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Based on record review and interview, the facility failed to coordinate Patient's Plan of care with the patients designated medical power of attorney in 1 of 10 sampled patient. Patient #1

Findings:
Review of patient #1 ' s clinical record ( Standard Patient Summary) dated 02/20/2010 revealed he was presented to the emergency room of the facility on 02/20/2010 with chief complaint of abdominal pain. A clinical impression of Small Bowel Obstruction with Inguinal Hernia was diagnosed. The Patient was admitted to the hospital on 02/21/2010.

Review of a medical History and Physical dated 02/21/2010, revealed the patient was admitted with diagnosis of small bowel obstruction secondary to incarcerated hernia. The history indicated that the small bowel obstruction was treated non surgically initially.
A general surgery consent was obtained from the patient's designated agent. The patient was treated with intravenous antibiotics and a naso gastric tube was inserted and place to low wall suction. The record revealed patient #1 did not respond to non- surgical intervention so subsequently the patient had abdominal surgery.
The patient was discharged from the facility to a skilled nursing facility on 03/03/2010 with a ileostomy tube, Foley catheter and two drainage tubes post surgery.


Review of the patient's clinical record revealed a Coding Summary for admission period 02/21/2010 - 03/03/2010. The summary indicated the following diagnosis for patient #1 : Alzheimer Disease, Dementia in Conditions w/o Behavioral Disturb.

Review of the patient's plan of care dated 02/20/2010 - 03/03/2010 revealed no evidence that the patient medical power of attorney was included in the care planning process for discharge planning and direction for care/ follow up visit for the surgical site and drainage tubes which the patient was discharged to the skilled nursing facility with.

Case Manager (A)
In an interview with Case Manager (A) on 07/27/10 at 1:27 p.m. in the conference room she stated that she only spoke with the patient ' s wife during the course of his stay. Case manager (A) said she spoke with the patient ' s daughter who called and notified her that she was the legal agent to make decision for the patient. Case Manager (A) said she recalled that the patient ' s daughter called her during the course of his hospitalization but she cannot recall discussing discharge planning with the patient ' s daughter (agent.)

Review of the facility's policy and procedure # 900 - 012 on patient's Rights and Responsibilities documented " You have the right to be informed and participate in decisions regarding care. to designate a person to make treatment decisions for you should you be unable to do so."

Based on observation, interview and record review, facility ' s care planning team failed to evaluate and develop a Discharge Plan and discuss the said plan with patient ' s designated , health care agent in 2 of 10 sampled patients #s 1 and 2.

Findings:

Review of patient #1 ' s clinical record ( Standard Patient Summary) dated 02/20/2010 revealed he was presented to the emergency room of the facility on 02/20/2010 with chief complaint of abdominal pain. A clinical impression of Small Bowel Obstruction with Inguinal Hernia was diagnosed. The Patient was admitted to the hospital on 02/21/2010.

Review of a medical History and Physical dated 02/21/2010, revealed the patient was admitted with diagnosis of small bowel obstruction secondary to incarcerated hernia. The history indicated that the small bowel obstruction was treated non surgically initially.
A general surgery consent was obtained from the patient's designated agent. The patient was treated with intravenous antibiotics and a naso gastric tube was inserted and place to low wall suction. The record revealed patient #1 did not respond to non- surgical intervention so subsequently the patient had abdominal surgery.
The patient was discharged from the facility to a skilled nursing facility on 03/03/2010 with a ileostomy tube, Foley catheter and two drainage tubes post surgery.

Review of the patient's clinical record revealed a Coding Summary for admission period 02/21/2010 - 03/03/2010. The summary indicated the following diagnosis for patient #1 : Alzheimer Disease, Dementia in Conditions w/o Behevioral Disturb.

Review of patient #1's clinical record ( nurses' notes, physicians' progress notes and case managers' progress notes), during the course of the patient's admission to the facility from 02/21/ 2010 - 03/03/2010 revealed no evidence that discharge planning was discussed with the patient's designated agent responsible for medical decisions. .

Review of the patient ' s clinical record revealed a Sedation / Anesthesia consent form dated 02/25/2010 signed by the patient's designated agent Medical Power of Attorney consenting to surgery for exploratory laparotomy, lysis adhesion.
The patient ' s clinical record indicated a signed and dated copy of Medical Power of Attorney in the patient's record.

Case Manager (A)
In an interview with Case Manager (A) on 07/27/10 at 1:27 p.m. in the conference room she stated that she only spoke with the patient ' s wife during the course of his stay. Case manager (A) said she spoke with the patient ' s daughter who called and notified her that she was the legal agent to make decision for the patient. Case Manager (A) said she recalled that the patient ' s daughter called her during the course of his hospitalization but she cannot recall discussing discharge planning with the patient ' s daughter (agent.)

DR (B)
In an interview with the patient's hospital attending physician (Dr B) on 07/27/10 at 10:58 a.m. in the conference room of the intermediate care unit, he stated that he was not the patient's physician but he saw and treated the patient, because the patient ' s physician did not have admitting privileges at the hospital. He said the patient was admitted over the weekend of February 20, 2010. He said the patient had dementia and although alert was not capable of making decisions. Dr (B) said he did not think that the patient was capable of making his own decision.
He said he read from the notes that patient had multiple problem and so initially conservative management was decided by putting in a nasogastric tube.

Dr (B) said he had spoken to the patient ' s wife on several occasions but had not met with the wife in person.He said he took for granted that the patient ' s wife was responsible for making medical decisions. He said he did not know that the patient had a designated agent to make medical decision. Dr (B) said the patiens's wife spoke to him on the phone. Said he met the patient ' s daughter in his room but she did not know that the patient ' s daughter was his legal agent to make health care decision.

Dr B said the patient spent 2-3 days in the intensive care unit. The patient progressed rapidly and was discharged to the intermediate care unit. He said the patient was evaluated by the surgeon who said the patient was ready for discharge. Dr (B) said he agreed that the patient was ready to be discharged to the rehabilitation center after the wife told him she wanted the patient sent to the skilled nursing facility.
DR B said he did not discuss discharge planning with the patient's daughter who was his designated medical power of attorney.

Patient #2

On 07/27/2010 at 10:38 a.m, patient # 2 was heard screaming inappropriately in her room.

Interview with the charge nurse of the unit on 07/27/10 at 10:40 a.m. at the nurses station revealed patient #2 was demented, resides in a nursing home and that her sister was responsible for her care.

Review of patient #2 ' s clinical record (demographic data) revealed she was admitted to the facility on 07/22/2010 with diagnosis of altered mental status and psychosis.

Review of a Sedation /Analgesic Anesthesia consent form dated 07/22/2010 for central line placement revealed a telephone consent from the patient ' s sister and a notation which stated " altered mental status. "

Review of the patient ' s clinical record revealed an order dated July 26, 2010 for " Notify G Psych to do Pre- Admission Assessment. "
Review of a physician ' s notes dated 07/26/10 revealed the following entry " Can D/C home with oral Doxy. "

Review of the patient ' s clinical record and nursing care plan revealed no evidence of a Discharge Planning Evaluation with the patient ' s sister who the hospital said was responsible for decision making for patient #2.

Interview with facility ' s case manager (A) on 07/27/10 at 12.05 p.m.in the conference room .She stated that she was thinking that the patient would go to the Geri psych unit after discharge from the facility, but she did not meet or discuss with the patient ' s family regarding the teams decision for discharge planning for patient #2.

Review of the facility's policy and procedure # 900 - 012 on patient's Rights and Responsibilities documented " You have the right to be informed and participate in decisions regarding care. to designate a person to make treatment decisions for you should you be unable to do so."