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Based on interview, and record review, the facility failed to notify and involve one of 30 sampled patient's (Patient 1) patient representative (RP), who was Patient 1's Durable Power of Attorney (DPOA, a legal document that grants another person the authority to make decisions on behalf of the patient should the patient becomes incapacitated [person's inability to manage his/her personal care, property or finances]), with regards to Patient 1's inpatient treatment course as well as provide clear discharge instructions to Patient 1's RP prior to Patient 1's discharge.

This deficient practice resulted in the violation of Patient 1's rights by not notifying Patient 1's appointed representative (RP) about Patient 1's treatment such as the use of restraints (devices that limit a patient's movement) on Patient 1 and not involving Patient 1's representative in discharge planning (the process of identifying and preparing for a patient's anticipated healthcare needs after they leave the hospital) before Patient 1's discharge to home. This deficient practice also had the potential to compromise Patient 1's treatment recovery after discharge, due to lack of communication regarding post hospital care instructions such as wound care treatment.

Findings:

During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/19/2023, the H&P indicated, Patient 1 was admitted for urinary tract infection (infection of any part of the urinary system such as the bladder), chest pain, and pneumonia (infection of the lungs).

During an interview on 12/26/2023 at 10:23 a.m. with Patient 1's representative (RP), the RP stated, the facility did not update Patient 1's RP of Patient 1's course of medical treatment and restraint (devices that limit a patient's movement) use on Patient 1 from 9/21/2023 through 9/22/2023. The RP stated, the facility did not request to provide proof of Durable Power of Attorney (DPOA, a legal document that grants another person the authority to make decisions on behalf of the patient should the patient becomes incapacitated [person's inability to manage his/her personal care, property or finances]), after Patient 1's RP notified the facility staff of being Patient 1's DPOA. The RP further stated, the RP was not provided discharge instructions when Patient 1 was discharged on 9/22/2023 and the discharge documentation did not provide details of Patient 1's admission diagnosis and treatment course during Patient 1's admission and treatment in the facility from 9/19/2023 through 9/22/2023.

During a review of Patient 1's medical record (MR) titled, "Progress Notes Report," dated 9/19/2023-9/23/2023, the MR indicated, on 9/19/2023, primary nurse documented information about Patient 1's RP/DPOA and informed of Patient 1's admission.

During a concurrent interview and record review on 12/27/2023 at 1:38 p.m. with Informatics Analyst (IA, responsible for digital technology to transform data and information), Patient 1's medical record (MR), dated 9/21/2023 through 9/22/2023 was reviewed. The MR indicated, Patient 1 was confused, agitated, and combative from 9/21/2023-9/22/2023. The MR further indicated, no documentation in Patient 1's medical record of Patient 1's family notification about on-going treatment plan and restraint application from 9/21/23 through 9/22/2023. The IA stated, the primary nurse did not make any documentation in Patient 1's medical record about updating Patient 1's RP/DPOA regarding Patient 1's treatment plan and restraint application.

During a concurrent interview and record review on 12/27/2023 at 1:38 p.m. with the director of nursing (DON), Patient 1's medical record (MR) titled, "Discharge Instructions," dated 09/22/2023, was reviewed. The Discharge Instructions indicated, home medications were not marked to be continued or changed. The MR further indicated, discharge instructions were provided on "Chest Pain" and "Wound Care" with no documentation of instructions provided. The MR further indicated, the discharge instructions were provided to Patient 1's caregiver, but there was no signature or full name placed in the "Received by" space allocated for the receiver to sign on the discharge instructions. The MR indicated, the primary nurse did not document contacting the Patient 1's RP to provide discharge instructions on the day of Patient 1's discharge on 9/22/2023. The DON stated, based on the documentation reviewed, the discharge instructions were not clear, and the primary nurse did not provide clear discharge instructions to Patient 1's caregiver about the wound care and the treatment course of Patient 1's admission stay from 09/19/2023 to 09/22/2023.

