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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance.

A-0131 The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. Based on observations, interviews, and document review, the facility failed to ensure patients were evaluated for decision-making capacity as their conditions changed in six of ten patients reviewed with capacity concerns.

Based on observations, interviews, and document review, the facility failed to ensure patients were evaluated for decision-making capacity as their conditions changed in six of ten patients reviewed with capacity concerns (Patients #3, #5, #6, #7, #8, and #10).

Findings include:

Facility policy:

According to the Patient Rights policy, patients have the right to receive care from competent personnel that is respectful and safe and recognizes their dignity, be free from abuse, neglect, and harassment, and participate in decisions involving care, and understand what is expected.

References:

According to the Decision Making Capacity pathway, the pathway establishes processes to assist the primary team in assessing and documenting a patient's capacity to facilitate their plan of care. The Physicians and advanced practice practitioners (APP) reassess patients' capacity as their clinical situation changes.

According to Assessing Patients' Capacities to Consent to Treatment by Paul Appelbaum and Thomas Grisso, dated 12/22/1988, provided by the facility, the right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions and be given an opportunity to demonstrate their highest level of mental functioning. The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally. Since competence is a legal concept and can be formally determined only in court, the clinical examiner's proper role is to gather relevant information and decide whether an adjudication of incompetence is required. Treatment for impairment of mental functioning can sometimes restore patients' capacities, making it unnecessary to deprive them of their decision-making powers.

1. The facility failed to ensure patients were evaluated for decision-making capacity as their conditions changed.

A. Document review

i. Upon request, the facility was unable to provide a policy with guidance on evaluating a patient's decision-making capacity.

ii. Upon request, the facility was unable to provide a list of patients who lacked capacity along with dates of their initial evaluations and re-evaluations.

iii. A review of Patient #3's medical records revealed the facility failed to evaluate them for the capacity to make medical decisions.

a. A review was conducted of Patient #3's medical record which revealed Patient #3 was admitted to the facility on 4/21/24. Patient #3 was diagnosed with vascular dementia and resistant hypertension (high blood pressure). At this time, the facility was coordinating with Patient #3's adult child to determine disposition. Due to Patient #3's diagnosis and altered mental status, providers screened Patient #3 for medical decision-making capacity. From 4/21/24 to 9/18/24, providers documented Patient #3 lacked the capacity to make their own medical decisions, including discharge disposition.

Although Patient #3's medical record documented a lack of capacity from 4/21/24 to 9/18/24, the providers failed to re-evaluate Patient #3 after their evaluation on 5/29/24 documented a lack of capacity. The record revealed Patient #3 was not re-evaluated for capacity until the facility was prompted by an Adult Protective Services (APS) social worker on 9/18/24, three months and 20 days later, who believed the patient was capable of making discharge decisions. On 9/18/24, Patient #3's primary medical team consulted Provider #1 who re-evaluated Patient #3 and determined Patient #3 had capacity for medical decision-making.

The medical record revealed providers had not performed recent capacity evaluations and providers found Patient #3 had capacity when they were reevaluated. The medical record also revealed Patient #3 wanted to leave the facility and was not able to do so as the last evaluation had documented Patient #3's lack of capacity.

On 12/5/24 at 12:05 p.m. during a review of Patient #3's medical record, an interview was conducted with registered nurse (RN) #6. RN #6 stated Patient #3 was on their unit from the end of May 2024 until their discharge on 9/20/24. They stated no significant care or discharge decisions needed to be made between June and September 2024 for Patient #3 which contributed to the lack of capacity evaluations, however, this was an unusually long amount of time between capacity evaluations.

RN #6 stated they were aware of a project on their unit which would require capacity evaluations every 30 days but stated this had not yet been implemented. They stated keeping patients with decision-making capacity in the facility involuntarily led to a loss of patient autonomy.

