Aging received the message or returned the phone call.

A review of patient #1's clinical record revealed Raleigh General Hospital did not arrange for post discharge services for him to accommodate his incapacity.

2. An interview was conducted with the psychiatrist on 7/30/19 at 10:00 a.m. He revealed patient #1 did not have the capacity to make informed medical decisions and poor medical decisions would result. He revealed patient #1 could not understand his medications and the side effects. He revealed family or someone would need to be involved in this situation as a safety net when discharged. The psychiatrist further stated he felt patient #1 would have difficulty following discharge instructions.

An interview was conducted with LPN #1 on 7/31/19 at 7:55 a.m. She revealed she did not change the plan of care after the psychiatrist made a determination patient #1 lacked capacity. She revealed the DHHR did not see patient #1 prior to discharge. She revealed she gave discharge instructions to patient #1. She revealed although patient #1 had the support of the Commission on Aging prior to admission, no post-discharge services were arranged. She revealed she did call the Commission on Aging but had to leave a message. She stated she did not receive a return phone call from the Commission on Aging.

3. Review of a document titled Discharge Planning, approved 11/2017, states in part: "Participants involved: case managers, social workers, all nursing staff, all hospital staff." It revealed it states in part: "The patient/family will be assisted in development of a realistic post hospital plan of care that allows for the patient to be discharged safely." The review revealed it states in part: "Discharge needs (i.e. home health, DME, community services) will be arranged by case managers/social workers keeping patient choice and payer restrictions."

An interview was conducted with the Assistant Chief Nursing Officer on 7/31/19 at 9:50 a.m. He concurred a patient who lacks capacity to weigh the risks and benefits of medical care and cannot understand their medications and their side effects should not be discharged without post discharge services.