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Based on document review, medical record review and staff interviews it was revealed the facility failed to follow state and local law related to the health and safety of patients regarding determination of capacity (see tag 0152). This failure has the potential to place all incapacitated patients in great harm.

Based on document review, medical record review and staff interviews it was revealed the facility failed to follow state and local law related to the health and safety of patients regarding determination of capacity in one (1) out of ten (10) patients. This failure has the potential to place all incapacitated patients in great harm.

Findings include:

1. A review was conducted of patient #1's medical record. The patient was brought in by Emergency Medical Services (EMS) on 02/05/19. The patient was admitted to this facility on 02/05/19 with an admitting diagnosis of uncontrolled pain. The patient was admitted to the Inpatient Unit with an observation status, accompanied by a Hospice nurse and Medical Power of Attorney (MPOA). The patient had a document titled Determination of Capacity which stated she lacked sufficient mental or physical capacity to appreciate nature and implication of health care decisions. The document was signed by a Nurse Practitioner. During the patient's Social Services case management assessment, it was noted in her discharge plan the capacity form on file is invalid per Department of Health and Human Resources (DHHR) as a Nurse Practitioner cannot take away capacity. The patient was discharged home on 02/07/19. The discharge instructions were discussed with the patient only and the patient's signature was at the bottom of the discharge instructions. The patient was discharged via ambulance service due to the caregiver not being available and as stated on the transfer request form, per patient request.

2. WV State Code §16-30-7 Determination of Incapacity states in part: "(a) ...A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced Nurse Practitioner who has personally examined the person."

3. An interview with the Registered Nurse (RN) who discharged patient #1 was conducted on 02/18/19 at 1:30 p.m. She stated: "I was unaware the patient was deemed incapacitated to make decisions. I attempted to call the MPOA and left a voicemail. He never returned my call. I asked the patient if she was OK to go home without the MPOA being there and she stated yes."

4. An interview was conducted with the Director of Case Management on 02/19/19 at 10:40 a.m. She stated: "We looked it up on the second day the patient was here and found a Nurse Practitioner can determine capacity." She was unsure why the information did not get discussed with the nursing staff.

5. An interview was conducted with the Director of Nursing on 02/19/19 at 9:00 a.m. She concurred with the findings that a patient with a lack of capacity signed her own discharge paperwork and was discharged home via ambulance without her MPOA's knowledge.

A. Based on document review, record review and staff interviews it was revealed the facility failed to furnish its health care services in accordance with its written policies in one (1) out of ten (10) patients. This failure has the potential to negatively impact all patients receiving care.

Findings include:

1. A review was conducted of patient #1's medical record. The patient was brought in by Emergency Medical Services (EMS) on 02/05/19. The patient was admitted to this facility on 02/05/19 with an admitting diagnosis of uncontrolled pain. The patient was admitted to the Inpatient Unit with an observation status, accompanied by a Hospice nurse and Medical Power of Attorney (MPOA). The patient had a document titled Determination of Capacity which stated she lacked sufficient mental or physical capacity to appreciate nature and implication of health care decisions. The patient had a MPOA Form on file at the hospital which stated a designated MPOA was chosen. The patient was discharged home on 02/07/19. The discharge instructions were discussed with the patient only and the patient signature was at the bottom of the discharge instructions. The patient was discharged via ambulance service due to the caregiver not being available and as stated on the transfer request form, per patient request.

2. An interview with the Registered Nurse (RN) who discharged patient #1 was conducted on 02/18/19 at 1:30 p.m. She stated: "I was unaware the patient was deemed incapacitated to make decisions. I attempted to call the MPOA and left a voicemail. He never returned my call. I asked the patient if she was OK to go home without the MPOA being there and she stated yes."

3. A review of the policy titled Discharge of Patient, last review date 06/2016, states under section "Procedure Part B. 1. Any patient who has been determined to be incompetent is discharged into the care of their guardian. 2. At or prior to discharge verify the Parent(s)/Guardian(s) accepting responsibility."

4. An interview was conducted with the Director of Quality Improvement Services on 02/19/19 at 11:30 a.m. She concurred with the above findings that policy was not followed.

