HospitalInspections.org

Based on interview, record review and policy and procedure review, the facility failed to ensure patient's rights were provided to the patient or responsible party for 1 of 5 sampled patients, Patient #1.

Findings:

Record review of the History and Physical for Patient #1 showed dated 03/14/2017, This is an 80 year old gentleman, demented severely.

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 03/13/2017 under Patient/Patient Representative Signature: Patient unable to sign. With two staff witnessing the form.

Record review of the History and Physical - Medical Clearance showed dated 04/08/2017 80- year-old male with history of dementia presents to the emergency department from The Vines for medical clearance. Staff from the memory care facility states patient was combative and swinging at nurses, so he was Baker Acted. History and physical limited due to patient's condition (dementia).

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 04/08/2017 under Patient/Patient Representative Signature: Patient unable to sign. With two staff witnessing the form.

Record review of the Diagnoses Admit Diagnoses showed dated 06/12/2017 Dementia.

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 06/13/2017 under Patient/Patient Representative Signature: Agitated. With two staff witnessing the form.

During an interview on 08/11/2017 at 3:58 PM with the Director of Patient Financial Services (DPFS) when asked if patient's rights are part of the Conditions of Admission of Consent for Outpatient Care, the DPFS stated, "Yes, they are." The Conditions of Admission of Consent for Outpatient Care were reviewed with the DPFS for Patient #1. When asked why the patient's spouse was not provided with the information the DPFS stated, "When a patient is not able to sign all we have to do is have two witnesses to show the patient is not able to sign." When asked in the case of a severely demented patient, an agitated patient, or if a patient is unable to sign should the responsible party be made aware of the patient's rights, and the Conditions of Admission the DPFS stated, "Was she here to the hospital?" Again, when asked when there is a medical condition that does not allow for the patient to sign as having received their patient's rights and Conditions of Admission should their responsible party be provided the information the DPFS did not answer. .

During an interview on 08/11/2017 at 4:50 PM with the Registered Nurse/Chief Nursing Officer she stated, "There is no verification the patient's wife was informed of the patient's rights."

During an interview on 08/11/2017 at 5:32 PM with the Chief Executive Officer West Marion (CEO) when the concerns of the complaint investigation were completed she stated, "Two people witnessed the resident wasn't able to sign the paperwork for the conditions of admission." When asked if the responsible party should have been notified of the patient's rights, and be provided the admission paperwork the CEO stated, "Was she here in the hospital?" The CEO stated, "Well, I guess we could send it through the mail."

Record review of the Policy and Procedure titled, "Informed Consent" Effective: 03/01/2000, Approved: 12/28/2016 showed Policy: A general consent form signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission and is valid for the duration of hospitalization.

Record review of the Policy and Procedure titled, "Florida Model Statement of Patient Rights and Responsibilities" Effective: 10/17/2016, Approved: 10/17/2016 showed Patient Rights: Each individual shall be informed of the patient's rights and responsibilities in advance of administering or discontinuing patient care.