HospitalInspections.org

Based on records reviewed and interviews, the Hospital failed to follow its policy and procedure for activating the Health Care Proxy for one of ten sampled patients (Patient #7) who lacked capacity and required activation of his/her proxy.

According to the Hospital policy titled, Advance Directives and Health Care Proxy, date of approval December 2014, the assessment of incapacity is determined and documented by the Attending Physician in the medical record. The Physician's determination must contain the opinion regarding the cause and duration of the incapacity.

The Surveyor interviewed the Nursing Supervisor at approximately 2:00 P.M. on 9/27/17. The Nursing Supervisor said Patient #7 was hospitalized after a significant fall, an acute kidney injury, a history of dementia and he/she was no longer able to make informed health care decisions.

Patient #7's medical record indicated a family member was making decisions about long term care placement instead of returning to his/her home; however, the medical record lacked evidence that Patient #7's Health Care Proxy had been invoked.

Based on observations and interview, the Hospital failed to consistently provide an environment that was free from potential safety hazards.

The Surveyor toured the Geriatric Psychiatric Unit at 8:25 A.M. on 9/26/17 followed by the Adult Behavioral Unit (BH4). The fire doors on both units had hinge arms that protruded approximately one foot from the face of the doors which created a potential ligature hazard.