During an interview on 12/28/2023 at 12:44 p.m. with the social worker (SW 1), the SW 1 stated, the SW 1 recalled speaking with Patient 1's RP on 9/9/20/2023, and the RP informed the SW, that the RP held Patient 1's DPOA. The SW 1 stated that Patient 1's RP did not provide physical proof of being Patient 1's POA. The SW 1 stated, the SW 1 documented in SW 1'assessment, that Patient 1 did not have DPOA representative. The SW 1 further stated, the SW 1 did not recall if the SW 1 provided Patient 1's RP with any means (fax number or email) to provide proof of DPOA to the facility for Patient 1.

During an interview on 9/28/2023 at 1:14 p.m., with SW 1, the SW 1 stated, the facility does not have a clear process as to who should update information about patients' representatives, DPOA's and or conservatorship (when a judge appoints another person to act or make decisions for a person who needs help) holders. The SW 1 stated, the responsibility of validating the patient's next of kin information and/or verification of legal representative status is not solely the social worker's responsibility, and all staff is responsible.

During an interview on 12/28/2023 at 2:32 p.m. with Patient Access Manager (PAM), the PAM stated, updating a patient's personal information, including but not limited to, patient's legal status, next of kin, and/or an emergency contact information is the responsibility of the admitting staff. The PAM further stated, patient's legal status and validating information such as DPOA is the responsibility of the facility's social worker. The PAM further stated, the facility does not have a step-by-step procedure on how to validate patient representative information and who should be held accountable for this process.

During an interview on 12/29/2023 at 9:58 a.m. with the Director of Medical Surgical and Telemetry unit (DMS), the DMS stated, if a patient is unable to make medical decisions for themselves, the facility should be aware of patient's representative choices, especially if a patient has a representative with a Durable Power of Attorney. The DMS further said, the facility should notify DPOA of patient treatment and discharge planning, and provide clear discharge instructions to DPOA, because discharge instructions are important for management of their health condition after hospital discharge.

During a review of the facility's policy and procedure (P&P) titled, "Consent for Treatment: determination of Patient's Legally Authorized Representative," dated 12/2023, the P&P stated, "The determination of who has the legal power of authority to consent to medical treatment for a patient is based on the patient's legal status and on the physical condition of the patient. If patient lacks capacity, someone else must consent to the treatment on the patient's behalf and the person authorizing the treatment should be verified."

Based on observation, interview and record review, the facility failed to:

1. Provide language services necessary in the care of one of 30 sampled patients (Patient 12) in order to explain planned treatment and to verify understanding of consent for a surgical procedure in accordance with the facility's policy and procedure regarding the use of interpreter services (verbal services bridging the language gap between a patient and a provider, which is essential to provide the best possible quality of care).

This deficient practice had the potential in providing patients with deficient care and causing patient harm due to ineffective communication between healthcare provider and the patient.

2. Ensure a full oxygen cylinder (stores oxygen under pressure and is used for patients with difficulty breathing) was checked, placed, and maintained on a crash cart (The intent of a crash cart is to ensure that the correct emergency equipment, medications, and supplies are readily available to manage an emergency situation) for one of two sampled oxygen cylinders in accordance with the facility's policy and procedure regarding oxygen cylinders in a crash cart.

This deficient practice had the potential to compromise patient health and safety in an emergent patient care situation due to the lack of available full oxygen cylinder that delivers needed oxygen to a patient.

3. Ensure Physician orders (a physician's direction for treatment)
regarding tube feeding (a flexible tube is inserted through the nose and goes directly to the stomach to deliver nutrition when someone cannot eat through the mouth) and restraints (a mechanical device or equipment that immobilizes or reduces the ability of a person to move freely) use were followed for three of six sampled patients (Patients 16, 18 and 25) in accordance with the facility's policies and procedures regarding tube feeding and restraints use when:

3a. Patient 16's tube feeding was not administered as a continuous feeding.

3b. Patient 18's tube feeding was not increased every 6 hours to reach the goal rate.

