HospitalInspections.org

Based on review of the medical records it was determined that the hospital failed to certify patient #3's capacity to make informed decisions but instead relied on her daughter as a surrogate decision maker as evidenced by:

Patient #3 presented to the ED 3/31/16 after fall at home with altered mental status. Patient #3 was admitted to Nelson 8. Patient #3 was asked if he/she had an advanced directive and stated "yes" but the patient did not wish to have a copy placed in his/her medical record. Since patient #3 had an altered mental status. the patient's daughter documented as his/her decision maker during the patient stay. Further review of the medical records revealed that the hospital staff failed to document the required certifications by two physicians indicating that the patient lacked capacity to make decisions about care. In order to use the daughter as the decision maker, the hospital must determine that the patient lacked the capacity to make their own decisions.

Based on the review of medical records it was determined that patient #3 was kept in the hospital on observation status but was provided with the necessary notice as evidenced by:
Patient #4 is a 79 male who presented to the ED on 06/02/16. Patient #4 was placed on observation status by the ED for cardiac monitoring. The notification form informing the patient of their observation status as outpatient level of care was not provided to patient #4 in the ED or upon arrival to an observation bed on Nelson 8. Patient #4 was not made aware of his observation status and therefore, was unaware of the possible financial implications associated with an observation stay.