HospitalInspections.org

Based on medical record review, and interview the facility failed to ensure that 1 of 18 patients (#1), or the complainant's designated power of attorney ( DPOA), received a copy of the Important Message from Medicare (IMM) resulting in the patient or their designee being uninformed regarding their rights. Findings include:
During medical record review on 01/13/2015 at approximately 1350 it was revealed that patient #1's medical record failed to have the required IMM documentation. During an interview with staff B on 1/14/2015 at 1000, it was confirmed that the IMM was not in the medical record for patient #1. Staff B stated, "The IMM was not on the chart and we do not know what happened to it." "It is our policy to have the admission clerk obtain the signature for the patient or the DPOA (durable power of attorney [for medical care]) upon admission."

Based on interview and document review the facility failed to implement their written policies and procedures related to disruptive patients and visitors, resulting in the potential loss of rights to all patients being served by the facility and for patient and/or visitor harm from aggressive behavior. Findings include:

On 1/13/2015 at 1300, staff D provided a handwritten log of events related to the power of attorney (POA) for patient #1, including documentation of a phone call from staff C on 11/18/2014 (no time was documented) stating that "the POA was not allowed back on (facility A) property."

On 1/14/2014 between 0800 and 1330 staff, two security, three administrators (including one vice president of nursing), two supervisors, a nurse manager, a social worker, and a case manager were interviewed regarding the behavior of patient #1's POA. Three of those interviewed reported hearsay and rumors that the POA had been banned from the facility. No one could produce documentation of any disruptive events or that the patient's POA was not allowed to visit.

On 1/14/2014 at 0800 staff A, director of compliance produced a policy titled, "Disruptive Patients and Visitors" dated/revised 7/2014, "#PC-128", this policy included a document to be filled out on page 15, titled, "Workplace violence-managing patient/visitor aggression Appendix G: Assessment of event." This document included the date and time of the incident, staff involved, manager notification, and a signature of the person completing the document.

Staff A was asked whether this Appendix G document had been completed for the reported patient #1's POA behavior. Staff A stated, "No one has filled out any of these forms, no incidents have been documented."