3c. Patient 25 did not have a Physician order for the use of bilateral (affecting both sided) soft wrist restraints (a mechanical device or equipment that immobilizes or reduces the ability of a person to move freely).

These deficient practices had the potential to compromise Patient 16 and Patient 18's nutritional status resulting in dehydration (body does not have as much water and fluids as it needs), malnutrition (lack of proper nutrition, caused by not having enough to eat), weight loss, and fluid and electrolyte imbalance (abnormal water and minerals in the body) leading to organ dysfunction or failure. The deficient practice also had the potential to cause harm such as skin laceration to Patient 25 due to lack of proper interventions to monitor restraints use.

4. Provide written discharge instructions (educational material given to patient/caregiver addressing the patient's activity level after discharge "exiting" from the hospital) for one of 15 sampled patients (Patient 16) in accordance with the facility's policy and procedures regarding discharge instructions.

This deficient practice had the potential to affect the medical care needed after discharge, due to a lack of knowledge of the patient/caregiver/patient representative regarding post hospital care, leading to healthcare complications that can result in readmission to the hospital, serious harm or death of the patient.

5. Provide two employee witnesses for verification of consent obtained by phone from a patient's representative for one of 15 sampled patients (Patient 18) during the admission process in accordance with the facility's policy and procedure regarding the consent process.
This deficient practice had the potential for Patient 18's family representative not to fully understand the scope of services provided by the facility and also had the potential for an important information not to be relayed to the patient's representative which may affect the patient's treatment plan.

Findings:

1. During a review of Patient 12's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/26/2023, the H&P indicated, Patient 12 was admitted to the facility on 12/25/2023 for evaluation of abdominal pain and was diagnosed with acute pancreatitis (a condition where the pancreas [an organ that helps with digestion and regulation of the body's blood sugar] becomes inflamed [swollen] over a short period of time).

During a review of Patient 12's medical record (MR) titled, "Admission Assessment Report," dated 12/25/2023, the MR indicated, Patient 12's preferred language (spoken and written) was Spanish.

During further review of Patient 12's MR titled," Admission Assessment Report," dated 12/25/2023, the MR indicated, Patient 12's primary nurse documented using a certified nursing assistant (CNA) as a translator when performing Patient 12's admission assessment on 12/25/2023.

During a concurrent interview and record review, on 12/29/2023 at 10:14 a.m., with Informatics Analyst (IA, responsible for digital technology to transform data and information) and the Chief Nursing Officer (CNO), Patient 12's medical record (MR) titled "Progress Note Report," dated 12/26/2023, was reviewed. The Progress Note Report indicated, Patient 12's primary nurse documented using a CNA as a translator to explain physician's orders and reasons for cancelling Patient 12's surgery on 12/26/2023 at 6:00 p.m. The IA stated, the facility does not have medical interpreter certified staff in any language, and nursing staff must use videoconferencing technology that offers the delivery of interpreter services (verbal services bridging the language gap between a patient and a provider, which is essential to provide the best possible quality of care), as per facility's policy and procedures.

During a concurrent interview and record review on 12/29/2023 at 10:30 a.m. with the Chief Nursing Officer (CNO), Patient 12's consent for a procedure titled, "Endoscopic Retrograde Cholangiopancreatography (a procedure to diagnose problems with the liver, gallbladder [organ that stores bile, a fluid produced by the liver to break down fatty foods], bile ducts [tubes that connects the liver and the gallbladder to the small bowel], and pancreas) with possible Splenectomy (surgical procedure to remove a damaged spleen [an organ that filters blood and protects the body from infection]), stone extraction, and stent (a small plastic tube to keep an obstructed bile duct open) placement," dated 12/26/2023 was reviewed. The consent indicated, no Spanish interpreter information was documented when verified consent was obtained on 12/26/2023. The CNO stated, a nurse, verifying the obtained consent for Patient 12 on 12/26/2023 did not document using translator services as per facility's policy.

