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Based on observation, interview and record review, the facility failed to obtain informed consent for treatment for one patient (P-3) and confirm the intent for treatment in this facility for one patient (P-12) of 13 patients reviewed resulting in the inability of both patients to exercise their right for informed consent and possible negative outcomes to the patients. Findings include:

On 5/19/25 at 1302 P-3 medical record was reviewed and revealed that patient was a 16-year-old female who arrived at facility ED (emergency department) on 5/13/25 at 1842 with chief complaint of suicidal ideations and depression. Patient was discharge from the facility ED on 5/14/25 1403.

Further review of the P-3's medical record indicated that this minor patient had a state appointed guardian. No consent for treatment was obtained by facility upon patient admission to ED.

On 5/19/25 at 1507, during interview with manger of registration services, Staff HH, he was asked who is responsible to sign a general consent for treatment in case patient was a minor. Staff HH stated that patient's parents or legal guardian should sign consent for treatment.


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P-12: This 48-year-old male arrived in the Emergency Department (ED) on 5/20/25 at 1051 with complaints of blurred vision for approximately 3 weeks. He was taken into triage at 1055, and into an ED bay at 1101. At 1107, Registration/Patient Access Staff S initiated the registration process. She confirmed demographic information, who to notify in case of emergency, employment, and requested insurance information to scan into the system. Staff S did not obtain consent or discuss the consent process with the patient during registration.

Staff S was queried on obtaining consent and stated P-12 had a hospital system consent from 8/5/24 in the medical record. Staff S was unable to determine at which location that consent had been obtained. She stated that if the medical record contains consent from within the last 12 months, she will not obtain a new one. Staff S also stated that she does not provide information about new consent or how to revoke consent.

These findings were reviewed and acknowledged by the regional accreditation manager Staff X during an interview on 5/20/25 at 1320. Staff X was queried if the system is using any nationally adopted or recognized standard of practice that permits system-wide consent for treatment that covers all procedures, test, and assessments for a whole year. Staff X stated she would bring this information back to leadership and inquire with the personnel who wrote the policy.

Facility policy "General Consent to Treat and Release of Information" was reviewed and revealed:
"1. Purpose
To establish a standard method for presentation, completion and distribution of the General Consent
for Treatment and Release of Information form (does not include Informed Consent).
2. Definitions
2.1. Ward: A person under the care and control of a guardian appointed by the court or their
parents.
4. Compliance
Corewell Health includes the Beaumont Health, Lakeland Health and Spectrum Health branded
facilities, collectively they are referred to throughout as Corewell Health. A General Consent for
Treatment and Release of Information form must be obtained for each branded facility, Beaumont
Health, Lakeland Health and/or Spectrum Health, at which the patient is receiving service. The General Consent for Treatment and Release of Information form must be saved/stored in the patient ' s legal medical record.
6. Procedure
6.1. How to obtain the General Consent for Treatment and Release of Information form
A Corewell Health staff member must present and explain to the patient or representative each section of the General Consent for Treatment and Release of Information form. A copy of the General Consent for Treatment and Release of Information form must be offered to the patient or their representative. A sample script that may be used when presenting the General Consent for Treatment and Release of Information form to the patient for signature is as follows:
6.1.1. "This document is the General Consent for Treatment and Release of Information, by signing you are giving your permission to treat you. It is also an authorization to release or receive medical information related to your care. There are also statements regarding privacy notice, valuables, patient rights and grievances, consent to contact, billing and assignment, and translations available. Please take a moment to read the consent and sign when you are ready. Would you like a copy of the consent form for your records?"
6.2. Signature Conditions
The General Consent for Treatment and Release of Information form must be completed using the following guidelines:
6.2.1. Signature Patient/Patient Representative Name
Patients 18 years and older and of legal competency should sign on this line of the
General Consent to Treat and Release of Information form.
6.2.2. Minor
6.2.2.1. When the patient is a minor, consent must be obtained from either
parent, foster parent, or legal guardian, if one has been appointed."

Based on interview and record review, the facility failed to discharge one patient (P-6) of 13 patients reviewed to a receiving facility with all necessary medical information pertaining to patient's course of illness and treatment resulting in possible negative outcomes to the patient. Findings include:

Medical record review for P-6 on 05/20/25 at 1007 revealed that the patient was admitted to the facility on 04/07/25 with diagnosis of pneumothorax and caloric malnutrition.

