HospitalInspections.org

Based on record review and interview the facility failed to ensure an executed informed consent and/or documentation of the Medicare "Important Message" for all patients presenting to facility for evaluation and/or treatment. Citing 12 of 27 patient records reviewed. (#2, 3, 5, 6, 7, 11, 12, 14, 15, 23, 24, and 27).

On 1/28/2013 while reviewing patient medical records the following was revealed:

1. Patient medical record #2- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
2. Patient medical record #3- no documentation of informed consent found.
3 Patient medical record #5- no documentation of informed consent found.
4. Patient medical record #6- no documentation of informed consent found.
5. Patient medical record #7- no documentation of informed consent found.
6. Patient medical record #11- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
7. Patient medical record #12- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
8. Patient medical record #14- no documentation of Medicare "Important Message" found.
9. Patient medical record #15- no documentation of Medicare "Important Message" found.
10. Patient medical record #23- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
11. Patient medical record #24- no documentation of patient signature, date/time, and/or witness signature documented on informed consent.
12. Patient medical record #27- no documentation of informed consent found.

Review of Paris Regional Medical Center Policy and Procedure Administrative Manual revealed the following:
Section: Adm/Business Office Effective date: 9/1/2001
Policy: Consent for Treatment
Purpose: To have the patient sign a Consent for Treatment prior to their admission or treatment.
Policy: All patients, their legally authorized representative, their legal guardian, or their family member must sign a Consent for Treatment/Financial Responsibility Acknowledgement.
Procedure:
1.0 At the time of registration or pre-registration the Registration Specialist will have the patient, their legal guardian or their legally authorized representative sign a General Consent for Treatment form and provide a "Patient Information Packet" that contains the following documents:
1.0 Privacy Notice
2.0 Information on Patient's Rights and Responsibilities
3.0 Communicating Your Health Care Choices (Advance Directive)
4.0 Important Message from Medicare
2.0 For direct admit patients the Registration Specialist will follow the Direct Admit policy.
3.0 Consents are not to be signed more than five (5) days in advance of the actual date of service.

Interview with Chief Nursing Officer and Supervisor of Registration on 1/28/2013 confirmed the findings.

Based on record review and interview the facility failed to ensure all nurses performing patient care in the facility had competencies documented. Citing 3 of 10 personal files reviewed. (#14, 15, and 16.)

On 1/29/2013 while reviewing personal files the following was revealed:
Staff #14- No documentation of competencies documented.
Staff #15- No documentation of competencies documented.
Staff #16- No documentation of competencies documented.

Interview on 1/29/2013 at 9:45 am with the Chief Nursing Officer confirmed the findings.

Based on Record review and interview the facility failed to conduct a medical screening examination on 1 of 25 Emergency Department (ED) records reviewed. (Record #20).

Review of ED patient medical records on 1/28/2013 revealed the following:
1. Patient record #20 - The patient was admitted to the Emergency Department (ED) on 1/1/2013 at 3:03 pm.
-The chief complaint was rash on face started one week ago.
- Patient received to Triage at 3:03 pm: Vital signs stable. Complaining of face itching. Priority level: SEMI-URGENT.
-Patient ambulated to exam room at 5:39 pm and chart up for physician to see.
-At 5:44 pm emergency physician in to see patient.
-At 5:45 pm the Registration Specialist was approached by physician. It was determined the patient condition was non-emergent and was advised to complete medical screening exam form.
-At 5:52 pm patient left declining care.
- Departure vital signs stable.
- No documentation of the physician medical screening examination found.

Review of Paris Regional Medical Center Screening Exam Form reveals:
*Non-Urgent Medical Condition: Following completion of this patient's medical screening exam. I have reasonable clinical confidence that this patient does not have an emergency condition. I would anticipate a good clinical outcome if the patient observes prudent self-care and pursues timely follow-up. The patient may be allowed to participate in financial decision regarding the location of his or her care. Signed by emergency room physician.

*Physician statement to patient: "I have determined that you do have a condition that requires further evaluation and/or treatment, but you do not have an emergency medical condition. We should be able to help you manage this problem, but first we will have a Registration staff member speak to you. They will help you make arrangements to continue your treatment while I get your chart written and arrange your care."

Patient elected not to continue treatment.
Signed by registration specialist on 1/1/2013 at 5:45 pm.
No patient signature and/or witness signature documented on form.

Interview with the ED Registration Specialist on 1/31/2013 at 10:30 am revealed the following:
"I am called at the end of the ED visit to complete forms as requested by the physician. If the physician determines the patient conditions are non-emergent I then go in and have patient sign the medical screening form after the physician completes his part. The physician refers patient to see a private provider if non-emergent. I don't question their financial status nor do I have access to past due bills. That's not part of my job. It is all left up to the physician during the patient medical screening examination as to whether to proceed with exam or not."

On 1/31/2013 at 1:30 pm a telephone interview with the Quality Director stated the following:
"Each patient presenting to the Emergency Department (ED) with a complaint should have a medical screening examination documented, unless patient leaves before being seen. Prior to determination that patient has emergent/non-emergent medical condition; the physician should still document a medical screening exam. This medical screening exam should be documented in the patient medical record."

Interview with the Quality Director on 1/31/2013 confirmed the findings.

