HospitalInspections.org

Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Patient Rights at 482.13.

Based on interview, record review, and policy review, the facility failed to:

-Inform patients or their patient representatives of the patient's rights prior to providing or discontinuing services. (A0117)

-Investigate and address a written concern about a patient's care in an outpatient setting in which the facility provides oversight. (A118)

-Provide a written notice of resolution following a complaint/grievance investigation, to the patient or patient representative. (A0123)

-Obtain a consent to treat in the emergency room setting prior to providing or discontinuing care. (A0131)

-Inform a patient of their right to formulate an advanced directive in an outpatient setting. (A0132)

-Inform a patient of their rights for visitation. (A216)

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Outpatient Services at 482.54.

Based on interview, record review, and policy review, the facility failed to develop and implement policies and procedures for their outpatient setting, to include mechanisms for triaging, pain management interventions, constipation management, and provider notification for 1 (#1) of 3 post operative patients sampled. This failure resulted in patient #1 passing away from a possible bowel obstruction and fecal vomiting with possible aspiration to the airway and lungs. This deficient practice had the potential to affect all post operative patients in the outpatient setting.

Findings include:

During an interview on 6/3/25 at 11:25 a.m., NF1 stated patient #1 was admitted to the hospital for a surgical procedure on 4/29/25 and was discharged home on 5/1/25. NF1 stated patient #1 lived with him and he was able to help care for patient #1 after his discharge from the hospital. NF1 stated patient #1 was doing well his first few days home. NF1 stated patient #1's pain was under control and there were no concerns at that time. NF1 stated patient #1 had a follow up appointment with his surgeon on 5/5/25 and everything had gone well at the appointment. NF1 stated later in the day, following his appointment, patient #1 started to complain of pain and told NF1 his pain was an 8 out of 10 on a scale of one to ten. NF1 stated patient #1 called his surgeons office and spoke to a nurse and the nurse told him to take some Tylenol or ibuprofen. The nurse instructed patient #1 to call back if he was still in pain or was unable to urinate. NF1 stated patient #1 called the surgeons office again on 5/6/25, spoke to different nurse and reported increased pain and heartburn. NF1 stated the nurse told patient #1 to hydrate, take some MiraLAX, and go to the ER if his pain got worse. NF1 stated patient #1 was never asked about how bad his pain was or to rate his pain, or the characteristics of his pain. NF1 stated patient #1 kept telling NF1 his pain was at an 8. NF1 stated he had asked patient #1 if he wanted to go to the emergency room and patient #1 told him no, as the (staff) told him not to go unless his pain got worse. NF1 stated patient #1's pain never got worse, but it never got better. NF1 stated on the morning of 5/8/25, patient #1 wanted to take a warm bath to see if that would help with his pain and discomfort, so NF1 helped patient #1 get a bath ready. NF1 stated, "I left the bathroom for a quick moment to get a towel and when I walked back into the bathroom I saw him (patient #1) hit the floor. I ran over to him, and he was unresponsive and started to vomit a black substance that smelled like feces. NF1 stated he started CPR and called 911. He stated he continued to do CPR on patient #1 until the ambulance arrived and they took over and took him to [Facility Name]. NF1 stated when patient #1 arrived to the ER, they continued to work on him. NF1 stated the doctor in the ER asked him what patient #1's wishes were, and he stated he was unsure. NF1 stated the ED doctor informed him patient #1 had been unconscious for too long and there was likely no brain activity, so they stopped working on him. NF1 stated he requested an autopsy and was told one would not be completed because the manner of death was not suspicious. NF1 stated, "I had an independent autopsy done because I want to know why he died. I feel betrayed by [Facility Name]. They took him (patient #1) from me. They did nothing to help him, even though he reached out to the doctor's office, like is discharge papers told him to do. We trusted the nurses that he talked to at the doctor's office, we trusted their guidance. We did everything we were supposed to do, and now he is dead."

Review of patient #1's electronic medical record dated 4/29/25-5/8/25 showed, patient #1 was admitted to the facility on 4/29/25 for a surgical procedure. The surgical procedure note showed patient #1 had "significant abdominal adhesions" and "an intraoperative decision was made to not perform the left pelvic lymphadenectomy given the risk-benefit ratio of the adhesions ..." After the procedure was completed and patient #1 was stable, he was transferred to the surgical unit to be monitored until discharge. While patient #1 was on the surgical unit, pain assessments show patient #1's pain was never higher than a 6 on a 1-10 pain rating scale." On 5/2/25 patient #1 was discharged home with NF1. Patient #1's pain at discharge was under control, with a pain rating of a 3-4 on a 1 to 10 pain rating scale.