During an interview on 12/29/2023, at 10:14 a.m. with the Director of Medical Surgical and Telemetry unit (DMS), the DMS stated, nurses are expected to use interpreter services through videoconferencing technology, offered by the facility. The DMS stated, staff must not use certified nursing assistants to translate medical terminology because CNAs do not have the qualifications to serve as language interpreters and may not fully understand and correctly translate health sensitive information to patients.

During a review of the facility's policy and procedure (P&P) titled, "Communication: Patients with Limited English Proficiency," dated 10/2023, the P&P indicated, "Day-to-day conversation or decision not related to treatment or medications may be interpreted by family members, friends, or staff members. Decisions or discussions related to treatment or medications may be interpreted by staff members who have validated competency in medical terminology. Language assistance will be provided using qualified translation services and technology and/or telephonic interpretation services."

During a review of the facility's policy and procedure (P&P) titled, "Communication: Patients with Limited English Proficiency," dated 10/2023, the P&P indicated, "Instances of translation must be documented in the patient's medical record to include translator services or translation number as provided by the vendor used for the translation."

2. During an observation on 12/26/2023 at 2:08 p.m., at the medical surgical floor (a nursing specialty unit and hospital floor where a variety of patients are cared for, including patients who just had surgery and are recovering), crash cart #3 (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate [to revive] a patient experiencing cardiac arrest [heart attack]) was observed. The Crash Cart #3 contained an oxygen cylinder (stores oxygen under pressure and is used for patients with difficulty breathing), and showing the amount of pressure of oxygen in the cylinder was below 1000 psi (pounds per square inch, an oxygen measuring unit) indicating there was only 12 minutes of oxygen to run if oxygen was administered at 10 Liters/minute (measuring unit).

During an interview on 12/26/2023 at 14:08 p.m. with the Director of Nursing (DON), the DON stated, crash cart oxygen cylinders should be full and the reading on the regulator should be above 1000 PSI as per facility's policy and procedures. The DON stated, the oxygen cylinder on crash cart #3 must be replaced with a full oxygen cylinder because if there is an emergency on the floor, patients may have negative outcomes and/or delay of care should they need oxygen, and the oxygen cylinder is not full.

During a concurrent interview and record review on 12/26/2023 at 14:20 p.m. with charge nurse (RN 3) 3, crash cart #3 checklist, dated 12/26/2023, was reviewed. The crash cart #3 checklist indicated, on 12/26/2023 at 7:00 a.m., a checkmark (indicating crash cart #3 was checked and maintained to ensure the correct emergency equipment and supplies are readily available to manage the emergency) was placed next to "Oxygen tank at least 1000 PSI" column. The RN 3 stated, the documentation indicated that the crash cart #3 was inspected and oxygen amount in the oxygen cylinder was verified. However, the RN 3 further checked the oxygen pressure on the regulator and stated there was less than 1000 PSI of available oxygen in the cylinder and the tank had to be replaced as per facility's policy.

During a review of the facility's policy and procedure (P&P) titled, "Crash Cart Equipment and Medications," dated 12/2023, the P&P indicated, "Emergency carts are to be checked at a minimum of once each calendar day by an assigned licensed nurse for the presence of including but not limited to, oxygen cylinder present and at least half full (more than 1000 PSI).

During a review of the facility's policy and procedure (P&P) titled, "Compressed Gases Cylinder Management Policy," dated 7/2023, the P&P indicated, "Only full oxygen cylinders (more than 2000 PSI) should be used for emergent patient care situations. Only full oxygen cylinders should be placed on crash carts."

3a. During a review of Patient 16's Face Sheet (a document that gives a patient's information at a quick glance), dated 12/12/2023, the face Sheet indicated Patient 16 was admitted to the facility on 12/12/2023 at 5:44 p.m. with diagnoses of urinary tract infection (UTI, infection of the bladder and/or other parts of the urinary system, where urine is produced and filtered), sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), and tachycardia (increased heart rate).
During a review of Patient 16's initial nutrition assessment, dated 12/13/2023 at 2:19 p.m., ithe initial nutrition assessment indicated recommendations by Registered Dietician (RD) to adjust enteral nutrition (EN, the delivery of nutrients beyond the esophagus by feeding tubes) regimen to Jevity 1.5 (a type of tube feeding formula) at 50 milliliters per hour (mL/h, a unit of measurement) to provide 1800 calories (kcals), 77 grams (g) protein.

