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Based on observation, interview, record review and policy review, the hospital failed to inform a patient ' s representative in advance of providing or discontinuing care for two confused discharged patients (#5 and #14) of three confused discharged patients reviewed (A-0117) and failed to complete temperature checks for the patient nutrition rooms refrigerators and freezers (A-0144).

These failures had the potential to affect the quality of care and safety of all patients.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient ' s Rights.

Please refer to A-0117 and A-0144

Based on interview, record review and policy review, the hospital failed to inform a patient's representative in advance of providing or discontinuing care for two confused discharged patients (#5 and #14) of three confused discharged patients reviewed.

These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's undated policy titled, "Informed Consent," showed:
- Prior to the start of the informed consent process, a provider should understand if the patient has the capacity to make healthcare decisions. Patients are presumed to have decision making capacity if the following four criteria are present, the ability to understand relevant information, to appreciate consequences, are able to reason about treatment options, and are able to make or communicate a choice.
- Adults without decision making capacity may not make their own decisions and will require someone else to make decisions on their behalf.
- If the patient has a designated surrogate decision-maker prior to their lack of decision-making capacity a legally appointed guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) or an agent appointed under a valid Healthcare Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own)
Document should make decisions for the patient.
- If the patient did not designate a surrogate decision-maker prior to losing decision making capacity, the next of kin or others may assist with decision-making.

Review of the hospital's undated policy titled, "Patient Discharge Education," showed:
- At discharge, the nursing staff should review the prepared instructions with the patient or caregiver and verify that they understand the instructions.
- The patient/family or caregiver should sign the discharge paperwork. A written or electronic signature is acceptable.
- The paper copy can be scanned into the electronic record.

Review of Patient #5's medical record showed:
- On 04/10/25 at 3:05 AM, Patient #5 presented to the Emergency Department (ED) via an ambulance from a locked memory care nursing home with aggressive behavior.
- His past medical history included stroke, hallucinations (seeing or hearing things which are not there), psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), dementia (a loss of thinking abilities and memory) and cognitive communicative deficit (a term used to describe a weakness in a person's communication abilities).
- Patient #5's spouse was listed as his next of kin.
- At 3:06 AM, he reported that he was brought to the ED because "the firefighter was trying to get my firearm away from me and they were making me ache."
- At 3:13 AM, the nursing neurological (neuro, relating to or affecting the nervous system) assessment indicated that he was oriented to person, which was his baseline, but was forgetful.
- His Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) assessment showed his best verbal response was confused.
- His learning barrier was mental impairment.
- At 3:15 AM, his provider physical examination indicated he was oriented to being at the hospital but not to the date. He followed simple commands and answered questions appropriately, although not accurately.
- At 7:36 AM, his mental health examination indicated he had poor insight and judgement. His presenting problem was "we lost our accountant for this position. It was terrible. She went to bed and didn't wake up the next morning." He reported that "he flew in from Vegas last night and the reason he was in the hospital was due to him losing his accountant."
- At 9:20 AM, the consent and authorization for treatment was signed "patient unable to sign due to condition. Verbal consent from patient." The consent was signed six hours and 14 minutes after his treatment was initiated.
- At 12:42 PM, he was discharged in stable condition.
- Discharge instructions and follow-up care were reviewed.
- Guardian contact was documented as "not required."
- His discharge paperwork did not have a signature, and no next of kin notice regarding arrival, treatment or discharge was documented.

During an interview on 05/13/25 at 2:27 PM, Staff Q, Registration Manager, stated that the clinical team was responsible for notifying the registration staff if a patient was confused. That would alert the registrar to contact the patient's representative for consent to treat. After reviewing Patient #5's medical record, he stated that the registrar did not follow the hospital's process. He acknowledged that it appeared that the consent to treatment was signed by a confused patient. The patient's representative should have been contacted. He stated that common sense should dictated that a confused patient could not consent to hospital treatment. He believed there was an opportunity for staff education.

During a telephone interview on 05/13/25 at 11:25 AM, Staff M, RN, stated that she did not recall caring for patient #5. A confused patient was not able to consent to treatment or discharge. The patient's representative should have been contacted. Her practice was to contact the patient's representative herself in order to obtain the consent to treat.

During an interview on 05/13/25 at 9:48 AM, Staff I, RN, stated that she discharged Patient #5. She did not notify Patient #5's spouse of his discharge plan. That was an oversight, the nursing home paperwork did not indicate the patient had a guardian. She failed to contact the next of kin for a confused patient prior to discharge.