Review of a facility document titled, "After Visit Summary," dated 5/1/25 at 1:27 p.m., showed:
... "Instructions: Call your provider if you experience pain not relieved by medication.
Start taking:
-cephalexin (an antibiotic) 500mg, take 2 capsules by mouth in the morning and 2 capsules at bedtime for 5 days.
-meloxicam (non-narcotic pain medication) 7.5 mg. Take 1 tablet by mouth 2 times a day for moderate pain for up to 12 days.
-oxybutynin (bladder relaxant) 5 mg. Take 1 tablet by mouth 3 times a day as needed for bladders spasms for up to 15 days."
... When to call the doctor?
-signs of infection such as a fever of 100.4 degrees Fahrenheit or higher, pain with passing urine, wound that will not heal, or pain.
... -not able to have a bowel movement ..."

Review of Patient #1's progress note titled, "Office Visit," dated 5/6/25, showed:
... "Patient presented for catheter removal. He has done well since hospital discharge."
... I will see him back in 3 months ..."

Review of patient #1's outpatient telephone nursing note dated, 5/5/25 at 2:58 p.m., written by staff member H, showed:
"[Patient Name] (patient #1) called because he was in pain surrounding the time when he was doing his kegels. He stated the cold of his urine was pink and he had been holding off doing anything because of the pain. H stated he hasn't taken any medication today. I let him know he could take some Tylenol or ibuprofen and if he is still in a lot of pain and/or hasn't voided to call back." [sic]

Review of patient #1's outpatient telephone nursing note dated, 5/6/35 at 2:04 p.m., written by staff member F, showed:
"Patient called today with complaints of abdominal pain. Patient states it is upper abd pain and heartburn. Patient states he has been taking pepto bismol for heartburn pain with some relief. Asked patient when the last time he had a bowel movement was, patient states some time last week and it was diarrhea. Explained to patient that is most likely the cause of his abd pain. Encouraged hydration and Miralax daily until he has a bowel movement ... Patient is to go to the ER if the pain gets worse or he is unable to have a bowel movement ..." [sic]

During an interview on 6/4/25 at 9:00 a.m., Staff member F stated she had talked to patient #1 on 5/6/25. Staff member F stated she knew he was a post-surgical patient. Staff member F could not verbalize the surgical complications that could accompany patient #1's surgical procedure and stated, "I do not have a surgical background." Staff member F stated, "Usually when patient calls in with constipation we encourage them to take something at home, and if it continues then go to the ER." Staff member F stated she was not sure if there were any policies, procedures, or protocols for patients with constipation. Staff member F stated patient #1 told her he was having pain. Staff member F stated she did not assess patient #1's pain level or assess the characteristics of his pain. Staff member H stated she was not sure if there was a policy, procedure, or protocol for assessing pain. Staff member F stated she did not notify the physician that patient #1 had called and complained of pain or constipation. Staff member F stated she did not look back into patient #1's chart to see if there was any other documentation of the patient calling and complaining of pain or constipation and had not looked to see what patient's current medications were.

During an interview on 6/4/25 at 11:00 a.m., staff member H stated she had worked in the physician's office for roughly three months. Staff member H stated she had talked to patient #1 when he called the office on 5/5/25. Staff member H stated, "When a patient calls into the office with pain or constipation I try to find out what could be the cause of the pain or constipation. I ask about pain location, and pain characteristics, I also try to have them rate their pain for me, and then I document it in the nursing note" Staff member H stated she did not ask patient #1 about his pain level or have him describe the type of pain he was having. Staff member H stated she knew what some of the surgical complications were for patient #1's procedure, but not all. Staff member H stated the only education she received in the physician's office was how to triage catheter patients and she had not received any type of education related to surgeries or surgical complications. Staff member H stated she had advised patient #1 he could take Tylenol or ibuprofen for his pain. Staff member K stated she did not look in the patient's chart to see if he already had pain medication prescribed to him prior to advising him to take the Tylenol or ibuprofen. Staff member H stated she was not aware that ibuprofen was contraindicated in conjunction with meloxicam or surgical procedures. Staff member H stated she did not notify the physician of patient #1's complaint of pain.

