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Based on interview and document review, the facility 1) failed to promote and protect patient rights by giving the Important Message from Medicare to 3 (#10, 11, 14) of 6 patients/patient representatives, 2) failed to obtain general consent for treatment for 3 (#10, 11, 12) of 6 patients/patient representatives, 3) failed to report an alleged sexual assault of 1 (#1) of 1 patients according to facility policy, 4) failed to conduct a 1-hour face to face assessment for 1 (#14) of 2 patients, and 5) failed to monitor a patient in violent/behavioral restraints according to facility policy resulting in the potential for loss of patient rights for all patients served by the facility. Findings include:

See Specific Tags:

A-117 Failure to give the Important Message from Medicare
A-131 Failure to obtain an informed consent for treatment
A-145 Failure to report an alleged patient assault per facility policy
A-179 Failure to obtain a 1-hour face-to-face assessment
A-205 Failure to monitor a patient in violent restraints per facility protocol

Based on interview and record review, the facility failed to present the Important Message from Medicare to 3 (#10, 11, 14) of 5 patients whose chart was reviewed for the Important Message from Medicare or their patient representative resulting in the failure to inform the patient or patient's representative of the right to appeal discharge and potential loss of rights for the patient. Findings include:

On 8/3/2022 at 0922, a targeted review of the medical record for Patient #10 revealed he was admitted to the facility from 7/9/2022-7/11/2022. Review of insurance information revealed he did have Medicare; however, no Important Message from Medicare (IMM) was found.

On 8/3/2022 at 0928, a targeted review of the medical record for Patient #11 revealed she was admitted to the facility from 6/15/2022-6/16/2022. Review of insurance information revealed she did have Medicare; however, no IMM was found.

On 8/3/2022 at 1005, a targeted review of the medical record for Patient #14 revealed he was admitted to the facility from 1/172022-1/26/2022. Review of insurance information revealed he did have Medicare insurance; however, no admitting IMM was found.

On 8/3/2022 at 1054, Patient Access Manager Staff AA stated whoever is completing the admission process was responsible for obtaining the IMM. If the patient was unable to sign the IMM for themselves, a yellow piece of paper was placed in the hard chart to indicate the IMM signature needed to be obtained from a patient representative or guardian.

Review of facility policy #11689048 titled "Medicare Beneficiary Notification of Hospital Discharge Appeal Rights (Important Message from Medicare)" effective 5/2022 states, "Important message from Medicare (IM) about your appeal rights: a standard notice that must be delivered to all Medicare inpatients on admission and before discharge; this notice explains the discharge rights of the patient... Hospitals must issue the important Message from Medicare within two calendar days of admission, must obtain the signature of the beneficiary or his or her representative and provide a copy to the patient at that time. The hospital must also deliver a copy of the signed notice as far in advance of discharge as possible, but no more than two calendar days before discharge and prior to four hours of discharge."

Based on interview and record review, the facility failed to obtain general consent for 3 (#10, 11, 12) of 6 patients who were reviewed for consents resulting in the potential of providing unapproved medical care. Findings include:

On 8/3/2022 at 0922, targeted review of Patient #10's medical record revealed a lack of general consent for treatment. This finding was confirmed by Clinical Informaticist Staff M at the time of discovery.

On 8/3/2022 at 0928, targeted review of Patient #11's medical record revealed a lack of general consent for treatment. This finding was confirmed by Clinical Informaticist Staff M at the time of discovery.

On 8/3/2022 at 0942, targeted review of Patient #12's medical record revealed the presence of a general consent for treatment form bearing the label of Patient #12; however, there was no handwriting on the document including the signature of the patient or patient representative to give consent. This finding was confirmed by Staff M at the time of discovery.

Review of facility policy # 11646318 titled "General Consent" effective 4/2022 states, "A General Consent Form is obtained and utilized before medical care, treatment and/or services which are provided within the hospital and do not require Informed Consent (See Informed Consent Policy), except in one of the following circumstances: An emergent or life-threatening condition is present; Outpatient laboratory testing is being sought; Outpatient radiology testing (involving plat plate images i.e. chest x-ray) is being sought... PROCEDURE: 1. The General Consent Form is presented to the patient or the patient's surrogate decision maker for signature prior to medical care, treatment and/or services provided at the hospital, outpatient clinic or physician office. 2. If a patient or surrogate decision maker is unable for any reason to sign their name, they may sign the Consent Form with an "X" or any other mark which the individual intends to constitute their signature. 3. If the patient has capacity and can communicate their consent but is unable to sign the Informed Consent due to impairment (visual, physical, or literacy) the facility associate must sign the form where indicated, noting the date and time. 4. If a patient or surrogate decision maker has a disability or language barrier which impacts their ability to understand the content or purpose of the General Consent Form, special equipment and/or personnel should be utilized to ensure the patient or surrogate decision maker understands the proposed care, treatment, and services before signing the form... 5. If a patient or surrogate decision maker refuses to sign the General Consent Form and still wishes to seek medical care, treatment, and/or services, the associate should contact his or her Chain of Command and/or Risk Management. 6. The completed Consent Form will become part of the permanent medical record."

