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Based on record review and staff interview, the facility failed to inform each patient, or when appropriate, the patient's representative of the patient's rights in advance of furnishing patient care (A-117). The facility failed to ensure patients had the right to make informed decisions regarding their care (A-131).

Based on record review and staff interview, the facility failed to inform each patient, or when appropriate, the patient's representative, of the patient's rights in advance of furnishing patient care for two of 14 records reviewed (Patient #7 and #12). This could affect all patients receiving services from the facility. The facility census was 111.

Findings include:

Review of the facility's policy and procedure titled, Patient Rights and Responsibilities, with a most recent approval reviewed date of 09/10/19, revealed it was the facility's responsibility to inform each patient, or when appropriate, the patient's representative, about how to execute his/her rights while receiving care or treatment at any of the facilities without fear of coercion, discrimination, retaliation, or denial of service. A patient or his/her representative will be provided a written notice of the facility's Patient Rights and Responsibilities (as a brochure or in electronic format through the electronic check in process).

Review of the facility policy titled, Documents Not Requiring Patient Signatures during the COVID Emergency, with an effective date of 04/08/2020. This policy was written to provide direction to caregivers in managing select documents that would typically include a patient or surrogate signature but that, during the period of the COVID emergency declaration for the facility system-wide, will not require signature per this Standard Operating Procedure (SOP): After Visit Summary (AVS) for inpatient, emergency department, and ambulatory surgical center discharges. In lieu of the patient's signature, the AVS may utilize either: (a) the signature field with the caregiver entry of the patients' verbal acknowledgement as described in this SOP or (b) the following verbiage if added to the AVS: The parent/guardian and/or patient representative verbalized understanding of all discharge instructions and were provided with a copy of the after visit summary. Caregivers must provide the AVS and discharge instructions to the patient within the same timeframe as required normally. Review of the document list not requiring signature included the following: The Patient Acknowledgement and Consent Form, The Important Medicare Message (IMM), the Patient Rights checklist, and the Medicare Outpatient Observation Notice (MOON).

1. Review of the medical record revealed Patient #7 was admitted to the facility via the emergency department on 10/22/2020. The Emergency Department provider note documented the emergency department physician had contacted the facility's Interpreter Service for assistance in the Kinyarwanda language (language of Rwanda) for obtaining information for the medical record and treatment plan for Patient #7. In addition to the language barrier, the medical record revealed the patient had diagnoses which included blindness, diabetes mellitus, hypertension, end stage renal disease which required hemodialysis, jejunitis and had presented with a complaint of abdominal pain, nausea and vomiting. Review of the gastrointestinal physician's consult note dated 10/22/2020 at 1:24 PM revealed Patient #7 was a refugee from the Democratic Republic of the Congo and arrived in the United States in January of 2019. The documentation revealed that Patient #7's first choice of language was Kirundi, second choice was Kinyarwanda and a third choice of Swahili.

Review of the medical record for Patient #7 revealed the Patient Acknowledgement and Consent form documented the following, by signing below I have indicated I have reviewed and acknowledged and consent to the terms of described the above (terms of the general consent). The consent form also included the statement that the patient had received a copy of Cleveland Clinic Health System Patient Rights and Responsibilities brochure or the Cleveland Clinic Health System Welcome Guide. Review of Patient #7's consent revealed on the signature line Staff U had hand written, "acknowledged verbally per SOP" (standard operating procedure), dated it 10/22/2020, and written Staff U's initials. Review of the electronic medical record admission revealed under the section marked "Interpreter needed," Staff U documented, "No, the patient was fluent in English."

Interview with Staff T on 10/29/2020 at 12:55 PM revealed the facility had a language interpreter service for non English speaking patients. This should be activated and the need for this service would be captured in the admission information area. This would trigger staff how to assist the patient in getting information in a way they could understand. Staff T confirmed the facility was unable to provide any information that the facility provided the required Notice of Rights in advance of care verbally or in writing in an understandable way to Patient #7.

Interview with Staff V and W on 10/29/2020 at 2:15 PM revealed it was the nursing unit's responsibility to provide the Welcome Packet. The staff verbalized the facility had the ability to print the documentation in multiple languages, including Swahili. Staff V verbalized the plan of care for Patient #7 for communication needs was not activated. This would have triggered to staff that Patient #7 had special communication needs both for vision and language and this was not done. The facility was unable to provide documentation that Patient #7 received notice of rights in advance of care.

2. Patient #12 was admitted to the facility via the emergency room on 10/14/2020 with diagnoses which included exacerbation of congestive heart failure (CHF), lymphedema, hypertension, and cardiomyopathy. Review of the Important Message from Medicare (IMM) patient access service staff had handwritten "Verbally Acknowledged per SOP" and dated 10/14/2020 at 8:27 AM. Review of the Medicare Outpatient Observation Notice (MOON) revealed the form was not signed but staff had handwritten the following: 1) No answer on the phone 10/14/2020 at 2:09 PM. 2) Patient asleep 10/14/2020 at 7:46 PM.