Patient #3's medical record revealed Patient #3's capacity was not re-evaluated as their health improved which prevented them from being able to leave the facility. This was in contrast to the Patient Rights policy which read, patients had the right to receive respectful care and were able to participate in decisions involving their care. This was also in contrast to the Decision Making Capacity pathway which read, providers reassessed patients' capacity as their clinical situation changed.

iv. A review of other medical records revealed the facility failed to evaluate patients for capacity on a timely and ongoing basis, even after the facility became aware of the concerns with Patient #3's capacity and lack of ongoing evaluation.

a. A review was conducted of Patient #5's medical record which revealed Patient #5 was admitted to the facility on 9/13/24 for encephalopathy (decreased blood flow or oxygen to the brain). The record revealed a note on 9/16/24 by a psychiatrist who documented Patient #5 lacked the capacity to make medical decisions. On 12/6/24, two months and 20 days after this note, another provider documented a formal evaluation of Patient #5's lack of capacity.

b. A review was conducted of Patient #6's medical record which revealed Patient #6 was admitted to the facility on 9/7/24 for neglect and failure to thrive (FTT). From 9/8/24 to 10/21/24, the record revealed several provider evaluations documenting Patient #6 lacked capacity. However, Patient #6's next capacity evaluation was not performed until 12/6/24, one month and 15 days later.

c. A review was conducted of Patient #7's medical record which revealed Patient #7 was admitted to the facility on 11/13/24 for shortness of breath. On 11/14/24, a provider documented "lacks capacity" although the record did not reveal an evaluation of capacity at this time. On 12/6/24, 23 days after admission, a provider documented a formal evaluation of Patient #7's lack of capacity.

d. A review was conducted of Patient #8's medical record which revealed Patient #8 was admitted to the facility on 9/7/24 for neglect and FTT. On 9/9/24 and 9/10/24, the record revealed a provider evaluation documenting Patient #8 lacked capacity. However, Patient #8's next capacity evaluation was not performed until 12/6/24, two months and 26 days later.

e. A review was conducted of Patient #10's medical record which revealed Patient #10 was admitted to the facility on 8/27/24 for dementia. From 8/30/24 to 9/19/24, the record revealed provider evaluations documenting Patient #10 lacked capacity. However, Patient #10's next capacity evaluation was not performed until 12/6/24, two months and 19 days later.

On 12/9/24 at 2:33 p.m. during a review of medical records, an interview was conducted with RN #6. RN #6 stated they had recently participated in a leadership huddle during which staff had discussed the newly created 30-day timeframe for repeat capacity evaluations. They stated they learned at this meeting that this was tied to the concerns with Patient #3's care.

The medical records for Patients #5-8 and #10, where the patients were evaluated not to have capacity and did not have frequent ongoing screenings of capacity, revealed the facility failed to re-evaluate their capacity until 12/6/24 even after becoming aware of the failure to evaluate which had impacted Patient #3's patient rights in September.

The medical records for Patients #5-8 and #10 were also in contrast to the Patient Rights policy which read, patients had the right to receive respectful care and were able to participate in decisions involving their care.

v. A review of a Collaborative Case Review (CCR) for Patient #3 revealed their case was sent to committee review on 10/10/24. The case summary documented Patient #3 came to the hospital in April 2024 with altered mental status and at that time, did not have capacity. The summary documented Patient #3's capacity was not reassessed for some time and when their capacity was reassessed, Patient #3 had capacity and was discharged home.

On 10/10/24, the committee members created action items to improve care for other similarly presenting patients. One action item, due 12/31/24, was to develop a standardized process for capacity assessment and discharge planning. Another action item, also due 12/31/24, was to develop processes for escalating concerns about capacity.

a. During an interview conducted on 12/9/24 at 11:19 a.m. with clinical quality and safety specialist (Specialist) #2, Specialist #2 stated they had participated in Patient #3's CCR. They stated CCR action items were typically due in 30 days however, the action items for Patient #3's CCR were scheduled further out to allow for better collaboration and coordination with all team members.

b. During an interview on 12/9/24 at 10:26 a.m. with physician and director of clinical operations (Director) #7, Director #7 stated they had participated in Patient #3's CCR. They stated the facility was working to make systemic changes in capacity evaluations after realizing Patient #3 "fell through the cracks" during their stay. They stated their team had reviewed the literature but did not find policies or national guidelines surrounding the timeframe for repeat evaluations of capacity. Director #7 stated currently, providers repeated the capacity evaluations upon clinical status changes but this was a nebulous and poorly defined concept. They stated the committee's work to create a standardized process for capacity evaluations was important as providers valued patient rights and did not want to keep someone at the facility who did not want to be there.

