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Based on interviews and document review, it was determined the facility failed to provide evidence that patients were informed of their patient rights in advance of furnishing care for three (3) of three (3) outpatient rehabilitation patients sampled.

Findings:

On 12/5/2023 in the afternoon, the surveyor conducted a review of three (3) outpatient rehabilitation (rehab) patient's medical records. A review of the records contained no evidence of a signed consent to treat or that the patient was informed of patient rights for Patients (P) 2, P3, and P4.

During a discussion with Staff Member (SM) 1, SM8, SM14, and SM15, the surveyor discussed that the facility's three (3) patient rights related policies and consent to treat form did not address evidence of informing outpatients and emergency department patients of their patient rights. SM1 stated that the facility would review their policies and procedures and update them to align with the federal regulations.

During an interview on 12/6/2023 at 10:57 a.m., SM1 advised that the registration staff member for the outpatient rehab stated that the electronic signature device used for patients to sign consent documentation was "broken", so the registration staff member was obtaining "verbal consent" and not documenting that consent was received. There was no documented evidence of signed consents or that P2, P3, and P4 were informed of patient rights. SM1 stated that the electronic signature pad has not been working since 2022. At the exit conference, SM1 confirmed that the electronic signature pad was working as of "today".

A review of the facility's policy titled "Patient's Rights and Responsibilities" states in part:
"... All inpatients and surgery patients are informed about their rights and responsibilities. These rights and responsibilities are found in the Patient Handbook that is given to patients at the time of admission and prior to surgery. Signs displaying Patient Rights and Responsibilities are posted in registration areas...." This policy only addresses inpatients and surgery patients, there is no mention of outpatients or emergency department patients and how they are informed of their rights.

A review of the facility's policy titled "Patient Rights" states in part:
"... Upon admission as an inpatient, each patient will receive a copy of the Patient Handbook, which includes a copy of the Patient Rights and information regarding contacting the Patient Advocate.

A review of the facility's policy titled "Communication of Patient Rights" related to Rehabilitation Services states in part:
... 1. On admission every patient will be given a patient handbook. 2. Nursing will document in the electronic record that patient received the patient handbook...." This policy only addresses patients admitted to the facility, not outpatients.

A review of the facility's "Agreement & Consent to Conditions of Treatment" states in part:
... 6. Patients Right To Decide: I understand that I have the right to make decisions about my care. I have the right to refuse or accept treatment. I have the right to have a "Living Will", Advance Directive or to designate someone to make decisions for my [sic] by using a "Durable Power of Attorney for Health Care".... There is no other evidence on this consent form that the patient was given or informed of all other patient rights.

The above concerns were discussed at the exit conference on 12/6/2023 at 12:30 p.m.

Based on observations, interviews, and document review, it was determined the facility failed to ensure risks were minimized for patients, employees, and visitors by not repairing a leaking toilet in a patient's room on the rehabilitation unit in a timely manner to assure the safety and well-being of the patient, staff, and visitors.

Findings:


A review of the documentation submitted by the complainant contained photographic evidence of Patient (P) 1's bathroom at the rehabilitation (rehab) facility with a disposable absorbent mat (PIG mat) on the floor and water surrounding the mat and toilet.

On 12/5/2023 at 11:42 a.m., the surveyor received a "work order" document for the leaking toilet in rehabilitation unit room 3303 from 9/21/2023. The work order contained evidence that the patient's family was concerned about the toilet leaking onto the floor, behind the commode. The work order was submitted on 9/21/2023 at 5:26 a.m. SM12 noted "labor" on 9/22/2023, another staff member documented "labor" on 9/26/2023, and the work was documented as "completed" on 9/26/2023 at 6:32 a.m. There is a note stating that the issue was inspected, extra hands were needed to complete, and the completion was planned for Monday 9/25/2023. The work order was prioritized as "Routine/Corrective".

