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Based on review of medical records and interview, the facility failed to ensure one of two patients (Patient#2) had the right to make informed decisions regarding his or her care, or that the patient's representative was notified to make informed decisions for the patient.

Findings included:

A review of the patient # 2's medical record revealed the patient was admitted to the hospital on 11/30/2021 from the emergency room for altered mental status, severe sepsis, acute respiratory failure, chronic obstructive pulmonary disease and hypertension. Further review of the medical record revealed the patient was showing improvement and continued to be confused. The review revealed a nurse progress noted from 12/05/2021 the nurse reported the patient was not able to speak, had become increasingly confused and the physician was notified. A case management note from 12/06/2021 revealed a referral to a skilled nurse facility when the patient was discharged, however the patient reported they no longer wanted to go to a skilled nurse facility and wanted to go home with home health. A review of a nurse progress noted from 12/06/2021 at 7:00 PM reported "upon entering the room, it appears pts family member-maybe daughter is yelling at patient for unknown reason. Pt yelling back at her. I told her we will assist him back to bed now. She begins to walk out of room and starts raising her voice to staff in RM. She said we were out of clean linens, pts bed is noted to have fresh linens and bed is made, and she mentions its 'ridiculous for him to be in the chair' I instructed her it is good for him to be up oob in chair. She continues to yell for unknown reason and leaves. PT now aggravated stating he's going to 'Kick our ass." I asked pt if he would like to get back in bed and he refused and continues to talk aggressively to staff. Posey on. Pt alert to self, not location or time." A review of another nurse's note dated 12/06/2021 at 8:36 PM, revealed the patient's son called the nurse's station stating the conversation was being recorded and wanted information regarding the nurses taking care of the patient and when referred to the house supervisor, became upset and stated they would be coming to the hospital with their lawyer. A review of another nurse's noted from 12/06/2021 at 8:50 PM, the patient was sitting up in the floor stating they were going home, the patient was reported to be swinging fists at the staff and appeared confused, there was an attempt to notify the patient's spouse that was unsuccessful.
A review of the medical record on for 12/07/2021 revealed case management attempted to contact the patient's spouse and the phone call went unanswered. A nurse note dated 12/07/2021 at 10:45 am, revealed the patient's daughter arrived at the hospital and signed the patient out of the hospital against medical advice.

A review of the patient's consent forms revealed they were signed by the patient's spouse. Further review of the patient's medical record revealed the patient's next of kin and emergency contact was the patient's spouse. There was no documentation found the patient's daughter had authority to sign the patient out of the hospital and the documentation revealed the patient was confused to time, location and situation. A review of the AMA form dated 12/07/2021 revealed the patient's daughter signed the AMA form and not the patient. There was no documentation found the patient expressed a desire to leave against medical advice.

A review of the facility policy titled "Leaving Against Medical Advice" date 03/01/2021, stated in part,
"Policy:
1.0 No person determined to have decision-making capacity who desires discontinuation of medical treatment and release from the hospital shall be held against their will.

2.0 If the patient chooses to leave the hospital against medical advice, the nurse will request that he/she sign AMA forms."

A interview with the Staff # 6 on 09/07/2022 at 2:00 PM, confirmed the above findings.