c. During an interview conducted on 12/9/24 at 10:26 a.m. with the associate chief medical officer of inpatient services (ACMO) #8, ACMO #8 stated they helped oversee the unit that housed Patient #3. ACMO #8 stated the CCR for Patient #3 led to action items which included repeating capacity evaluations every 30 days. They stated as there was no guidance in the medical literature for when to repeat capacity, this was a date the team had chosen. ACMO #8 stated the team had also created a capacity decision-making tool which they rolled out to providers on 12/3/24, which included determining discharge capacity. They stated they had emailed all providers on 12/6/24 with education on this tool and the expectation for capacity evaluations to be done every 30 days. ACMO #8 stated moving forward, there would be checks and balances given the multiple members of the patient care team which would ensure patients were evaluated for capacity when needed. ACMO #8 stated their goal with this project was to respect patient rights and provide patient-centered care.

Although Patient #3 was determined to have capacity on 9/18/24, the CCR review of their case revealed concerns with patient rights on 10/10/24, and quality and leadership staff felt systemic changes in capacity evaluations were needed, the facility failed to ensure action plans were implemented in a timely manner to prevent other patients with capacity from remaining at the facility involuntarily for weeks-months.

The 10/10/24 CCR and interviews with quality and leadership staff were in contrast to a review of the medical records for Patients #5-8 and #10 which revealed the facility failed to re-evaluate their capacity, although there were concerns with the lack of capacity evaluations, until 12/6/24.

vi. A review of a PowerPoint titled "Systems Improvement Conference: Patient Capacity Assessment" and dated 10/10/24 revealed Patient #3 remained in the facility after regaining capacity due to multiple factors, including the lack of documentation of capacity conversations, the patient distrust of the medical system and providers involved, and a lack of protocols for standardized reassessment of capacity.

This presentation of Patient #3's case on 10/10/24 revealed that the facility was aware of systemic failures which led to a violation of Patient #3's patient rights. However, other similar patients, including Patients #5-8 and #10, were still not re-evaluated for capacity until 12/6/24 (one month and 26 days later).

B. Interviews

i. On 12/5/24 at 11:03 a.m., an interview was conducted with licensed clinical social worker (Social Worker) #3. Social Worker #3 stated they worked with patients at the facility who had significant discharge barriers. They stated they had participated in disposition planning for Patient #3 and were aware Patient #3's family was not able to care for the patient. Social Worker #3 stated as such, the care team originally planned to discharge them to a nursing facility.

Social Worker #3 stated the medical team had ongoing conversations with all patients about their understanding of their medical conditions and plans for discharge and were aware of changes in condition that could lead to a change in capacity. They stated repeat capacity evaluations were performed if the providers saw improvements in a patient's condition. Social Worker #3 stated Patient #3 was originally evaluated as lacking capacity for medical decision-making and discharge planning in part because they were paranoid and not able to create a discharge plan. They stated providers reassessed Patient #3 frequently but had not formally reevaluated Patient #3 for capacity as the patient was not able or willing to have conversations with the providers regarding their understanding of their situation, their medical history, and their plan after discharge from the facility. Social Worker #3 stated although Patient #3 displayed the ability to problem-solve towards the end of their stay, they never independently or consistently executed the action items they had identified.

Social Worker #3 stated Patient #3 lacked trust in the primary medical and clinical team as Patient #3 felt they were being held captive. They stated as Patient #3 failed to make progress with planning or involve hospital staff in discharge planning, which they stated was still the patient's right, staff was not able to ascertain their progress towards increased capacity. Social Worker #3 stated Patient #3 was more forthcoming and engaged with Provider #1 and the social worker from APS which had led to the re-evaluation of their capacity. They stated they and the care team had not realized Patient #3 would feel more trust and respond more openly with outside providers and agencies. Social Worker #3 stated Patient #3's providers felt they lacked capacity.

Social Worker #3 stated capacity evaluations were important to assessing whether patients needed support in making decisions and identifying needs. They stated knowing capacity was important to ensure patients understood the risks versus benefits of their choices and if patients had capacity, that their voices were heard.

