HospitalInspections.org

Based on interview, record review, and review of facility policy, the facility failed to provide evidence that 1 of 5 sampled patients were informed of their Patient's Rights in advance of furnishing or discontinuing care or treatment (#2).

Findings:

Patient #2's record revealed she went to the Emergency Department (ED) on 4/19/21 at 2:23 PM. Diagnoses included closed head injury post fall from a chair, concussion, and hypertension. The patient underwent diagnositic treatment and was discharged by the physician in stable condition on 4/20/21 at 1:16 AM.

Patient #2's Patient Access Department information listed the patient's name, and identification number. In the notes section read, "Comments: pt. not able to sign forms." There was no further documentation in the Access notes or in the legal record regarding her inability to sign her consent.

In an interview with the Patient Access Assistant Manager (PAAM) and Risk Manager on 4/30/21 at 1:30 PM, the PAAM related the Patient Rights Forms are not given out on paper or in a handbook for the ED patients. She related all patient information and rights are in the computer and the patients are given the laptop to read the information and then sign the Consent for Treatment. The PAAM agreed the Patient's Consent form was not signed, and stated there was no evidence in the record that the patient received her Patient Rights, as the Consent to Treat form was not signed by the patient. There was no further documentation following the initial entry by Patient Access that the patient had been reproached, and no further documentation explaining why the patient was unable to sign. The PAAM presented a printout of the forms the hospital uses in the computer Patient Access System. The forms contained sections of the following: "Your right to decide and make your wishes known, Consent for treament, Advance Directives, Living Will, Healthcare surrogate, and a page entilted Summary of the Patient's Bill of Rights and Responcibilities, Your Rights and Your Responcibilities."

Review of the facility poliy entilted "Patients' Rights and Responcibilities #1480", revised 11/2019 read, "It is the policy of (Name of facility) to protect the basic human rights of its patients for independence of expression, decision, action, human relationships and personal dignity to the extent consistent with sound medical cate and the rights of other patients and hospital employees."

Based on interview and record review, the facility failed to ensure 1 of 5 sampled patients admitted to the Emergency Department for treatment, signed the facility Informed Consent for Treatment prior to discharge (#2).

Findings:

Patient #2's record revealed she went to the Emergency Department (ED) on 4/19/21 at 2:23 PM. Diagnoses included closed head injury post fall from chair, concussion, and hypertension. The patient underwent diagnositic treatment and was discharged by the physician in stable condition on 4/20/21 at 1:16 AM. The electronic record revealed the patient did not sign a Consent for Treatment following emergency admission to the ED.

Patient #2's Access Department information listed the patient's name and identification number, and in the notes section read, "Comments: pt. not able to sign forms." There was no further documentation in the Access notes or in the legal record regarding her inability to sign her consent.

In an interview with the Patient Access Assistant Manager (PAAM) and Risk Manager on 4/30/21 at 1:40 PM, the PAAM related the department representative documents if the patient cannot or refuses to sign the consent. The PAAM related a second opportunity can be made at a later time to obtain the patient's signature as many admitted to the department were unable to sign due to their condition.

Review of the patient's electronic record revealed there was no second attempt documented and no further information related regarding the patient signing her Consent for Treatment.

Review of the facility Policy entitled "Informed Consent Process #1225", revised 6/20, read on page 4, under category "IV. Procedure: B., Emergency/urgent conditions: 1. If the patient is an emergency/urgent condition and is unable to give consent for any reason and there is no other person available who is legally authorized to consent, the treatment may be performed. 2. The physician must document in the patient's record the emergency/urgent condition and the procedure/treatment needed. 3. Attempts to reach other authorized persons must be documented in the patient's record...."

Patient #2 did not have any family member with her in the ED, and there was no documentation in the legal record that any attempts were made to reach any authorized persons.

Based on interview, record review, and review of facility policy, the facility failed to re-evaluate the needs of a patient's discharge plan prior to discharge from the Emergency Department for 1 of 5 sampled patients (#2).

Findings:

Patient #2's record revealed this 89 year old went to the Emergency Department (ED) on 4/19/21 at 2:23 PM. Diagnoses included closed head injury after a fall from a chair, concussion, and hypertension. The patient underwent diagnositic treatment and was discharged by the physician in condition stable on 4/20/21 at 1:16 AM.

Patient #2's ED patient care record under Triage assessment, read, "Chief complaint: fall. Triage assessment: Pt. brought in via EMS (emergency medical services) status post fall. Pt was found by daughter and EMS was called."
Page 4 of 4, read, "Preferred language for discussion of healthcare: Spanish."