During a review of Patient 16's physician order, dated 12/13/2023 at 10:30 a.m., the physician's order indicated an order for tube feeding, Jevity 1.5 continuous at 50 mL/h. The order further indicated this order was active until discontinued 12/26/2023 at 6:50 p.m.

During a review of Patient 16's daily gastrointestinal (GI, stomach and intestines) assessment, dated 12/13/2023 at 4 p.m., indicated the patient was "seen by nutrition evaluated gastrostomy tube (g-tube, a tube surgically placed through the abdomen into the stomach for feeding). Ok to go up to 50 mL/h."

During a review of Patient 16's intake and output (I&O), dated 12/13/2023 at 7:00 p.m., the I&O indicated, Patient 16's tube feeding was initiated at 50 mL/h.

During an observation 12/26/2023 at 1:17 p.m., Patient 16's g-tube was connected to the tube feeding tubing (a device used to transfer medications or fluids to someone), with the tube feeding pump not running. Observed the bottle "Jevity 1.5 CAL (1.5 calories per ml)" hanging from the IV pole (a place to hang medications or fluids) was empty with the tubing closest to the bottle dry and tubing closest to the patient with residual formula. The label on the bottle stated it was hung "12/25/2023 at 12 p.m."

During a concurrent observation and interview on 12/26/2023 at 1:25 p.m. with Registered Nurse 2 (RN 2), RN 2 verified Patient 16's tube feeding pump was off. RN 2 stated the tube feeding ended around 9 a.m., and the feeding was not restarted. RN 2 stated that she forgot to call to request a new bottle from dietary. RN 2 stated each tube feeding formula bottle should run continuous at 50mL/h for a total of 20 hours and each bottle contains 1 liter (L) of formula. RN 2 verified the Physician's order in Patient 16's chart as Jevity 1.5 CAL at 50 mL/h, continuous. RN 2 confirmed the tube feeding is not running per the Physician's order, and stated if the orders are not followed the g-tube can get clogged, the patient can miss calories, become dehydrated, and lose weight.

During a record review of Patient 16's daily tube feeding assessment, dated 12/26/2023 at 2:00 p.m., the daily tube feeding assessment indicated, "spike set and pump tubing were changed once a new formula bag was hung (due 7:00 am- 7:00 p.m. shift and 7:00 p.m.- 7:00 a.m. shift)."

During a review of the facility's policy and procedures (P&P) titled, "Feeding by Nasoenteric (tube passed from the nose into the stomach), Gastrostomy (a surgical opening into the stomach from the abdominal wall where a feeding tube is inserted to bring nutrition directly to the stomach), or Jejunostomy (a surgical procedure wherein a plastic tube is inserted through the abdominal skin into the small intestine to deliver nutrition) Tube," dated 10/2023, the P&P indicated:

"Policy: Initiation and discontinuation of enteral tube feeding requires a Physician/Nurse Practitioner (NP) order. RNs and LVNs may administer enteral feedings. Continuous tube feeding will be regulated by an enteral pump ... Procedure: A. Non-air dependent closed tube feeding system ... 12. Turn on pump ... 14. Set infusion rate per hour per physician order and start infusion."

3b. During a review of Patient 18's Face Sheet (a document that gives a patient's information at a quick glance), dated 12/23/2023, the face Sheet indicated, Patient 18 was admitted to the facility on 12/23/2023 at 1:55 p.m. with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection) and non-ST-elevation (NSTEMI, a type of heart attack that usually happens when your heart's need for oxygen can't be met).

During a review of Patient 18's daily gastrointestinal (GI, stomach and intestines) assessment, dated 12/25/2023 at 8 p.m., the daily gastrointestinal assessment indicated, Patient 18 had a gastrostomy (g-tube, a tube surgically placed through the abdomen into the stomach for feeding).

