HospitalInspections.org

Based on interview and record review, the hospital failed to ensure a Medicare Outpatient Observation Notice (MOON) (a document that informs patients that they are outpatients and not inpatients, which can impact their costs) was provided to one sampled patient (Patient 9), per hospital policy.

Findings:

The clinical record was reviewed on 9/18/24 and 9/19/24.

Patient 9 was admitted to the hospital as Outpatient/Observation status on 9/16/24, per the patient information form.

In the Electronic Health Record (EHR), was a scanned copy of the patient's Medicare Outpatient Observation Notice. On the last page, there was no signature, however the words "patient unable to sign due to being in recovery" were written on the signature line and was dated 9/16/24 at 1:22 P.M.

Per a physician's progress note, dated 9/17/24, the patient had surgery 9/16/24 and was discharged from the hospital on 9/17/24.

On 9/19/24 at 10:10 A.M., the Patient Access Director stated during an interview, that when a patient is unable to sign, "If we have the ability to send someone every day, we will. It's staffing dependent."

The Patient Access Director further stated, "I did go into the system for this patient. There were no documented attempts. We're trying to enforce that for staff to go in manually to add those notes into system." The Patient Access Director acknowledged that the form was scanned into the EHR but there were no notes about further attempts during the patient's stay.

According to the hospital's policy, Notice of Outpatient/Inpatient Status, dated 7/9/19, "When the decision is made to place a patient in Observation Status, the registration personnel will notify the patient of their outpatient status and provide them with a copy of the Notice of Outpatient/Inpatient Status...The registration clerk will have the patient, or the beneficiary acting on behalf of the patient, sign and date the form, then witness the document. The original document will be placed in the medical record, and a copy (pink copy) provided to the patient."

According to the hospital's policy, Admission for Services, last reviewed 8/17/22, "When the patient is comatose or otherwise unable to participate in required signing of forms or admission process, Admitting will admit/register the patient with whatever information is available, then follow up on a daily basis to obtain correct information, completion of required forms, signatures, etc."

Based on interview and record review, the facility failed to ensure the staff obtained signatures for the Conditions of Admissions in a timely manner for four out of 30 sampled patients (1, 4, 7 and 8).

As a result, there was a potential treatments were performed without consents.

Findings:

Patient 1 was admitted to the facility on 9/13/24 with diagnoses which included acute kidney injury per the facility's facesheet.

A review of records was conducted. The document titled Conditions of Admissions (COA) indicated Patient 1 was unable to sign on 9/13/24 due to "medical condition."

Patient 4 was admitted to the facility on 9/12/24 with diagnoses per the facility's facesheet.

A review of records was conducted. The document titled COA indicated Patient 4 was "unable to sign" on 9/12/24.

Patient 7 was admitted to the facility on 8/6/24 per the facility's facesheet.

A review of records was conducted. The document titled COA indicated Patient 7 was unable to sign on 8/6/24.

Patient 8 was admitted to the facility on 9/11/24 per the facility's facesheet.

A review of records was conducted. The document titled COA indicated Patient 8 was unable to sign on 9/11/24 due to patient is "altered per nurse."

On 9/17/24 at 3:45 P.M., an interview with the Patient Access Director (PAD) was conducted. The PAD stated the staff should document attempts to obtain the patient's or the patient representatives' signatures on the COA.

On 9/19/24 at 10:10 A.M., an interview with the PAD was conducted. The PAD stated when a patient was unable to sign, "If we have the ability to send someone everyday [to obtain the signatures], we will. It's staffing dependent."

Per the facility's policy and procedure titled, Admission for Services last reviewed 8/17/22, "Patient is unable to communicate/No family members present When the patient is comatose or otherwise unable to participate in required signing of forms or admission process, Admitting will admit/register the patient with whatever information is available, then follow-up on a daily basis to obtain correct information, completion of required forms, signatures,etc."