Review of online drug information for Meloxicam showed, Meloxicam and Ibuprofen both belong to the same drug class of non-steroidal anti-inflammatories and should not be taken together. Taking meloxicam and ibuprofen together can cause stomach ulcers, bleeding, stomach perforation, kidney damage, and an increased risk for heart attack, stroke, or high blood pressure. (https://medlineplus.gov/druginfo/meds).

During an interview on 6/4/25 at 11:40 a.m., staff member K stated he evaluated patient #1 on 5/5/25 at his post operative appointment. Staff member K stated patient #1 was recovering well. Staff member K recommended patient #1 come back for a follow up in three months. Staff member K stated he was not made aware of patient #1's phone calls or complaints. Staff member K stated, "I expect the nursing staff to bring concerns to our (physician's) attention. Pain and constipation are the two most calls the office gets post-surgery. They (staff) should know how to triage those calls and use nursing judgement accordingly." Staff member K stated nursing staff should be notifying the physicians of any complications, know what surgical complications were, and how to handle them appropriately.

During an interview on 6/4/25 at 12:40 p.m., staff member G stated outpatient nurses do not get any additional training other than shadowing and working with the other nurses and providers to learn the flow and how to triage patients. Staff member G stated, "There are not really any polices or procedures that are followed in the outpatient setting. They do not have anything like a phone tree, protocol, or algorithm to assist with triage or different situations that may come up."

During an interview on 6/5/25 staff member L stated, "The outpatient nurses did their normal process based on their clinical understanding of the patient. There are some areas that can be improved. We are doing an action plan for outpatient staff about pain or when a patient calls in. There has not been any education provided yet until we finalize our plan. The plan we have is very vague at this time, it's just a starting point. We are trying to come up with some kind of algorithm. This is just one of those things you don't think about until you have an incident. It is an awful situation."

Outpatient policies, to include triage, pain assessment, and post-operative complications were requested on 6/2/25 and 6/4/25. Specific policies were not received prior to the end of the survey.

During an interview on 6/5/25 at 11:10 a.m., staff member A stated, "The policies in our clinics are generic, they are not really specific."

Review of a facility policy titled, "Provider Practices Documentation Requirements for Staff," with a revision date of 7/2024, showed:
... "XIII. Phone Calls
... B. Send message to provider/nurse group if needing clarification or further action ..."

Review of a document titled, "Verbal Visual Preliminary findings," dated 5/15/25, showed:
"1. Bowel obstruction with fecal vomiting
2. Leaked bowel causing Gastric contents into the abdominal cavity
3. Aspiration in the lungs
4. Hemorrhagic bowels adhered to wall ..." [sic]

Review of a document titled, "Preliminary Autopsy," showed:
... "evidence of fecal vomiting with possible aspiration to the airway and lungs ...
... "pending pathologist review for final diagnosis ..." [sic]

Based on interview, record review, and policy review, the facility failed to inform 1 (#7) of patient rights prior to providing or discontinuing care; and failed to provide IM (Important Message from Medicare) within two days of admission and two days prior to discharge for 4 (#s 1, 2, 9, and 10) of 10 sampled patients. This deficient practice had the potential to affect all patients who were provided care for inpatient or outpatient services. Findings include:

1. Review of patient #7's electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not informed of her patient rights prior to being provided care or being discharged from the emergency department.

During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no documentation the patient received her patient rights. Staff member B stated patient #7 was intoxicated when she presented to the emergency department for care, but she should have had her rights given to her upon discharge. Staff member B stated patients or patient representatives are given a handout about their patient rights when the care agreement is signed.

Review of a facility policy titled, "Care Agreement Policy," with an effective date of 7/2024, showed:
"Policy:
[Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ...
... I. The Care Agreement document is explained to the patient and/or representative by the
A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services."
... III. The patient and/or representative sign and date the document ..."

2. Review of patient #1's electronic medical record, dated 4/29/25-5/8/25, showed patient #1 was admitted into the hospital for a surgical procedure on 4/29/25 and was discharged from the hospital on 5/1/25. There was no documentation showing patient #1 received the IM (Important Message from Medicare).

