HospitalInspections.org

Based on interview, record review, and facility policy review, the facility failed to obtain consent from the Power of Attorney (POA) for 1 (Patient #1) of 10 sampled patients reviewed for informed consent.

Findings included:

A facility policy titled, "Informed Consent for Care, Treatment & Services," reviewed/revised 01/2025, revealed, "3. Procedure -
a. Informed consent must be given by the legally authorized representative of a patient admitted under the voluntary or involuntary statues, or by the patient himself if he meets the following criteria:
b. Legal Capacity - The patient is an adult and has not been adjudicated incompetent to manage his personal affairs by an appropriate court of law;
c. Receipt of Information - The person giving the consent has been informed of the nature, purpose, risks, and benefits of specific care, treatment, & services.
d. Voluntariness - The consent has been given voluntarily Information required to be given: Before providing specific care, treatment, & services to any patient the treating physician/licensed practitioner/provider shall explain to the patient and/or the patient's legally authorized representative, the following in a simple, non-technical language.
e. The nature of the patient's mental illness and condition.
f. The beneficial effects of the patient's mental illness and/or condition expected as a result of treatment.
g. The probable consequences to the patient of not receiving treatment, as appropriate, unnecessarily prolonged hospital stays, repeated hospital admission, deterioration in the patient's ability to care for self.
h. family, social or work adjustment, and the occurrence or reoccurrence of frightening, painful, or
i. incapacitating signs and symptoms of mental illness.
j. A description of the proposed course of care, treatment & service.
k. An offer to answer any questions concerning care, treatment & service.
l. The patient's right to refuse care, treatment & service at any time.
m. Those patients are not here voluntary that are here on an Emergency Detention Order/Involuntary or a court order will follow the court order or law concerning care, treatment, and services."

"Physician Medication Orders," indicated Patient #1 was admitted to the hospital on 06/21/2025 at 5:19 PM.

A nurse's "Admission" note, dated 06/21/2025 at 5:41 PM, indicated Patient #1 was involuntarily admitted to the hospital with diagnoses of dementia and aggressive behavior and was oriented only to person.

"Initial Nursing Assessment: Summary Notes," dated 06/21/2025 at 5:43 PM, revealed Patient #1 had learning barriers with cognitive capacity, emotional barriers, and impaired thought processes. The Initial Nursing Assessment: Summary Notes revealed, "Pt [patient] presents to [hospital name] d/t [due to] aggression towards caretakers r/t [related to] [the patient's] memory issues. Pt only responds with single word, nonsensical responses to assessment questions. Per records pt has h/o [history of] Alzheimer's [a disease that effects memory and the ability to care for one's self], HTN [high blood pressure], HLD [hyperlipidemia, high fat levels in the blood], Thyroid problems."

An "Intake Assessment: Conservator," dated 06/22/2025 at 1:04 PM, revealed, "Legal Guardian and Power of Attorney Notes" and included [family member's name and phone number]."

A provider "Medical History and Physical Examination (H&P)," dated 06/22/2025 at 3:48 PM, revealed, "Impression 1. Dementia."

A provider "Psychiatric Progress Note," dated 06/24/2025 at 4:14 PM, revealed, "Patient is confused, illogical disorganized, patient will continue with 1:1 [one-to-one, continuous observation of one observer to one resident] observation. Patient is unable to care for self, patient is isolating, withdrawn, patient is guarded, requires frequent redirections. Patient's appetite is poor, patient is irritable, and agitated."

A "Patient Rights and Responsibilities," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:13 PM.

An "Advance Consent and Assignment for Insurance Benefits," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM.

An "Agreements and Conditions of Voluntary Admissions," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM.

A "Professional Services Insurance Authorization and Guarantee," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM.

An "Advance Directive Acknowledgment for Behavioral Health and Medical Care," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM. The form revealed Patient #1 indicated "No" in the boxes "I have executed an Advance Directive for Medical Care" and "I have executed an Advance Directive for Behavioral Health Care."

A "Personal Property Disclaimer," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:12 PM.

A "Consent to Routine Procedures and Treatment," form revealed Patient #1 gave verbal consent on 06/29/2025 at 8:11 PM.

During an interview on 07/23/2025 at 8:20 AM, the Regional Director of Quality stated the POA paperwork for Patient #1 was not received until after the patient was admitted and gave verbal consent. The Regional Director of Quality stated the POA was with the patient in the emergency room and was aware the patient was admitted to the hospital.

A review of Patient #1's medical record failed to reveal documentation that the hospital contacted the POA for consents once the POA paperwork was received.