B. Based on document review, record review and staff interviews it was revealed the facility failed to furnish its health care services in accordance with its written policies in one (1) out of ten (10) patients. This failure has the potential to negatively impact all patients receiving care.

Findings include:

1. A review of the policy Discharge Planning for Inpatients, Observation Patients and Outpatients, last review date 01/2019, states in part: "The Registered Nurse (RN) Case Manager coordinates information from each discipline with the patient's social and environmental strengths and disadvantages to determine with the patient and other health care professionals the patient's plan of care upon discharge. Section Objective Part B. Initiate and follow through on procedures which allow for easy transfer from: Hospital to home with appropriate skilled or custodial services. Hospital to another health care agency/facility to provide continuous nursing care or supervision."

2. An interview was conducted with the Director of Case Management on 02/19/19 at 10:40 a.m. She stated in part: "I do not check up with the nurse after discharge to make sure the appropriate agencies are contacted. Usually if a Home Health or Hospice needs more information, they call us and ask."

3. An interview was conducted with the Director of Quality Improvement Services on 02/19/19 at 11:30 a.m. She concurred with the above findings that case management does not follow through with discharge according to policy.

Based on document review and staff interviews it was revealed the facility failed to ensure patient care policies are reviewed at least annually. This failure, in two (2) out of three (3) policies reviewed, has the potential to negatively impact all patients receiving care.

Findings include:

1. A review of the Policy Discharge of Patient has a last approval date as 06/2016.

2. A review of the policy Discharge Instructions has a last approval date as 06/2016.

3. An interview with the Executive Assistant was conducted on 02/19/19 at 9:45 a.m. She stated the two policies had not been reviewed since 06/2016.

4. An interview was conducted with the Vice President on 02/19/19 at 1:30 p.m. She concurred the policies had not been reviewed annually.

Based on record review and staff interviews it was revealed the facility failed to provide complete discharge instructions to one (1) out of ten (10) patients. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review was conducted of patient #1's medical record. The patient was admitted on 02/05/19 with a diagnosis of uncontrolled pain. The patient was discharged home on 02/07/19, the discharge instructions were discussed with the patient only and the patient's signature was at the bottom of the discharge paper work. The discharge instructions given to the patient included a medication list in which the next dose due stated take as directed. There were no times for future doses or past dose listed on the form and no paper prescriptions were given for the new medication. There was no follow up physician information given.

2. A telephone interview was conducted with patient #1's discharge Registered Nurse (RN) on 02/18/19 at 1:30 p.m. She stated: "We do not have the next dose due time listed on the medication list. I assume the patients will understand if it is a daily med, they would've already taken it and if it's twice daily, they will need to take another dose."

3. An interview was conducted with the Director of Nursing on 02/19/19 at 9:00 a.m. In regards to the discharge medication list, she stated: "The physician fills it out from the medication reconciliation and the next dose due transfers to the discharge paperwork as TAKE AS DIRECTED. The nurse is unable to change this and I'm unsure if we write anything in the free text, if it will transfer to the discharge paperwork." She concurs there were no times listed for medication last dose or next dose due and no follow up physician instructions included in the discharge paperwork.

Based on document review and staff interviews the facility failed to ensure the health care policies are reviewed as a part of its annual program review in two (2) out of three (3) policies reviewed. This failure has the potential to negatively effect all patients receiving care at the facility.

Findings include:

1. A review of the policy Discharge of Patient has a last approval date as 06/2016.

2. A review of the policy Discharge Instructions has a last approval date as 06/2016.

3. An interview with the Executive Assistant was conducted on 02/19/19 at 9:45 a.m. She stated the two policies had not been reviewed since 06/2016.

4. An interview was conducted with the Director of Quality Improvement Services on 02/19/19 at 1:15 p.m. She stated: "Policies are reviewed then sent to the board for approval. They only see the policies that are actually reviewed or revised and would be unaware of any policies lost in queue or policies not reviewed timely."

5. An interview was conducted with the Vice President on 02/19/19 at 1:30 p.m. She concurred the policies had not been reviewed annually.