There was a provider note dated 4/08/25 1238: "This is a 36 year old male (P-6) with a history of quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function), nonverbal, CVA (Cerebrovascular accident is the medical term for a stroke or brain attack), hypertension (elevated blood pressure), trach (tracheostomy tube that is placed in a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea), peg tube (Percutaneous endoscopic gastrostomy feeding tube that is used for giving food, fluids and medicines directly into the stomach) presented secondary to blood around his PEG tube. He was found to have a right-sided pneumothorax on imaging. He was seen by thoracic surgery and a right-sided chest tube was placed. His tube (PEG) was also replaced by surgery".

Chest tube was placed by general surgery on 4/07/25 to treat P-6's right-sided pneumothorax and was removed on 4/09/25. Thoracic surgery provider's note dated 4/10/25 0758 revealed: thoracostomy catheter removed per thoracic surgery 4/9 (4/09/25). Post-pull CXR (post removal Xray exam) revealed no re-accumulation or PTX (pneumothorax). Occlusive dressing to remain in place until 4/12 (4/12/25), as noted on dressing. Until then reinforce as needed.

Medical record review did not reveal any nursing documentation under LDAs (line, drain, airway) for chest tube insertion or removal, any dressing type or if there was one.

On 5/20/25 at 1138, during interview with Nurse manager, Staff II, she was asked if her expectations were for staff nurses to chart existing and new lines under LDA documentation field in patients' record. She stated yes. Staff II was asked if that should be done before patient's discharge from facility. She stated that this documentation should be done on admission or when new tube/line was established.

On 04/08/25 the general surgery provider replaced the patient's PEG tube with a Foley catheter (type of urinary catheter that helps drain urine from the bladder). There was no nursing documentation in patient's chart on admission (in LDAs) regarding PEG tube size and also what size/type of Foley catheter was used for the tube replacement. Further, there was no general surgery documentation regarding switching the Foley catheter back to the PEG tube before P-6 was discharged from the facility on 04/11/25.

There was a registered dietitian (RD) note dated 4/11/25 1525: "4/11 (2025) catheter removed. D/C (discharge) planning".

On 5/20/25 at 1422 during interview with general surgeon, Staff Y, he stated that it is possible that P-6 was discharged with a Foley catheter instead of PEG tube since there was no documentation from general surgery services regarding replacement.

P-6 was discharged back to skilled nursing facility (SNF) on 04/11/25. Patient's "After visit summary" dated 04/11/25 1601 was reviewed and did not reveal any documentation (that was sent to receiving facility) regarding changes in PEG tube or PEG tube/ Foley care. Further, there was no nursing documentation regarding communication to facility of any patient's changes (Foley catheter instead of the PEG tube) and /or instructions for use or care. P-6 was nonverbal and unable to care for himself, therefore receiving nursing facility was acting as his caregiver and needed to receive discharge education/communication. In addition, there was no indication in discharge summary that P-6 had a chest tube, that it was removed and if there was a dressing in place or instruction for care. No nursing note was evident with date, time and manner of discharge, who accompanied the patient and his belongings disposition (if any).

Care Management Reassessment and Plan note dated 4/11/25 1528 had the following documented: Discharge disposition- custodial care facility. Has change in functional or clinical condition changed discharge plan?: no. CM (case management) notes discharge. [name of the skilled nursing facility] is able to accept patient back. Guardian notified via voicemail that patient will be returning today. EMS arranged for 4pm. Facility and RN notified. Packet delivered to floor".

Facility policy "transition of Care- Discharge Planning", effective 07/21/24, was reviewed and revealed:
"1. Purpose
Outline the process for discharge / transition planning for inpatient and observation patients.
IV. Functions and Roles of the Care Team in the Transition/Discharge Plan:
b. RNs:
1. Ensure that all required patient care processes within scope of practice have been completed prior to discharge.
2. Engage patient, designated caregiver and family in the assessment, planning, and implementation of a comprehensive plan for post discharge needs, considering changes to needs or plan every shift.
3. Proactively coordinate and partner with the physician, care manager and other care team members to assure the patient's ongoing transition/discharge needs are identified and addressed (e.g. patient education) during interdisciplinary rounds and/or escalating concerns directly to the care manager and provider via internal communication systems or face to face communication.