Based on record review and interview the facility failed to ensure an executed informed consent and/or documentation of the Medicare "Important Message" for all patients presenting to facility for evaluation and/or treatment. Citing 12 of 27 patient records reviewed. (#2, 3, 5, 6, 7, 11, 12, 14, 15, 23, 24, and 27).

On 1/28/2013 while reviewing patient medical records the following was revealed:

1. Patient medical record #2- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
2. Patient medical record #3- no documentation of informed consent found.
3 Patient medical record #5- no documentation of informed consent found.
4. Patient medical record #6- no documentation of informed consent found.
5. Patient medical record #7- no documentation of informed consent found.
6. Patient medical record #11- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
7. Patient medical record #12- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
8. Patient medical record #14- no documentation of Medicare "Important Message" found.
9. Patient medical record #15- no documentation of Medicare "Important Message" found.
10. Patient medical record #23- no documentation of informed consent found. No documentation of Medicare "Important Message" found.
11. Patient medical record #24- no documentation of patient signature, date/time, and/or witness signature documented on informed consent.
12. Patient medical record #27- no documentation of informed consent found.

Review of Paris Regional Medical Center Policy and Procedure Administrative Manual revealed the following:
Section: Adm/Business Office Effective date: 9/1/2001
Policy: Consent for Treatment
Purpose: To have the patient sign a Consent for Treatment prior to their admission or treatment.
Policy: All patients, their legally authorized representative, their legal guardian, or their family member must sign a Consent for Treatment/Financial Responsibility Acknowledgement.
Procedure:
1.0 At the time of registration or pre-registration the Registration Specialist will have the patient, their legal guardian or their legally authorized representative sign a General Consent for Treatment form and provide a "Patient Information Packet" that contains the following documents:
1.0 Privacy Notice
2.0 Information on Patient's Rights and Responsibilities
3.0 Communicating Your Health Care Choices (Advance Directive)
4.0 Important Message from Medicare
2.0 For direct admit patients the Registration Specialist will follow the Direct Admit policy.
3.0 Consents are not to be signed more than five (5) days in advance of the actual date of service.

Interview with Chief Nursing Officer and Supervisor of Registration on 1/28/2013 confirmed the findings.

Based on record review and interview the facility failed to ensure all nurses performing patient care in the facility had competencies documented. Citing 3 of 10 personal files reviewed. (#14, 15, and 16.)

On 1/29/2013 while reviewing personal files the following was revealed:
Staff #14- No documentation of competencies documented.
Staff #15- No documentation of competencies documented.
Staff #16- No documentation of competencies documented.

Interview on 1/29/2013 at 9:45 am with the Chief Nursing Officer confirmed the findings.

Based on Record review and interview the facility failed to conduct a medical screening examination on 1 of 25 Emergency Department (ED) records reviewed. (Record #20).

Review of ED patient medical records on 1/28/2013 revealed the following:
1. Patient record #20 - The patient was admitted to the Emergency Department (ED) on 1/1/2013 at 3:03 pm.
-The chief complaint was rash on face started one week ago.
- Patient received to Triage at 3:03 pm: Vital signs stable. Complaining of face itching. Priority level: SEMI-URGENT.
-Patient ambulated to exam room at 5:39 pm and chart up for physician to see.
-At 5:44 pm emergency physician in to see patient.
-At 5:45 pm the Registration Specialist was approached by physician. It was determined the patient condition was non-emergent and was advised to complete medical screening exam form.
-At 5:52 pm patient left declining care.
- Departure vital signs stable.
- No documentation of the physician medical screening examination found.

Review of Paris Regional Medical Center Screening Exam Form reveals:
*Non-Urgent Medical Condition: Following completion of this patient's medical screening exam. I have reasonable clinical confidence that this patient does not have an emergency condition. I would anticipate a good clinical outcome if the patient observes prudent self-care and pursues timely follow-up. The patient may be allowed to participate in financial decision regarding the location of his or her care. Signed by emergency room physician.

*Physician statement to patient: "I have determined that you do have a condition that requires further evaluation and/or treatment, but you do not have an emergency medical condition. We should be able to help you manage this problem, but first we will have a Registration staff member speak to you. They will help you make arrangements to continue your treatment while I get your chart written and arrange your care."

Patient elected not to continue treatment.
Signed by registration specialist on 1/1/2013 at 5:45 pm.
No patient signature and/or witness signature documented on form.

Interview with the ED Registration Specialist on 1/31/2013 at 10:30 am revealed the following:
"I am called at the end of the ED visit to complete forms as requested by the physician. If the physician determines the patient conditions are non-emergent I then go in and have patient sign the medical screening form after the physician completes his part. The physician refers patient to see a private provider if non-emergent. I don't question their financial status nor do I have access to past due bills. That's not part of my job. It is all left up to the physician during the patient medical screening examination as to whether to proceed with exam or not."

On 1/31/2013 at 1:30 pm a telephone interview with the Quality Director stated the following:
"Each patient presenting to the Emergency Department (ED) with a complaint should have a medical screening examination documented, unless patient leaves before being seen. Prior to determination that patient has emergent/non-emergent medical condition; the physician should still document a medical screening exam. This medical screening exam should be documented in the patient medical record."

Interview with the Quality Director on 1/31/2013 confirmed the findings.