Review of patient #2's electronic medical record, dated 4/11/25-4/12/25, showed patient #2 was admitted to the hospital on 4/11/25 and discharged on 4/12/25. There was no documentation showing patient #2 received the IM (Important Message from Medicare).

Review of patient #9's electronic medical record, dated 5/14/25-5/15/25, showed patient #9 was admitted to the hospital for a surgical procedure on 5/14/25 and discharged on 5/15/25. There was no documentation showing patient #9 received the IM (Important Message from Medicare).

Review of patient #10's electronic medical record, dated 3/4/25-3/6/25, showed patient #10 was admitted to the hospital for a surgical procedure on 3/4/25 and discharged on 3/6/25. There was no documentation showing patient #10 received the IM (Important Message from Medicare).

During an interview on 6/4/25 at 10:40 a.m., staff member A stated, "The Medicare letter could not be found in the patient charts and medical records could not locate them either, I am not sure where they are at this time. They should be in the charts."

Review of a facility policy titled, "Medicare Regulatory Notice Delivery Policy," with an effective date of 11/2024, showed:
- ..."It is important that Medicare beneficiaries are informed of their rights ...
- ... All patients and their representatives shall have notices delivered ...
- ... Scan the signed notice into the associated patient encounter."

Based on interview and record review, the facility failed to investigate and address a written concern about care received in an outpatient setting, in which the facility provides oversight, for 1 (#1) of 10 sampled patients. This deficient practice had the potential to affect all patients who received care in an outpatient setting. Findings include:

NF1 stated patient #During an interview on 6/3/25 at 11:25 a.m., NF1 stated he had sent a written complaint to the facility about the care patient #1 received from staff at one of the physician's offices. NF1 stated patient #1 had been an inpatient from 4/29/25-5/1/25, due to a surgical procedure. NF1 stated patient #1 was doing well the first few days he was home. NF1 stated on 5/5/25 patient #1 had a follow up appointment with a physician and had his foley catheter removed. NF1 stated later on in the day on 5/5/25, the patient had placed a call to the physician's office and talked with staff member H. NF1 stated patient #1 told staff member H he was having pain in his abdomen and pelvis. NF1 stated staff member H did not assess his pain and recommended he take Tylenol or Ibuprofen, and to call back if he could not urinate or the pain was worse. 1 called back the next day and spoke with staff member F. NF1 stated patient #1 told staff member F he was having abdominal pain and acid reflux. NF1 stated staff member F told patient #1 to take a laxative and stop taking the antacid, and to go to the emergency room if the pain gets worse or he cannot have a bowel movement. NF1 stated staff member F never assessed patient #1's pain. NF1 stated the staff never asked patient #1 to rate his pain, or to describe the pain to them. NF1 stated, "When I would ask him about his pain, I would ask him to give me a number and he would tell me his pain was at an 8 and it was constant, he was not getting relief. The nurses never did that, how can they (the nursing staff) give advice if they don't assess the pain?" NF1 stated patient #1 was in a lot of pain on the morning of 5/8/25. NF1 stated patient #1 wanted to take a warm bath to see if that would help with his pain. NF2 stated he had left the bathroom to grab a couple things for patient #1 and he returned less than a minute later to find patient #1 unresponsive on the bathroom floor. NF1 stated he started CPR until the ambulance could get there. NF1 stated when he was doing CPR, patient #1 vomited a black, foul substance that smelled like feces. NF1 stated patient #1 was transferred back to the hospital via ambulance in cardiac arrest and was pronounced deceased in the ER. NF1 stated the hospital contacted him about the emergency room visit and let him know they were looking into the situation. NF1 stated that was round 5/14/25. NF1 stated he had a couple of conversations with different staff members about patient #1 and the visit to the emergency room. NF1 stated the main staff member he was communicating with over this incident was staff member C. NF1 stated staff member C called and let him know that a case review was done on patient #1 and it was determined that the facility did everything they could to try and save patient #1. NF1 stated they never addressed the complaint that I filed on the physician's office. NF1 stated he never really had a concern with the care that was provided in the emergency room or the emergency room staff. NF1 stated, "The only thing that upset me was the coroner approved not doing an autopsy because [Patient Name] did not die a suspicious death, so I paid to have an independent autopsy done. I feel like the nursing staff at the physician's office contributed to his (patient #1's) death, I feel like they just blew us off. We had concerns, we did what the discharge paperwork told us to do, and now I am am without [omit]. The facility has done nothing with my complaint. I filed that complaint on 5/20/25."