During a review of Patient 18's Physician order, dated 12/22/2023 at 5:12 a.m., the Physician order indicated an order for nothing by mouth (NPO, a period of time in which someone may not eat or drink).

During a review of Patient 18's Physician order, dated 12/25/2023 at 3:18 p.m., the Physician order indicated an order for tube feeding (a tube that goes directly to the stomach or small intestine), Glucerna 1.2 (a type of tube feeding formula), increase 10 milliliters (mL, a unit of measurement) q (every) 6 hours as tolerated with a goal of 60 milliliters per hour (mL/h).

During a review of Patient 18's intake and output (I&O, a document that records fluids in and out of a person's body), the I&O indicated Patient 18's Glucerna tube feeding was initiated at 10 mL/h on 12/25/2023 at 8 p.m., then increased to 20 mL/h on 12/26/2023 at 8:00 p.m., 30 mL/h on 12/26/2023 at 4:00 p.m., and 40 mL/h on 12/27/2023 at 12:00 a.m.

During a concurrent interview and record review of Patient 18's medical record on 12/27/2023 at 2:05 p.m. with the Clinical Informatics Nurse (CIN), the medical record indicated on Patient 18's physician orders that Patient 18 was previously NPO, and tube feedings were ordered on 12/25/2023 at 3:18 p.m. CIN verified the Physician order for tube feedings to increase 10 ml/h every 6 hours a tolerated. A review of Patient 18's daily tube feeding assessment indicated tube feeding on 12/25/2023 at 8 p.m. was at 20 mL/h. CIN confirmed that Patient 18's tube feedings were not increased per Physician's orders. Patient 18's daily tube feeding assessment further indicated, Patient's 18's tube feedings were at 20 mL/h on 12/26/2023 at 8:00 a.m., and at 30 mL/h on 12/26/2023 at 8 p.m. CIN verified Patient 18's gastric residuals were not checked every 4 hours per policy for continuous feedings, with one documented residual (amount of liquid drained from the stomach following administration of enteal feed) of less than 100 milliliters (mL) from 12/25/2023 8:00 p.m. and on 12/26/2023 8 p.m.

During an interview on 12/29/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), DMS stated that tube feedings should be followed and titrated in accordance with the doctor's orders. DMS stated that if the doctor orders for tube feedings are not followed, the patient will not get the proper nutrition needed.

During a review of the facility's policy and procedures (P&P) titled, "Feeding by Nasoenteric (tube passed from the nose into the stomach), Gastrostomy (a surgical opening into the stomach from the abdominal wall where a feeding tube is inserted to bring nutrition directly to the stomach), or Jejunostomy (a surgical procedure wherein a plastic tube is inserted through the abdominal skin into the small intestine to deliver nutrition) Tube," dated 10/2023, the P&P indicated:

"Policy: Initiation and discontinuation of enteral tube feeding requires a Physician/Nurse Practitioner (NP) order. RNs and LVNs may administer enteral feedings. Continuous tube feeding will be regulated by an enteral pump ... Patient Care Policies: C. Patient is checked for gastric feeding residual every (4) hours until goal rate is achieved, then checked every 8 hours and as needed (PRN) .... Procedure: A. Non-air dependent closed tube feeding system ... 14. Set infusion rate per hour per physician order..."

3c. During a review of Patient 25's Face Sheet (a document that gives a patient's information at a quick glance), the Face Sheet indicated Patient 25 was admitted to the facility on 12/26/2023 at 2:46 a.m. with diagnoses of sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), right sided pneumonia (lung inflammation caused by bacterial or viral infection), hyperkalemia (a higher than normal level of potassium in the bloodstream), and hypernatremia (a higher than normal level of sodium in the bloodstream).