Interview with Staff T on 10/29/2020 at 12:15 PM revealed staff were instructed during COVID-19 to call the patient's room and speak to the patient to obtain verbal consent or to enlist the nursing unit staff in obtaining signatures or obtaining verbal consents. Staff T verbalized that if the facility was unable to reach the patient during the inpatient stay the facility mailed the documents via certified mail with return receipt to the patients' homes. Staff T confirmed the facility was unable to provide documentation Patient #12 had received his/her MOON notice and confirmed the patient did not sign receipt of the IMM nor was the facility able to provide documentation it mailed a certified letter to Patient #12.

Based on record review and staff interview, the facility failed to ensure patients had the right to make informed decisions regarding their care for seven patients of 17 patients reviewed (Patient #3, #5, #6, #7, #10, #11 and 12). The facility census was 111.

Finding include:

The facility policy titled, Documents Not Requiring Patient Signatures during the COVID Emergency, with an effective date of 04/08/2020, was reviewed. The policy was initiated to provide direction to caregivers in managing select documents that would typically include a patient or surrogate signature but that, during the period of the COVID emergency declaration for facility system-wide, will not require signature per this Standard Operating Procedure (SOP): After Visit Summary (AVS) for inpatient, emergency department, and ambualtory surgical center discharges. In lieu of the patient's signature, the AVS may utilize either: (a) the signature field with the caregiver entry of the patient's verbal acknowledgement as described in this SOP or (b) the following verbiage if added to the AVS: The parent/guardian and/or patient representative verbalized understanding of all discharge instructions and were provided with a copy of the after visit summary. Caregivers must provide the AVS and discharge instructions to the patient within the same timeframe as required normally. Review of the document list not requiring signature included the following: The Patient Acknowledgement and Consent Form, The Important Medicare Message, and the Patient Rights Checklist.

1. Review of the medical record revealed Patient #11 was admitted to the facility on 10/09/2020 at 2:18 PM with diagnoses which include Chronic Obstructive Pulmonary disease (COPD), hypoxia and shortness of breath. Review of the Patient Acknowledgment and Consent form revealed it was unsigned by the patient. However, Patient Access Service staff had handwritten the following documentation: 1. Staff in with patient 10/09/2020 at 2:20 PM; 2) Staff in with patient 10/09/2020 at 2:50 PM, 3) Staff in with patient 10/09/2020 at 3:20 PM.

Interview with Staff T on 10/29/2020 at 12:55 PM confirmed the facility was unable to provide documentation the patient had received his/her patient rights in advance of care as required. Staff T verbalized staff should have tried to provide the Patient Acknowledgement and Consent to the patient after he/she was transferred to the inpatient nursing unit. Staff T stated that staff was instructed to have the nursing staff assist in getting patient consent and providing the patient rights and responsibilities information as well.

2. Review of the medical records for Patient #3 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. Although Patient #3 had a verbal acknowledgement of the Patient Acknowledge and Consent form prepared by the facility's Patient Access Service staff during the admission process, Patient #3 signed the Behavioral Health Application for Voluntary Admission Form on 10/12/2020. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

3. Review of the medical record for Patient #5 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. Although Patient #5 had a verbal acknowledgement of the Patient Acknowledge and Consent form prepared by the facility's Patient Access Service staff during the admission process, Patient #5 had signed the Behavioral Health Application for Voluntary Admission Form on 10/19/2020. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

4. Review of the medical record for Patient #6 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. However, review of Patient #6's medical record revealed although he/she had a verbal acknowledgement of the Patient Acknowledge and Consent form prepared by the facility's Patient Access Service staff during the admission process on 10/02/2020, he/she had signed the Behavioral Health Inpatient Interdisciplinary Treatment Plan on 10/02/2020, the Psychiatric Patient's Rights notice on 10/02/2020 at 4:10 PM, the Behavioral Health Application for Voluntary Admission Form on 10/02/2020 and the patient valuable and release Form on 10/02/2020 at 3:29 PM. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

5. Review of the medical record for Patient #7 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

6. Review of the medical record for Patient #10 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

7. Review of the medical record for Patient #12 revealed the Patient Acknowledgement and Consent form was processed by the facility's patient access service staff and the signature line contained the handwritten statement "Verbally Acknowledged per SOP." The Patient Acknowledgement and Consent form contained the general consent for health care services, financial responsibility, assignment of benefits/third-party payers, and use and disclosure of health information. This was confirmed with Staff T during interview on 10/29/2020 at 12:55 PM.

Based on record review and staff interview, the facility failed to ensure the results of the discharge planning evaluation was discussed with the patient or the patient's representative for one of nine discharged records reviewed (Patient #7). The total sample size was 14. The facility census was 111.