During an interview on 6/4/25 at 1:35 p.m., staff member C stated she had reached out to NF1 about patient #1 and the sequence of events that happened on 5/8/25 regarding patient #1's cardiac arrest and death. Staff member C stated she had found out about this incident from the funeral home because they had called me and informed me NF1 had requested an autopsy and had requested a pending death certificate. Staff member C stated she informed the funeral home that she could not do that because she did not have a final cause of death. Staff member C stated that was when she first reached out to NF1. Staff member C stated she had let NF1 know a case review had been completed. Staff member C stated she and NF1 about the code and the situation in the emergency room. Staff member C stated NF1 started talking about the situation at the physician's office. Staff member C stated, "I told him that I do not know much about the outpatient side of things but would pass on his concerns to the right people." Staff member C stated she had let staff member J know about the concerns." Staff member C stated when they were doing the case review, they also started to look into patient #1's inpatient visit on 4/29/25-5/1/25, and noticed patient #1 had called the physician's office and spoke to staff on a couple of different occasions prior to 5/8/25.

Review of a facility document titled, "Patient Relations Worksheet," showed:

NF1 had submitted a written complaint via email, about the concerns with the outpatient physician's office which was received by the facility on 5/20/25. On 5/21/25 at 10:21 a.m., the information was forwarded to staff members G and J.

During an interview on 6/4/25 at 12:40 p.m., staff member G said she had not done any type of investigation and had not provided any education to staff after NF1's complaint.

During an interview on 6/4/25 at 3:20 p.m., staff member J stated NF1 had arrived at the outpatient clinic and was asking questions about patient #1's death. Staff member J stated, "I placed a call to staff member L, and she asked me to go and talk with NF1, so I took NF1 into a private room where we could talk. I just basically listened to him. After I listened to NF1 I called staff member L back and I was told she or [Staff Name] would handle it from there. I did not do an investigation into the outpatient side. I really did not know there was a concern."

During an interview on 6/5/25 at 9:00 a.m., staff member L stated, "I had actually heard about the incident prior to the complaint being filed. We were already in the process of getting a case review scheduled. As a group we went over the case to see what could have been done differently or what we could have done better. We went thought the surgical notes, inpatient notes, notes from the outpatient visit, nursing notes." Staff member L stated, "At this time no education has been provided to staff." Staff member L stated, "[Staff member J] was supposed to address the nursing concerns with [Staff members F and H]. We are aware there are some changes that need to occur in our outpatient setting and [Staff member J] and I have talked about that and what we need to do, but we have not done anything at this time."

During an interview on 6/9/25 at 12:32 p.m., NF1 stated he was never notified the complaint was resolved. NF1 stated, "They have done nothing, the only thing they did was look into when [patient #1] came to the ER and that was not even my concern."

Review of a facility document titled, "Patient Relations Worksheet," showed:

"REVIEWER: [STAFF NAME] (staff member C)
STATUS: RESOLVED
DATE CLOSED: 5/22/25."

Review of a facility document titled, "Complaint/Grievance Procedure (Customer), with an effective date of 7/2024, showed:

... "IV. Grievance Investigation

A. The grievance must be reviewed, investigated and resolved within a reasonable timeframe ...

Based on interview, record review, and policy review, the facility failed to provide a written resolution following a complaint/grievance investigation to the patient or patient representative for 1 (#1) of 10 sampled patients. This deficient practice had the potential to affect all patients or patient representatives that have filed complaints or grievances with the facility. Findings include:

During an interview on 6/3/25 at 11:25 a.m., NF1 stated he file a complaint with the hospital on 5/20/25 and on 5/22/25 he stated he received a phone call from a staff member but could not remember who it was. NF1 stated, "She (staff member C) called and told me they (the hospital) had completed the case review, and it was determined they did all they could for patient #1. She did not even address the complaint I filed about the physician's office."

During an interview on 6/4/25 at 1:25 a.m., staff member C stated she felt she had a good rapport with NF1, so she had called him and let him know the results case review. Staff member C stated she did not speak with him about the inpatient complaint because that is not her area, and she is not familiar with how outpatient complaints are handled.

During an interview on 6/9/25 at 10:32 a.m., NF1 stated he had not had any type of communication from the hospital regarding the complaint. NF1 stated he had not received any type of verbal or written communication indicating anything was resolved. NF1 stated, "Nothing has been resolved, they have not done anything."