During a concurrent interview and record review on 12/28/2023 at 11:35 a.m. with the Clinical Informatics Nurse (CIN), Patient 25's Physician orders was reviewed. The Physician orders indicated an order for soft wrist restraints, dated 12/26/2023 at 11:13 p.m. and on 12/28/2023 at 10:25 a.m. The CIN verified there was no order for restraints on 12/27/2023. Patient 25's restraint nursing assessment indicated bilateral (affecting both sides) soft wrist restraints were applied 12/27/2023 at 12:00 a.m. and continued through 12/28/2023. CIN verified there was no notification to the family when initiating the restraints and for ongoing bilateral soft-wrist restraint use. CIN stated that the restraint policy indicated there must be a new order placed every calendar day for restraint use and it can be at any time during the day.

During a review of Patient 25's Care Plan (form that summarizes a person's health conditions, specific care needs, and current treatments), initiated 12/27/2023 at 2:02 a.m., the Care Plan indicated, "patient will not pull out tracheostomy (trach, a surgically created hole "stoma" in your windpipe (trachea) that provides an alternative airway for breathing)/tubes: apply bilateral soft wrist restraints as ordered, apply restraints as ordered, educate family on how they can participate in the patient' care, notify family that patient was placed in restraints ..."

During an interview on 12/28/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), DMS stated that patients should have an order for restraints and the restraint order should be renewed every calendar day by a physician. DMS stated that family should be notified immediately or as soon as possible when a patient is placed in restraints. DMS stated if the family is not notified of restraints, they may not know what is going on with their family member and it may be upsetting to the family.

During a review of the facility's policy and procedures (P&P) titled, "Use of Restraint or Seclusion," dated 10/2023, the P&P indicated:
" ...Notification of the Patient's Attending Physician: The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. The attending physician is the physician who is responsible for the management and care of the patient.
Orders for Restraint for Safety / Non-Violent/ Non-Self Destructive Behavior: Orders obtained in accordance with this policy to address a patient's medical care-related needs (safety) that are evidenced by non-violent or non-destructive behavior (non-behavioral restraint) are considered in full force and effect for up to 24 hours or 1 calendar day - which includes the day the order was obtained ..."

4. During a review of Patient 16's Face Sheet (a document that gives a patient's information at a quick glance), dated 12/12/2023, the Face Sheet indicated, Patient 16 was admitted to the facility on 12/12/2023 at 5:44 p.m. with diagnoses of urinary tract infection (UTI, infection of the bladder and/or other parts of the urinary system, where urine is produced and filtered), sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), and tachycardia (increased heart rate).

During a concurrent interview and closed record review on 12/27/2023 at 10:40 a.m. with the Clinical Informatics Nurse (CIN), the CIN verified that Patient 16 did not have written discharge instructions (educational material given to patient/caregiver addressing the patient's activity level after discharge "exiting" from the hospital) in the electronic medical chart (collective documentation of an individual patient's important clinical data and medical history over time). CIN stated she checked Patient 16's physical medical chart for a signed written discharge instructions and was unable to find the signed discharge instructions. CIN stated that all discharged patients should have a signed copy in the patient chart by the patient and nurse, per policy.

During an interview on 12/28/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), the DMS stated that for discharge instructions, the patient/family and family needs to sign off. DMS stated instructions and signatures are scanned and put into the electronic chart. DMS said that if discharge instructions are not provided, the patient or family may not follow instructions, because they will not know what to do. DMS stated discharge instructions are patient specific and it is important for the patient to have clear discharge instructions so the patient/family will know what to do per doctor's orders (a physician's direction for treatment).

During a review of the facility's policy and procedures (P&P) titled, "Discharge- Process," dated 12/2023, the P&P indicated: "1. Policy: ...2. Discharge/transfer summary will be documented by the Registered Nurse (RN) or Licensed Vocational Nurse (LVN) and placed in a patient's record. 2. Procedure: ...5. Complete discharge instructions 6. Educate patient/significant other regarding discharge instructions; take home prescription copy, and the Food and Drug interaction. 7. Obtain patient/significant other with copy instructions ... 9. Place a copy in the chart ..."