Based on interview and document review, multiple facility staff members failed to report the allegation of sexual assault of a patient by a staff member according to facility policy for 1 (#1) of 1 patients resulting in the potential for loss of protection for other patients within the facility and the potential for poor patient outcomes. Findings include:

On 8/3/2022 at 1405, review of the medical record for Patient #1 revealed she arrived to the Emergency Department (ED) on 6/29/2022 at 1000 via ambulance with acute mental status changes. While in the ED, Patient #1 was confused, and was experiencing delusions and hallucinations. ED physician notes dated 6/29/2022 state, "Patient is uncertain how she arrived at the hospital. Patient is able to state her name, cannot correctly identify the date, is not oriented to current situation ...the patient has been making statements to nursing staff that she has been assaulted at various facilities, including this hospital. There is no physical signs of this externally. I did discuss with nursing staff, and did evaluate the patient with female nurse present ...Discussed with nursing staff that while the concerns she raised are somewhat inconsistent (sic) she does appear to have some hallucinations, that we will discuss the case with SAFE (Sexual Assault Forensic Nurse Examiner) nurse as well as Adult Protective Services (APS) to have her concerns fully evaluated ..." Physician documentation further stated Patient #1 became very agitated and was unable to be redirected. Haldol (an antipsychotic) was administered.

Following labs and a CT scan (computerized tomography "cat scan"), an order was placed for admission to a cardiac unit. Consults were requested for cardiology, EP (electrophysiology-study of the electrical conduction of the heart) cardiology, neurology, and psychiatry. She was admitted to the cardiology unit with the diagnoses of encephalopathy (altered brain function), elevated troponins (lab value indicating a type of protein found in the muscles of the heart), and acute kidney injury.

ED nursing documentation revealed the following note on 6/29/2022 at 1615: "(Patient #1) states she was raped and man who did it was arrested (sic) 2 minutes ago. Pt then changed (sic) story and stated (Cardiologist Staff Y) and pain manager (doctor name written) raped pt in conference room..." Another note on 6/29/2022 at 1905 stated, "pt states she was 'shot up with pain meds to make kidneys fail.' pt states (Cardiologist Staff Y) confessed... (ED Physician) was notified to incident. RN informed to contact (SAFE) and APS."

During an interview with ED Registered Nurse (RN) Staff W on 8/3/2022 at 1102, Staff W stated she had received a phone call from the internal medicine nurse practitioner (NP) stating the patient had told her she had been sexually assaulted at her rehabilitation center and that the alleged perpetrator had been arrested. Staff W then went to speak to Patient #1. "I can't remember her mentation, but she was all over the place. A lot of what she said didn't make sense ... She told me she was raped in a conference room by (Cardiologist Staff Y) and (another physician name)... She said she had not showered and was able to do a rape kit. I informed the ED doctor and called (company name for the SAFE nurse). (Patient #1) became very agitated and upset. We had to give her medication to calm her down." Staff W further stated APS, hospital security, and the local police department had all been notified of Patient #1's allegations.

Further review of the medical record revealed an entry made by Cardiologist Staff W on 6/29/2022 at 1905 which stated, "Given her continued hallucinations to ER (emergency room) staff, primary team, consultants, and her false accusation against myself, I cannot provide an appropriate physician-pt relationship with the pt. I have asked (EP Cardiologist Staff Z) to take over further cardiac care for the pt."

When interviewed on 8/3/2022 at 0946, Cardiologist Staff W admitted he had seen Patient #1 in the ED "around noon" when the request for consultation came through. "She was confused. Her history was confused ... I have no idea why she would make these allegations against me ..." He stated the nurse from the cardiology unit had paged him around 1800-1900 on 6/29/2022 and told him of the allegations of rape Patient #1 was making against him. "She (Patient #1) said she was assaulted by several other people too ... I did not rape her, and I assume that none of the others did either. I did not see her or meet with her in any conference room ... I did not feel it was appropriate for me or my partner to see her and care for her further." Staff W stated he spoke with the facility's legal counsel regarding the allegations.