A Nurse Note Summary for P1 from 9/20/2023 at 11:40 p.m. contained evidence of documentation from SM19 that the patient's spouse was "anxious" that the patient's bathroom was "not clean enough and toilet leaking." There was a work order placed by the day shift charge nurse and SM19 placed "black absorb [sic] pads around toilet to make sure area was dry if patient needed to get up ... I would not allow [the patient] to use restroom if there was any water on the floor ... Patient used urinal throughout the night." There was no documented evidence that the patient was provided a bedside commode or used a bedside commode during the patient's hospital stay.

A nursing progress note from 9/21/2023 at 3:26 p.m. contained the documentation that the patient's spouse "expressed concerns about [the patient's] toilet in [the patient's] room leaking and I directed [the spouse] to the Charge RN who then placed a work order for building maintenance." There was no documented evidence that the patient was provided a bedside commode or used a bedside commode during the patient's hospital stay.

During an interview on 12/5/2023 at 10:58 a.m., SM5 stated that the inpatient rehabilitation unit has seventeen (17) rooms with a total of thirty (30) beds. SM5 stated that some rooms have two (2) beds per room and some rooms are private.

During an interview on 12/5/2023 at 11:42 a.m., SM7 stated that SM7 worked night shift on the day P1 was admitted. P1's spouse had notified day shift that the toilet was leaking, and SM7 placed absorbent pads around the toilet, and would not take the patient in the bathroom if it was leaking at the time. SM7 stated that there was a urinal and a bedside commode, and "facilities" was supposed to come to fix the leak the next day. SM7 notified the nurse manager and was told that they were "full" and did not have another room available for the patient.

During an interview on 12/5/2023 at 12:46 p.m., SM13 stated that the work order for the leak was submitted in the "evening" and then SM12 went to assess the leak the next day. SM12's background was in "electrical" so SM12 required assistance with fixing the leak. SM13 stated that the leak was assessed on a Friday, and since facilities management did not work on the weekends, the repair had to wait till Monday. SM12 stated that the issue was "pretty minor" and the rags on the floor were damp, but there was "no visible water." SM13 noted that the work order was documented as "Routine." The surveyor inquired what would have been done if the water was "spraying out" and SM13 stated that "it would have been taken care of right then." SM13 stated that work orders are prioritized based on the priority level identified by the person submitting the work order. SM13 stated that the nurse entered the work order as "routine." SM13 stated that there is no training of staff about priority levels for work orders, the priority level is designated based on the staff members assessment of the situation. SM14 later confirmed that there is no facility policy or procedure that outlines "priority" designations for work orders.

During an interview on 12/5/2023 at 3:32 p.m., SM20 stated that P1's spouse was upset about the leaking toilet and a work order was submitted, but facilities couldn't come fix it that evening since it wasn't an "emergency." SM20 did not recall any other information about the leak including when it was fixed or other concerns from the spouse. SM20 did not recall if there was a bedside commode in the patient's room.

During an interview on 12/5/2023 at 3:38 p.m., SM21 recalled that P1's spouse made the staff aware that there was a "leak" in P1's bathroom, and that absorbent mats were placed around the toilet. SM21 did not recall if the patient had a bedside commode and did not assist P1 to the toilet or the shower.

On 12/6/2023 at 11:40 a.m., SM8 confirmed that there was no evidence in P1's medical record documenting that the patient was offered or given a commode, or that the patient used or was assisted to the commode during the patient's admission.

A review of the rehabilitation units census from 9/20/2023 through 9/25/2023 provided by SM1 on 12/6/2023 at 11:25 a.m. contained evidence that there were between thirteen (13) to sixteen (16) patients on that unit on any of those nights. SM5 had stated that there were seventeen (17) rooms on the rehabilitation unit, so as per the above census information, there would have been a room available every night even if all patients on the census had their own room. As per the complaint, P1's spouse requested to be moved to a different room, but was told there were no other beds available.

Document Review
A review of the facility's policy titled "Patient Rights" states in part:
... 4. Personal Safety - The patient and/or patient's representative have the right to receive care in a safe setting, free from all forms of abuse, neglect, harassment, and mistreatment, as well as an expectation of reasonable safety insofar as the Hospital practices and environment are concerned.

The above concerns were discussed at the exit conference on 12/6/2023 at 12:30 p.m.