The electronic record had a form entitled "XA D/C Planning Short Form", dated 4/19/21 at 7:32 PM, which read, "met with patient at bedside to assess for discharge planning needs....Patient Spanish speaking, translator line used....chart reviewed and demographics verified. Patient reports not knowing any phone numbers. currently resides with husband....Patient has no DME (durable medical equipment). Patient reports having HHC (home health care) and home health aide, does not know company....Patient will utilize family for transportation at the time of discharge, Tentative discharge plan is pending hospital course....will continue to follow as needed." There were no further Discharge Planning notes or documentation regarding the patient's plan from the Case Manager.

Patient #2's record contained a handwritten "ED Workflow" form completed by the physician on 4/19/21 at 3:01 PM. Page 2 of the form, under "Progress" was the person's first name, a telephone number, and a name of a Hospice agency.

Patient #2's discharge instructions in the electronic record revealed they were last updated 4/20/21 at 12:53 PM by an ED nurse. The Discharge Instructions were 7 pages long and were not signed by the patient. The complete Discharge Instruction materials were in English language, and there was no family member or representative with the patient upon discharge. The discharge instructions documented the patient received the instructions from the physician and was "discharged to home. Accompanied by: Self via ambulatory."

Review of the 2021 Cab Account Charge Log, provided by the facility Risk Manager (RM) and guest services, revealed the following documentation: ED; name of RN requesting a Taxi transport from the ED for patient #2; date called was 4/20/21; time cab called was 12:58 AM, with the name of patient #2. The patient's home address was also listed under destination, along with an estimated cost.

A review and observation of the facility ED security video was completed with the RM and Director of Security showing discharged patients leaving the facility from 4/20/21 at midnight until 1:50 AM on 4/20/21. Patient #2 was identified by the RM and security. She was observed on the video being wheeled out of the facility in a wheelchair by a security officer into an outside area where a yellow marked taxi was waiting. The patient was observed being assisted and helped out of the wheelchair at 1:40:23 AM on 4/20/21 and into the taxi which soon left the facility property.

Review of the facility Department Guideline "Discharge Planning #GUID-493303002, Revised 1/2021" read on page 2, D., "The Care Management team member will ....#4. Implement and revise discharge plans in accordance with the patient's medical progress and patient/family input....G. Upon receipt of discharge order the Care Management team member will finalize plans with the patient/family, community resources and healthcare team...."

Patient #2 was discharged from the ED on 4/20/21 at 1:40 AM via taxi, alone, with Discharge Instructions not in her chosen language, and no documentation that a family/representative had been notified.

Based on interview and record review, the facility failed to complete a referral to a post hospital care provider that was identified as a patient discharge need for 1 of 5 sampled patients reviewed for discharge planning (#2).

Findings:

Patient #2's record revealed an 89 year old went to the Emergency Department (ED) on 4/19/21 at 2:23 PM. Diagnoses included closed head injury post fall from chair, concussion, and hypertension. The patient underwent diagnositic treatment and was discharged by the physician in stable condition on 4/20/21 at 1:16 AM.

The electronic record contained a form entitled "XA D/C Planning Short Form", dated 4/19/21 at 7:32 PM, which read, "met with patient at bedside to assess for discharge planning needs....Patient Spanish speaking, translator line used...chart reviewed and demographics verified. Patient reports not knowing any phone numbers. currently resides with husband....Patient has no DME (durable medical equipment). Patient reports having HHC (home health care) and home health aide, does not know company.... Patient will utilize family for transportation at the time of discharge, Tentative discharge plan is pending hospital course....will continue to follow as needed. There were no further D/C Planning notes or documentation regarding the patient's plan from the Case manager.

Patient #2's record contained a handwritten "ED Workflow" form completed by the physician on 4/19/21 at 3:01 PM. Page 2 of the form, under "Progress" listed the person's first name, telephone number, and a name of a Hospice agency.

Patient #2's record showed a physician's order, dated 4/19/21 at 5:18 PM, for Physical Therapy (PT) Evaluation and Treatment. A PT initial evaluation read, "Prior level of function Additional Information: Prior to this admission, patient modified independent with ambulation with walker....Discussed discharge planning for home health physical therapy. Discussed her high risk for fall and 30-day readmission if she returns home without completing a short course of home health physical therapy. She expressed understanding....Discharge needs: Equipment recommended - No equipment needs identified at time of evaluation, She has a rollator with seat. Recommend discharge to/Other discharge recommendation: Home Health/other. She would benefit from home health aide and home health nurse.
Discharge recommendation: Patient; Physician; Social Services. Treatment Plan Reviewed: Plan of care and Goals discussed with and agreed upon with: Patient." The evaluation was signed off by the physical therapist on 4/19/21 at 5:47 PM.

Review of the patient's record did not reveal that home health services were ordered by the physician, and there was no documentation by the ED Social Worker or Case Manager, that an order for home health was obtained, or that a home health referral was completed after the patient was identified as needing services.

In an interview with the facility Risk Manager on 4/30/21 at 2:20 PM, she agreed that the record identified the patient's need for home health care. However, a physician's order was not obtained and there was no evidence that a referral to a home health agency was completed.