On 8/3/2022 at 0909, EP Cardiologist Staff Z stated Cardiologist Staff W had taken care of Patient #1 for years and had discussed the case with him stating he no longer felt comfortable caring for her in light of the accusations she was making against him. Staff Z stated Patient #1 was "a difficult case. She was having delusions at times ... The patient never mentioned any of the accusations to me about (Cardiologist Staff W) or any other physician assault."

Review of the security report dated 6/30/2022 at 0918 revealed the time of the incident's occurrence was "6/29/2022 at 12:00 AM" well before Patient #1's arrival to the ED. The report stated Security Officer Staff X had been dispatched to Patient #1's room regarding allegations of CSC (Criminal Sexual Conduct).

On 8/3/2022 at 1113, Security Officer Staff X stated during interview he had gone to the cardiology unit to speak with the patient. "She reported she was sexually assaulted, and that it didn't happen here, but at her nursing home. She said she didn't remember it, but staff told her it happened. While talking, she became very upset. She said she was told by staff she was assaulted by her cardiologist and that other staff were standing in the hallway watching and laughing ... I told her I wrote everything down and that the police would be called. I went and told my manager."

Review of the Complaints/Grievance Log from 2/2022-present and the Incident Report Log from 2/2022-present revealed no entries regarding Patient #1 or any allegations of alleged rape. Regulatory Compliance Specialist Staff C was queried on 8/2/2022 at 1430 as to if the risk or quality personnel were aware of these allegations prior to the beginning of survey to which she stated "no."

Review of facility policy #9464552 titled "Abuse and Neglect: Report" effective 3/2021 states, "Any associate who witnesses or receives a report of alleged abuse or neglect from a patient/family, other patient, staff member, visitors, or other person should immediately notify the on-duty department leader and Risk management should be contacted immediately... The department leader and/or House Nursing Supervisor will ascertain the safety of the patient by: 1. Removal of patient caregiver/staff member from providing direct patient care... An ERS Report (Incident Report) should be completed... Human Resources should be notified of the allegation as soon as possible following an allegation of abuse to assure the employee subject (of) the allegation is placed on administrative leave during the course of the investigation until the analysis is completed and closed."

Based on interview and record review, the facility failed to conduct a 1-hour face-to-face assessment following the initiation of restraints in 1 (#14) of 2 patients reviewed for behavioral restraint usage resulting in the potential for unnecessary restraint of a patient. Findings include:

On 8/3/2022 at 1005, a targeted review of the medical record for Patient #14 revealed a lack of documentation for the 1-hour face-to-face assessment following the application of restraints. This finding was confirmed by Clinical Informaticist Staff M and Regulatory Compliance Staff E at the time of discovery.

Review of facility policy #12061849 titled "Restraint Policy" effective 7/2022 states, "Initiation of Restraint... Perform face to face evaluation of the patient in restraint within 1 hour after the initiation of restraint. This evaluation will include the patient's: immediate situation, reaction to the intervention, medical and behavioral condition, AND the need to continue or discontinue the restraint."

Based on interview and record review, the facility failed to monitor 1 (#14) of 2 patients in violent restraint according to facility policy resulting in the potential for poor patient outcomes up to and including death. Findings include:

On 8/3/2022 at 1005, review of the medical record for Patient #14 revealed an order for violent (or behavioral) 4-point hard restraints dated 1/19/2022 at 1650. Four point hard restraints were placed on Patient #14 at 1645. Dates and times of patient monitoring were as follows:

1/19/2022 1650
1/19/2022 1700
1/19/2022 1800

Restraints were released on 1/19/2022 at 1909.

On 8/3/2022 at 1012, Regulatory/Compliance Staff E was queried as to facility policy for monitoring a patient in behavioral restraint to which she stated it should be done "every 15 minutes... It looks like they did hourly checks like they would for a non-violent (medical) restraint." The nurse who documented the restraint was unavailable for interview as she was no longer under contract with the facility.

Review of facility policy # 12061849 titled "Restraint Policy" effective 7/2022 states, "The RN (registered nurse) performing neuro-vascular assessments must document findings in the medical record at least every 15 minutes or at more frequent intervals if indicated."