HospitalInspections.org

Based on medical record review, policy review, and patient and staff interviews, the ACH ' s administrative staff failed to ensure Emergency Department (ED) staff appropriately involved the designated representative of 1 of 5 sampled patients (Patient #15) in the development of his or her plan of care. Failure to appropriately involve all patients and their respective representatives in care planning and treatment decisions could result in the provision of medical services contrary to the patient ' s wishes, as well as the withholding of services preferential to said patient or representative.

The ACH ' s administrative staff identified a total census of 17 patients who presented to the ED on 1/21/25 requesting medical services.

Findings include:

1. Review of Patient #15 ' s 1/21/25 medical records revealed the following:

a. On 1/21/25 at 8:42 AM, Patient #15, a 98-year-old resident of an assisted living facility (ALF), presented to the ED with increased confusion, weakness, somnolence (drowsiness), shaking, yelling out, and inability to ambulate (move or walk independently). Staff PP (ED RN) documented the patient repeatedly stated, " Oh [expletive], " " I ' ll freeze, " and " I don ' t know what ' s wrong with me " and had limited ability to communicate beyond these refrains. Staff H (Patient Access Representative) documented " not physically able to sign " on the patient ' s consent for treatment form in lieu of a signature from the patient or their designated representative.

b. On 1/21/25 at 8:48 AM, Staff PP documented the patient was unable to answer basic questions or follow simple instructions. Staff PP characterized the patient ' s behavior and verbal responses as " moans " and " confused conversation " and identified the patient as " cognitively impaired. " At 9:16 AM, Staff WW (ED Physician) diagnosed the patient with acute altered mental status (AMS) and acute encephalopathy (serious brain dysfunction associated with confusion and memory loss), and at 6:41 PM, Staff YY (ED RN) identified the patient as " cognitively unable " to swallow oral medication.

2. Review of Patient #15 ' s 6/3/2011 Durable Power of Attorney (DPOA), which hospital staff uploaded to the patient ' s medical records on 11/6/23, revealed the following: " I, [Patient #15] . . . designate: [DPOA designee] . . . as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical surgical, hospital and related health care . . . This power of attorney is effective on my inability to make or communicate health care decisions. "

3. During an interview on 1/23/25 at 11:30 AM, Patient #15 could neither articulate the reason for their hospitalization nor approximate the length of the admission, estimating " At least a few weeks, " despite arriving at the hospital two days prior.

4. During an interview on 1/22/25 at 2:25 PM, Patient #15 ' s DPOA designee reported hospital staff had not-in accordance with the patient ' s advanced directives-contacted them to enable their participation in the development and implementation of the patient ' s care plan.

5. During an interview on 1/23/25 at 10:35 AM, Staff PP (ED RN) reported the patient presented to the ED on 1/21/25 with ALF staff, who reported the patient had developed an inability to communicate intelligibly, instead repeating " Oh [expletive], oh [expletive], oh [expletive]. " Staff PP reported awareness that registration staff unsuccessfully attempted to obtain the patient ' s signature for informed consent. Staff PP confirmed they documented the patient was unable to answer basic questions or follow simple instructions but denied asking said questions or providing said instructions to the patient. Staff PP acknowledged they were expected to contact a patient ' s DPOA if the patient could not make their own informed medical decisions but stated, " It wasn ' t clear if the POA needed to be contacted, " despite the patient ' s inability to communicate or make decisions.

6. During an interview on 1/27/25 at 11:30 AM, Staff H (Patient Access Representative) reported they attempted to obtain consent from the patient upon their arrival to the ED; however, the patient was unable to communicate, open their eyes, or hold the provided writing instrument. Staff H reported the patient appeared to flutter their eyes but appeared otherwise unresponsive. Given this information, Staff H acknowledged the appropriate response would have been to obtain a signature for consent from the patient ' s representative. Staff H identified a need for further staff education on the appropriate steps to take when a patient has a representative (e.g., legal guardian or DPOA assignee).

7. During an interview on 1/22/25 at 3:10 PM, Staff C (Director of Outpatient and Emergency Services) reported they expected staff to review the patient ' s emergency contact list if unsure whether a patient had a guardian or representative and to inform the patient representative, if applicable, of any procedures or other aspects of the patient ' s care.

8. During an interview on 1/23/25 at 9:35 AM, Staff II (ED Supervisor) reported they expected ED providers to make a determination of whether a patient with altered mental status could make their own medical decisions, and they expected staff to contact the patient ' s representative, when applicable, as soon as they had an opportunity to do so.

9. Review of the hospital ' s 11/2022 " Patient or Representative Rights and Responsibilities " policy revealed in part: " Patient or Representative Rights and Responsibilities. The patient or representative has the right to: . . . 7. Participate in the development and implementation of his/her plan of care. Participate in making decisions about the medical care that he/she may receive. "