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Based on record review, policy review, and interview, the facility failed to ensure the patient or his or her representative has the right to make informed decisions regarding his or her care for one of 10 medical records reviewed (Patient #5). The facility's census was 1107.

Findings include:

The facility's policy titled, Informed Consent Policy (Version 6, Effective Date 06/22/22) stated patients with Decision-Making Capacity (or their Authorized Representatives) have the right to provide Informed Consent for those treatments that are defined as Health Care Treatments in this Policy. References to "patients" in this Policy shall be interpreted as references to Authorized Representatives when appropriate. Informed Consent must be obtained prior to rendering a Health Care Treatment. Informed Consent must be documented on an Informed Consent Form signed by the patient or Authorized Representative in accordance with this Policy. Informed Consent includes a discussion with the patient followed by the patient's informed and voluntary consent. Adults who lack Decision-Making Capacity, whether formally adjudged so or not, cannot give Informed Consent for a Health Care Treatment for themselves or others. Consent or permission to treat an Adult who lacks Decision-Making Capacity" must be obtained from the first-listed Adult(s) ("Authorized Representative(s)") with Decision-Making Capacity from the following list, in order, if such person(s} exists and is reasonably available:
1. Court-appointed guardian or Attorney-in-fact under a durable power of attorney for health care (if both are in place for the Adult, consent from both must be obtained).
2. Spouse
3. Majority of Adult children
4. Parent
5. Majority of Adult siblings
6. Next closest relative by blood or adoption

A Care Management Assessment and Discharge Plan note by Staff D on 06/20/23 at 3:54 PM stated "Telephone call to and spoke with Patient #5's brother. Introduced myself and role of care management. Patient #5 lives alone in a third floor apartment with stair and elevator access. Independent and active. No durable medical equipment or home oxygen use prior to admission. Physical therapy and occupational therapy when able. Patient #5 is not married and has no children. Per Patient #5's brother, Patient #5's mother is not able to make medical decision. Patient #5's brother is surrogate decision maker. Care management will continue to follow."

Staff D was interviewed on 06/22/23 at 2:20 PM. Staff D stated Patient #5's brother was the surrogate decision maker for Patient #5. Staff D reported Patient #5's mother had dementia and was unable to make decisions and Patient #5's father was deceased.

On 06/20/23 at 8:59 AM, Patient #5's mother signed a consent for Diagnostic Craniocervical Angiogram.

The findings were shared with Staff A and B on 06/22/23 at 2:35 PM and confirmed.

Based on medical record review, policy review, and interview, the facility failed to ensure the use of restraint or seclusion was in accordance with the order of a physician for one of eight medical records reviewed of patients who were restrained (Patient #6). The total sample was ten patients. The facility's census was 1107.

Findings include:

The facility's policy titled, Restraint and/or Seclusion Use Policy (Version 6, Effective 11/01/22) stated physicians/LIPs (licensed independent practitioners) are responsible for accurate and timely restraint and/or seclusion electronic orders and patient evaluations and for the notification of restraint and/or seclusion orders to the attending physician/LIP.

Review of Patient #6's medical record revealed the patient was placed in bilateral soft wrist restraints on 06/23/23 at 5:15 PM. A nursing flowsheet stated, "emergency restraint, attending notified and order obtained". Patient #6's restraints were discontinued on 06/24/23 at 11:10 AM. The medical record for Patient #6 did not contain an order for restraints.

The findings were shared with staff A on 06/26/23 at 8:11 AM and confirmed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00143890.