HospitalInspections.org

Based on record review and interview, the facility failed to provide consent forms which allowed the patient's informed consent, to know what their rights are, and/or to allow or deny medical treatment for 11 (P#1-11) of 11 (P#1-11) patients. The facility also failed to inform its patients with written notice that there is no Doctor of Medicine or Osteopathy present in the hospital 24 hours per day, seven days per week for 11 (P#1-11) of 11 (P#1-11) patients. This failed practice does not give patients information in order to consent to care or treatment.
The findings are:

A. Record review of 11 (P#1-11) of 11 (P#1-11) patients' medical charts revealed two different consent forms: (1) [facility name] Consent to treat and conditions of admission (sic) revised 05/09/18 and (2) [facility name] Consent to treat and conditions of admission (sic) dated Revised 04/15/19. Neither form provided information to allow patients to refuse treatment. Niether form provided information as to who could receive patient's medical information and to whom this medical information could be released.

B. On 10/16/19 at 3:15 pm during interview, the Quality Director S#1 confirmed their [facility name] consent forms do not include a space for initials, signature line, or a check mark box indicating permission for release of records. The consent form also did not not include a space for initials, signature line, or a check mark box indicating refusal of treatment or permission for whom to allow release of information.

C. Record review of 11 (P#1-11) of 11 (P#1-11) patients' medical charts revealed signed consents for treatment which did not indicate there is no Doctor of Medicine or Osteopathy present in the hospital 24 hours per day, seven days per week.

D. On 10/16/19 at 3:15 pm during interview, the Quality Director S#1 stated, "there is no Doctor on premises 24/7." She further confirmed the facility does not have any consent forms which specifically states this.

Based on record review and interview the facility failed to document RN supervised nursing care in 4 (P#5, P#6, P#7, and P#9) of 11 (P#1-P#11) patients. This deficient practice can lead to patients not receiving interventions necessary for their change in status which could lead to patient death. The findings are:

A. Record review of P#9 medical chart revealed the patient died on 09/15/19 at 5:16 am. Record reviewed further revealed no documentation of change in status was documented for P#9.

B. Record review of Night Shift Staffing Sheet dated 09/13/19 for 6:00 pm to 6:00 am revealed LPN S#10 was assigned P#5, P#6, P#7, and P#9. No evidence was documented that an RN supervised or evaluated LPN S#10 for P#5, P#6, P#7, and P#9.

C. On 10/16/19 at 11:38 am during interview S#3 CNO confirmed there was no way to establish RN supervision or evaluation of patient care on the Nurse Staffing Sheet dated 09/13/19 for 6:00 pm to 6:00 am for P#5, P#6, P#7, and P#9. S#3 CNO stated, "patients just die" when asked about the change of status for P#9.

Based on record review and interview the facility failed to update medical record information including nursing interventions and a reassessment for the patient's change in health status in 1 (P#9) of 11 (P#1-P#11) patients. This deficient practice could lead to patient death.
The findings are:

A. Record review of ED Transfer Summary from transferring hospital (hospital #1 dated 09/10/19) indicated, P#9 presented to hospital #1 ER following a fall out of bed and hit head on bedside table. P#9 then transferred to hospital #2 (current facility) on 09/12/19 to receive physical therapy.

B. Record review of Admission History & Physical dated 09/12/19 revealed Physician S#5 referred to P#9 as "his" or "him" in all of Physician S#5 documentation. Record review of P#9 reveals this patient was a female.

C. Record review of MAR on 09/14/19 for P#9 revealed 4 mg of Zofran was administered at 7:00 am and 11:00 am. No evidence of documentation was found in medical chart that any change in assessment was noted. No assessment was documented revealing change in signs and symptoms which required administration of Zofran.

D. Record review of medical chart for P#9 occupational therapy notes dated 09/14/19 at 12:27 pm indicated, S#16 OT documented, "[P#9] with decreased strength in RUE discussed with charge RN and tech. Placed heating pad on patient and discussed possible need for psych consult." No evidence of reassessment by an RN for P#9 was found in the patient's medical chart.

E. Record review of medical chart for P#9 physical therapy notes dated 09/14/19 at 16:15 (sic) pm indicated, S#18 PT documented, "UE will not move new symptom painful to bend nursing notified." No evidence of reassessment by an RN for P#9 was found in the patient's medical chart.

F. Record review of medical chart for P#9 dated 09/14/19 at 22:04 (sic) pm indicated S#17 RN completed full assessment charting WNL on all body systems. Pain score at that time was documented as 7 out of 10 for upper arm. No evidence of documented interventions or reassessments by an RN were found in the chart for 09/14/19.

G. On 10/15/19 at 11:38 am during interview, S#3 CNO confirmed there was no documentation in the chart of a reassessment by an RN for P#9.

H. On 10/15/19 at 11:38 am during interview, S#1 Director of Quality confirmed there was no evidence of documentation of a reassessment by an RN for P#9.