5. During a review of Patient 18's Face Sheet (a document that gives a patient's information at a quick glance), dated 12/23/2023, the Face Sheet indicated, Patient 18 was admitted to the facility on 12/23/2023 at 1:55 p.m. with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection) and non-ST-elevation (NSTEMI, a type of heart attack that usually happens when your heart's need for oxygen can't be met).

During a review of Patient 18's Conditions of Admission (an agreement between the patient/family representative and facility, signed during admission, for treatment and services provided by the facility to the patient), dated 12/26/2023, the COA indicated, Patient 18's family representative, was verbally consented by one facility representative. Patient 18's family representative provided verbal consent for the following services provided by the facility, as listed on the Conditions of Admission:

1. Consent to Medical and Surgical Procedures
2. Photography
3. Prescription history
4. Nursing Care
5. Legal Relationship
6. Personal Belongings
7. Financial Agreement
8. Assignment of All Rights
9. Health Plan Contracts
10. Maternity (pregnant) Patients
11. Health Information Exchange
12. Telephone Consumer Protection Act (TCPA)
13. The Cellular Telecommunications Industry Association Guidelines (CTIA)
14. Advanced Directives (a written statement of a person's wishes regarding medical treatment)

Patient 18's Conditions of Admission further indicated "I certify I have read the forgoing and my signature below represents that I am the patient, patient's legal representative, or am otherwise authorized by the patient to sign the above and accept its terms on his/her behalf." Patient 18's Conditions of Admission form was signed by one facility staff and Patient 18's family representative, indicating verbal consent by phone on 12/26/2023 at 1:06 p.m.

During a concurrent interview and record review on 12/27/2023 at 2:05 p.m. with the Director of Nursing (DON), DON verified the Conditions of Admissions was signed by one staff member and should have been witnessed by two staff when obtaining verbal telephone consent.

During an interview on 12/29/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), the DMS stated that when obtaining consent by telephone (verbal consent), it is important to make sure there are two staff witnesses otherwise the patient or family may be signing something they do not fully understand.

During a review of the facility's policy and procedures (P&P) titled, "Consent," dated 7/2022, the P&P indicated:
"Purpose: To clearly define a patient's right to consent to treatment and an employee's from this facility, role in the consent process, as well as to clarify the consent process.

Procedure: A competent, adult patient has the fundamental right to participate in his/her own medical care, to exercise control over his/her own body, and to determine whether he/she will submit to prescribed medical care. Obtaining informed consent is an active process in which each participant in the treatment of a patient and anesthetist, physician and surgeon provides all material information to enable the patient to make an informed decision regarding any proposed procedures and/or recommended care...

The basic agreement between the patient and this facility is the Condition of Admission. This agreement when signed by the patient or legal representative upon admission, permits the Hospital and attending physician to proceed with the care of the patient...

Obtaining and Verifying Signed Permit: 1. Obtaining/Witnessing Consent: The Admitting Office has the primary responsibility for obtaining signatures on the Hospital Admissions Agreement form at the time the patient is admitted. Employees of the facility may sign Hospital forms while acting in the capacity of a witness. All witnesses must be 18 years of age or older, and must be present when the form is signed. The witness must indicate in the designated space on the form that he/she witnessed the actual signing, a. If a patient is incompetent and the patient's legal representative is unable to come to the Hospital to sign consent(s) prior to treatment, consent over the phone or by wire (telegram or facsimile) is acceptable, b. Written record of both types of consent should be attached to the patient's permanent medical record ...

3. Consent by Telephone, Telegraph, or Facsimile: Consent for medical or surgical treatment may be obtained via telephone, telegraph, or facsimile only If the person has legal capacity to consent for the patient and is not physically available. If consent is obtained using the above-mentioned media, the physician must provide the decision-maker with the information he/she would otherwise disclose. Hospital personnel must verify that the patient's decision-maker and physician have discussed the patient's condition and recommended treatment, and the patient's decision-maker must be informed that another employee will be listening to the decisions. Both employees are to sign and date the verification of consent ..."