Findings include:

Review of the facility's policy and procedure titled, CCHS Nursing discharge Planning and Discharge of Patient (SOP), with a most recent reviewed and approved dated of 07/10/19, revealed the purpose of the policy was to describe the role of registered nurses (RN) in the discharge planning process for hospitalized patients. The goal of discharge planning is to facilitate the successful transition of the patient from hospital to home or extended care facility, after identifying barriers and ensuring the patient receives and understands complete discharge instructions and self-care expectation related to their primary diagnosis. The policy further directed as follows, the registered nurse RN(s) shall oversee the discharge planning activities of each patient and insure completion with collaboration of the health care team. The nursing responsibility to the discharge planning process begins by assessing the patient's potential discharge needs upon admission. Throughout the hospital stay, the nurses assigned to the patient are responsible to coordinate with physician/licensed independent practitioner (LIP) and other members of the multidisciplinary team by identifying any additional barriers to discharge and for the provision of patient education for discharge/survival needs. The RN assigned to the patient on the day of discharge is responsible for coordinating discharge activities. The patient's discharge plan involves three processes: a. An assessment of discharge planning factors conducted within 24 hours of admission; b. Ongoing multi-disciplinary evaluation of discharge needs; c. Discharge summation.

Further review of the policy revealed the RN provides appropriate discharge education regarding all patient conditions, Core Measures (i.e., Heart Failure) and will also provide smoking cessation advisement. Ensures complete documentation of the elements of patient education provided for discharge planning. Ensures that documentation of the specifics of the education provided and patient/caregiver understanding is reflected in the Patient Education section of the medical record. Ensures that appropriate written materials and other tools to support the education (disease related, nutrition, medications, wound and/or drainage care, etc.) have been received by the patient/caregiver. The documentation shall address patient's medical stability, physical assessment findings, and patient's and/or significant other(s) abilities to manage continuing care needs after discharge.

The policy titled, Documents Not Requiring Patient Signatures during the COVID Emergency, with an effective date of 04/08/2020 was reviewed. The policy was initiated to provide direction to caregivers in managing select documents that would typically include a patient or surrogate signature but that, during the period of the COVID emergency declaration for facility system-wide, will not require signature per this Standard Operating Procedure (SOP): After Visit Summary (AVS) for inpatient, emergency department, and ambulatory surgical center discharges. In lieu of the patient's signature, the AVS may utilize either: (a) the signature field with the caregiver entry of the patient's verbal acknowledgement as described in this SOP or (b) the following verbiage if added to the AVS: The parent/guardian and/or patient representative verbalized understanding of all discharge instructions and were provided with a copy of the after visit summary. Caregivers must provide the AVS and discharge instructions to the patient within the same timeframe as required normally.

Review of the medical record revealed Patient #7 was admitted to the facility via the emergency department on 10/22/2020. The Emergency Department provider note documented the emergency department physician had contacted the facility's Interpreter Service for assistance in the Kinyarwanda language (language of Rwanda) for obtaining information for the medical record and treatment plan for Patient #7. In addition to the language barrier, the medical record revealed the patient had diagnoses which included blindness, diabetes mellitus, hypertension, end stage renal disease which required hemodialysis, jejunitis and had presented with a complaint of abdominal pain, nausea and vomiting. Review of the gastrointestinal physician's consult note dated 10/22/2020 at 1:24 PM revealed Patient #7 was a refugee from the Democratic Republic of the Congo and arrived in the United States in January of 2019. The documentation revealed that Patient #7's first choice of language was Kirundi, second choice was Kinyarwanda, and a third choice of Swahili.

Review of the After Visit Summary (AVS) for Patient #7 dated 10/27/2020 revealed the document was written in English and was in regular font print. The AVS contained important instructions to Patient #7 for things such as medication list and medication regimens, upcoming post discharge follow up medical appointments, next scheduled dialysis treatment in the community, emergency after discharge telephone numbers, along with a physical prescription to take to the pharmacy for new medications as well as information for disease management and patient education.

Review of the electronic medical record adult discharge form which provided information of how the discharge instructions were presented to the patient or representative revealed the following categories: follow up appointments, homegoing instructions, disposition of patient upon discharge, how the patient left the unit, additional discharge instructions free text box, signature and co-signature line, patient valuables returned and signature were all left blank and unanswered.

Interview and electronic chart review with Staff V and W on 10/29/2020 at 2:15 PM revealed the nursing flowsheet communication care plan was never initiated for this patient. Staff V explained that if this plan of care was correctly completed and the interpreter services drop down selection was initiated it would have triggered Patient #7's need for interpreter services for all staff during the patient's facility stay. Staff V verbalized, "I don't see anywhere in the chart where this was selected for Patient #7. I remember this patient. She couldn't speak or understand English. She was from Africa." When asked how discharge instructions were provided for this patient, Staff V answered, "that's a good question, there's nothing in the chart. I don't know." Staff V and W confirmed the facility was unable to provide documentation the facility had provided discharge instructions to Patient #7 that were readable or understandable to Patient #7.

Administrative Staff F was asked on 10/29/2020 at 2:15 PM and again at 4:00 PM how the facility could track when the facility's staff utilized the Global Interpretative Services call service during patient care. Staff F stated it was tracked and audits were available. A request for these audits was made during the interviews. A follow up request for the audits was made via email on 10/29/2020. The facility provided an email on 11/02/2020 stating that the interpretative service usage audits would not be provided.