Review of Patient #14's medical record showed:
- On 11/19/24 at 7:34 PM, Patient #14 presented to the ED via an ambulance from a locked memory care nursing home with aggressive behavior.
- His past medical history included dementia.
- Patient #14's daughter was listed as next of kin.
- Patient #14's nursing home documentation indicated the patient's daughter was his guardian.
- At 7:44 PM, his presenting complaint was aggressive outburst. He resided on a dementia floor and became agitated with staff members.
- At 7:48 PM, the nursing documentation indicated he was able to follow simple commands, but was forgetful.
- At 7:48 PM, his GCS best verbal response was confused.
- On 11/20/24 at 12:56 AM, Patient #14 attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) and stated he wanted to talk to the highway patrol because he believed he had been kidnapped.
- At 7:45 AM, his neuro exam indicated he was oriented to person and forgetful.
- At 10:53 AM, his mental health examination indicated that he stated that he probably tried to get some pain medicine because he had it 20 minutes before that and then they called the police. There was a gang in the school down there, he did not want to play for them, and they were making it rough on him. He stated he lived three weeks in the past.
- At 11:47 AM, Patient #14 was discharged in stable condition. Discharge instructions and follow up care was provided via the discharge summary to the nursing home.
- There was no signed consent or authorization to treat.
- The discharge paperwork did not have a signature, and no guardian was notified of discharge.

During an interview on 05/13/25 at 1:33 PM, Staff O, RN, stated that she typically contacted a confused patient's next of kin prior to discharge. She would document her communication with the patient's representative in the patient's medical record. She was aware the next of kin must be notified prior to discharge and she agreed there was no documentation of that notice for Patient #14.

During an interview on 05/13/25 at 3:47 PM, Staff K, Chief Nursing Officer (CNO), stated that she expected if a patient was not alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) and/or had a neurological deficit a patient's representative was to be contacted for consent and that representative contact should be documented in the medical record. The patient's representative should also be contacted prior to discharge. The hospital's failure to contact Patient #5's and Patient #14's representatives did not meet her expectations. She believed the hospital had an opportunity to improve representative awareness of patient arrivals, treatment and discharge from the hospital.

Based on observation, interview, record review and policy review, the hospital failed to complete temperature checks for the patient nutrition room refrigerators and freezers.

These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's undated policy titled, "Cold Storage Temperatures: Food and Nutrition," directed staff to place a new temperature log form on the clipboard monthly and to record the temperature of each storage unit every morning at opening and every evening at closing.

Review of the hospital's documents titled, "Temperature Log Food Refrigerators," dated 05/2025, showed:
- The refrigerator temperature range for food was 34 to 41 degrees Fahrenheit (F).
- If the temperature was out of range staff were to increase or decrease the temperature. If the temperature was too warm, check for food spoilage. Ensure the appliance is securely plugged into an electric outlet and notify Facilities Management if unable to correct the temperature. Relocate food to another refrigerator.
- No freezer temperatures were recorded 23 of 23 shifts in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), Telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) Unit, Medical Surgical 100 Unit, Medical Surgical 200 Unit, Obstetrical (relating to childbirth and the processes associated with it) Unit, Emergency Department (ED) zone one, and ED black zone two.
- No refrigerator temperatures were recorded 22 of 23 shifts in the Telemetry Unit, Medical Surgical 100 Unit and Medical Surgical 200 Unit.
- No refrigerator temperatures were recorded for 11 of 23 shifts in the ICU, ED zone one, ED white zone two and ED black zone two.
- On 05/05/25, The ICU refrigerator temperature was 42 F, no action was taken.
- On 05/12/25, the Medical-Surgical 200 Unit refrigerator temperature was 28 F, the Medical-Surgical Unit 100 was 43 F and the Telemetry Unit was 42 F; no actions were taken.

Observation on 05/12/25 at 10:15 AM, in the Medical-Surgical Unit 100, showed no refrigerator/freezer temperature logs for the patient nutrition room refrigerator and freezer.

Observation on 05/12/25 at 10:20 AM, in the Medical-Surgical Unit 200, showed no refrigerator/freezer temperature logs for the patient nutrition room refrigerator and freezer.

During an interview on 05/12/25 at 10:05 AM, Patient #3 stated that she was served sour milk that morning.

During an interview on 05/13/25 at 3:47 PM, Staff K, Chief Nursing Officer (CNO), stated that she expected staff to follow the hospital's policies and procedures. She was not aware the policy required refrigerator/freezer temperature assessments twice each day. She expected staff to intervene when the temperatures were out of range.

During an interview on 05/12/25 at 9:30 AM, Staff B, Nurse Manager, stated that the temperature checks was a new process for the staff. She agreed there were no temperature logs in the medical-surgical and telemetry units for 05/2025.