6. Documentation will be completed as close to real time as possible and include:
o Nursing Documentation
-Finalize Nursing Plans of Care
-Complete Patient Education
-Time, date, and manner of discharge
-Personnel who accompanied patient at time of discharge
-Belongings Disposition."

Based on interview and record review, the facility failed to ensure that emergency department staff followed the facility policy and procedure regarding patient plan of care development for one patient (P-1) resulting in the possibility for unidentified patient needs and negative outcomes for the patient. Findings include:

On 05/19/25 at 1030 during the tour of facility emergency department (ED) nurse manager, Staff Q, was asked how soon nurses need to develop plan of care for emergency department patients. Staff Q stated that it should be done as soon as possible after nursing assessment and 30 minutes after patient was assigned a bed, as per facility policy.

P-1 medical record was reviewed on 05/19/25 at 1320 and revealed that P-1 arrived at facility ED on 04/14/25 at 1209 with a chief complaint of leaking PEG tube (Percutaneous endoscopic gastrostomy feeding tube that is used for giving food, fluids and medicines directly into the stomach). P-1 was "roomed" (assigned a bed) at 1210. At 1223 the registered nurse was assigned to the patient. P-1 was discharged at 1505. Further record review revealed that the Care Plan Guideline was not developed by the nurse for P-1 during her stay at the facility ED.

During a different encounter, on 05/07/25 at 0926, P-1 arrived at the facility ED with a chief complaint of leaking PEG tube. Patient was assigned an ED bed at 0928 and discharged at 1257. The Care Plan Guideline was not developed by the nurse for P-1 during her stay at the facility ED.

Facility policy "Patient Plan of Care", effective 07/21/24, was reviewed on 05/20/25 and revealed:
"I. Purpose
To establish guidelines to provide an individualized plan of care for each patient that is interprofessional, coordinated, high quality, and both patient and family-centered within the acute care setting (inpatient, ED and surgical/procedural care spaces).
III. Policy
A. Plan of Care Principles:
i. Each patient will have a plan of care that is appropriate to their unique needs. It begins on arrival in the Emergency Department (ED), admission to the hospital and/or surgical/procedural setting.
ii. The patient and/or guardian/decision maker is involved in the development and ongoing review/revision of the patient plan of care whenever possible.
iii. Planning care starts with learning the patient's chief complaint or medical diagnosis, assessment findings, and results of diagnostic testing to determine their individual needs.
B. Emergency Department Plan of Care:
i. The patient care plan is initiated as soon as enough information is available to select appropriate Care Plan Guide (CPG), and within thirty minutes of ED bed assignment.
a. A "rule-out" diagnosis may be used as the basis for selecting CPGs.
ii. The patient's care plan is evaluated at disposition/departure from the ED".

Based on interview and record review, the facility failed to ensure a discharge planning evaluation was made in a timely manner in 2 (P-2, P-9) of 13 records reviewed, resulting in the potential for delays in discharge and unmet care needs. Findings include:

P-2: This 80-year-old female entered the emergency department (ED) on 3/27/25 at 1406 with symptoms of fatigue and loss of appetite. An order for care management consultation was placed in the ED on 3/27/25 at 2141. The social work assessment was documented on 3/31/25 at 1535.

P-9: This 70-year-old female was admitted to the facility on 5/11/25 with altered mental status and cystitis. The care management initial assessment was documented on 5/14/25 at 1133.

These findings were reviewed and acknowledged by the Manager of Care Management Staff T and Director of Care Management Staff U during an interview on 5/20/25 at 1300. Staff T stated that per hospital policy, care management will conduct an initial evaluation within 24 hours of admission or the next business day as weekend staff focus on immediate discharge needs.

The facility failed to follow their policy for screening within one business day of arrival at the hospital.

Policy 6189 - Transitions of Care-Discharge Planning (effective 7/21/24). All patients in the hospital for observation services, or inpatient admission will be screened by care managers for any actual or potential transition of care needs within one business day of arrival to the hospital.