Social Worker #3 stated there was a risk to patient autonomy if capacity was not re-evaluated. They stated this could lead to emotional harm due to long hospital stays, a lack of support, a lack of freedom to move around, and a significant impact on mental health. Social Worker #3 stated in the long term, there was a risk of physical health as well due to decreased mobility.

ii. On 12/5/24 at 12:48 p.m., an interview was conducted with Social Worker #5. Social Worker #5 stated they and their team were brought on to consult several times during Patient #3's treatment as there were concerns Patient #3 was abandoned by their family. They stated Patient #3 was also not engaged in discharge planning with the care team and had failed to provide financial information and documents pertinent to discharge. Social Worker #5 stated for patients who lacked trust in their care team, such as Patient #3, they created trust by showing honesty, transparency, and sharing the team's goal of quality patient care.

Social Worker #5 stated although it was typically the responsibility of the primary medical team to perform capacity evaluations, once Social Worker #5's team was consulted for Patient #3, they performed a capacity evaluation. Social Worker #5 stated this had revealed Patient #3 had capacity.

Social Worker #5 stated the capacity evaluation was important as it informed the team if the patient was able to engage in discharge and medical decision-making choices. Social Worker #5 stated if capacity changed and a repeat capacity evaluation was not performed, there was a risk to patient autonomy.

iii. On 12/5/24 at 2:16 p.m., an interview was conducted with physician assistant (Provider) #4. Provider #4 stated they were one of the providers who had cared for Patient #3. They stated capacity was usually assessed before patients were transferred to their unit. Provider #4 stated then while on the unit, they and the other providers assessed capacity daily in conversation with patients. They stated when a change in capacity was seen, the providers involved the attending physician to perform a formal assessment of capacity. Provider #4 stated there was no set frequency for capacity assessments as this was based on clinical judgment. This statement was in contrast to the medical record for Patient #3 which revealed they had not assessed a change in Patient #3's capacity as the patient's condition improved.

Provider #4 stated Patient #3 was acutely ill and paranoid when they first transferred to their unit. They stated the patient refused medications, treatments, and diagnostics. Provider #4 stated Patient #3 lacked trust and was frustrated with the social workers and case managers due to not feeling involved in the care plan and seeing various discharge plans falling through. Provider #4 stated they had built trust with Patient #3 by spending time together and remembering their interests.

Provider #4 stated although Patient #3 appeared to gain capacity over time, their capacity fluctuated and Patient #3 was not able to speak to their plan for discharge. They stated they were not sure if Patient #3's inability to work through a discharge plan with the medical team was due to paranoia or frustration. Provider #4 stated Patient #3 lacked insight into their medical concerns and even at discharge, Patient #3 was not able to speak to their discharge plans. Provider #4 stated they continued to be concerned for Patient #3's safety.

Provider #4 stated capacity evaluations were important as this allowed patients autonomy in their medical decision-making. They stated they did not want to imprison a patient even if the patient made decisions about their care or discharge that they as a provider disagreed with.

iv. On 12/5/24 at 1:44 p.m. and 12/9/24 at 10:26 a.m., interviews were conducted with Provider #1. Provider #1 stated their team had been consulted to assess Patient #3. They stated when performing capacity evaluations, they gave patients every opportunity to show the fullest extent of their capacity. Provider #1 stated they were an advocate for older adults and it was important that older adults had their voices heard and autonomy respected. Provider #1 stated the assessment of capacity was part of the art of medicine although having standard guidance to provide patient-centered care could benefit the patients.

Provider #1 stated capacity reassessments were performed after clinical changes, including acute medical illnesses, losing weight, and changing medications, although there was no set frequency for the evaluations. They stated ideally providers waited until patients were medically stable before assessing capacity. However, Provider #1 stated for patients believed to have dementia and assessed to lack capacity, such as Patient #3, there was no reason to redo the capacity assessment as dementia was a degenerative process. They stated dementia patients were expected to get worse with time and not improve so it was appropriate not to reassess capacity in patients with dementia.

Provider #1 stated Patient #3 was a medical mystery as they had initially presented with what appeared to be dementia. They stated Patient #3's presentation, history, as given by the patient's adult child, signs, symptoms, imaging, and laboratory workup, led the medical team to a diagnosis of dementia. They stated Patient #3 was an outlier whose course was outside the normal range of illness.

Provider #1 stated ensuring providers accurately assessed patients for capacity was important when caring for patients and respecting their autonomy.