Review of a facility document titled, "Patient Relations Worksheet," showed:

"REVIEWER: [STAFF NAME] (staff member C)
STATUS: RESOLVED
DATE CLOSED: 5/22/25."

Review of a facility document titled, "Complaint/Grievance Procedure (Customer), with an effective date of 7/2024, showed:

... "Grievance Resolution

A. A grievance is considered resolved when the complainant is satisfied with the actions taken on their behalf.

... C. Upon grievance resolution, except when filed anonymously, a written response to the complainant is required providing:

1. Name of [Facility Name] contact person;
2. The steps taken on behalf of the complainant to investigate the grievance;
3. The results of the grievance process;
4. The date of completion." [sic]

Based on interview, record review, and policy review, the facility failed to obtain a consent to treat in the emergency room setting prior to providing or discontinuing care for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented to the emergency room for care. Findings include:

Review of patient 7's electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. An informed consent to treat was not completed by patient #7 prior to being provided care or being discharged from the emergency department. There was no care agreement located in patient #7's electronic medical record.

On 6/3/25 at 4:15 p.m., a request was made for patient #7's signed consent to treat form.

During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no consent to treat for patient #7. Staff member B stated patient #7 was intoxicated when she presented to the emergency department for care, but she should have signed the consent prior to discharge.

Review of a facility document titled, "Care Agreement," showed:
"This agreement includes and is effective for all acute care admissions, emergency room services....
...2. MEDICAL CONSENT:
I understand I was ... under the care and supervision of my attending physician or my physician's designee. ...I understand that it is the responsibility of [Facility Name] and its staff ...I consent to ...medical treatment ..."

Review of a facility policy titled, "Care Agreement Policy," with an effective date of 7/2024, showed:
"Policy:
[Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ...
... I. The Care Agreement document is explained to the patient and/or representative by the
A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services."
II. The patient and/or representative agree to the following:
A. Consent is given to the Hospital to provide appropriate nursing care
B. The patient gives permission to the Hospital to administer the care directed by their physician or physician's designee, ..."
... III. The patient and/or representative sign and date the document ..."

Based on interview, record review, and policy review, the facility failed to inform a patient of their right to formulate an advanced directive in an outpatient setting for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented for care in an outpatient setting. Findings include:

Review of patient 7's electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not notified of her right to formulate an advanced directive. There was no care agreement or documentation of information provided to patient #7 about the right to formulate an advanced directive located in patient #7's electronic medical record.

On 6/3/25 at 4:15 p.m., a request was made for patient #7's care agreement and documentation of notification of the right to formulate an advanced directive. No documentation was provided by the facility.

During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no signed care agreement or documentation the patient received information on the right to formulate an advanced directive, which is part of the facilities care agreement.

Review of a facility document titled, "Care Agreement," showed:
"This agreement includes and is effective for all acute care admissions, emergency room services....
...13. ADVANCED DIRECTIVES:
I have been informed Advanced Directive information is available to me from [Facility Name] at my request.

Review of a facility policy titled, "Care Agreement Policy," with an effective date of 7/2024, showed:
"Policy:
[Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ...
... I. The Care Agreement document is explained to the patient and/or representative by the
A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services."
... R. The patient acknowledges that they have been informed about the availability of Advanced Directive documents."
... III. The patient and/or representative sign and date the document ..."

Based on interview, record review, and policy review, the facility failed to inform a patient of their visitation rights for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented for care within the facility. Findings include:

Review of patient 7's electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not notified of visitation rights. There was no care agreement or documentation of information provided to patient #7 about visitation rights located in patient #7's electronic medical record.

On 6/3/25 at 4:15 p.m., a request was made for patient #7's care agreement and documentation that patient #7 was notified of visitation rights. The facility did not provide this documentation.

During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no signed care agreement or documentation showing patient #7 received information on visitation rights, which is part of the facilities care agreement. Staff member B stated visitation rights are on a pamphlet that are given to patients at the time they sign their care agreement.

Review of a facility policy titled, "Care Agreement Policy," with an effective date of 7/2024, showed:
"Policy: for their care and treatment ...
... I. The Care Agreement document is explained to the patient and/or representative by the
A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services.
... III. The patient and/or representative sign and date the document ..."