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Based on interviews, facility documents and medical record review, it was determined the facility failed to notify a patient of their rights and responsibilities for one (1) of seven (7) patient records sampled (Patient #2).

The findings include:

On May 6, 2025, a review of Patient #2's medical record was conducted. Patient #2's "Conditions of Admission and Consent for Inpatient and/or Surgical Care", which included Consent for Treatment, Patient Self Determination Act, and Acknowledgement of Notice of Patient Rights and Responsibilities, was not signed by Patient #2. The form was signed by one (1) Patient Access Representative as a witness and the box "Patient is Unable to Sign" was checked. In addition, the Patient Self Determination Act box was checked by the statement "I have not executed an Advance Directive and do not wish to execute one at this time".

On May 6, 2025 a review of Patient #2's medical record was conducted. Patient #2's medical record documented the objective assessment as P2 being alert and oriented times four (4) and ambulatory. There was nothing documented in P2's medical record from a physician or a licensed clinical person that P2 was unable to sign any documents.

On May 7, 2025, an interview was conducted with Staff Member #14. Staff Member #14 stated that Patient Access Representatives round in the Emergency Department (ED) to register and obtain signatures from patients. If a Patient Access Representative was unable to obtain the registration and signature, the Patient Access Representative would follow up on that patient again at a later time. Staff Member #14 stated that the Patient Access Representatives were required to obtain signatures from all patients, unless the patient were unable to sign or refused to sign, and regardless of why the patient is being seen in the facility.

A review of the facility's policy "PAPA.PP.PTAC.038 Procedure for Registration Forms and Signatures", last approved 5/1/24 and provided by Staff Member #14 indicated in part:
"...The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time from based upon the patient circumstance...The Consent should be obtained for each account within the episode of care. Reasonable attempts will be made for follow up on signatures not obtained during the registration process...
Documentation requirements when a patient is unable to sign: A physician or a licensed clinical person should document a medical reason why the patient is unable to provide a signature, within the medical record. The documentation should include the physician's or licensed clinical person's signature and title including the last and first name..."

Based on interviews, facility documents and medical record reviews, it was determined the facility's nurses failed to follow facility policy and procedure for a patient discharge for one (1) of seven (7) patient records sampled Patient #1).

The findings include:

On May 6, 2025, a review of Patient #1's medical record revealed that Patient #1 was discharged from the facility on March 18, 2025. Patient #1's Discharge General Information, which included discharge instructions, was not signed by Patient #1. The discharge instructions were only signed by the assigned Registered Nurse (RN).

Patient #1's discharge nursing notes were also reviewed and found no documentation to indicate that the RN reviewed the discharge instructions with the patient and/or that the patient refused to sign the discharge instructions.

A review of the facility's policy "Discharge of Patients", effective 5/2023, indicated in part: "...Policy Statements...F. Discharge instructions will be reviewed by a nurse with the patient or significant other...Documentation: A. Complete discharge instruction form, discuss with patient/significant other and have them sign. Provide patient with copies...".

Based on observation, staff interview, and facility policy review, it was determined the facility failed to clean food delivery carts in accordance with the facility's Cleaning Food Carts, Tray Closets, and Menus, and Food and Nutrition Department Infection Control/Prevention policy.

The findings include:

On May 6, 2025 at approximately 12:15 PM, during a tour of the third floor unit in the facility's behavioral health facility, a food delivery cart was observed on the unit. The food delivery cart contained lunch trays for the patients on the unit. Observation and inspection of the food delivery cart revealed the cart was visibly soiled at the bottom inside portion of the cart doors in the area of the door hinges, as well as on the exterior portion of the cart. There was a brown substance at the bottom of each of the three doors in the area of the door hinges. There were ink marks on the outside of the cart, as well as streaks of dried liquid on the inside of one of the cart doors.

Staff Member #8 reported during an interview on May 6, 2025 that the meal delivery carts are supposed to be cleaned three times a day. When asked to provide documentation to show the most recent cleaning schedule, such as the times and dates of the cleaning of the meal delivery carts, Staff Member #8 stated that there was no documentation to show the dates or times of the cleanings.

Review of the facility's policy titled: "Cleaning Food Carts, Tray Closets, and Menus" with a most recent revision date of August 2022, was reviewed and reads in part: "...Food carts will be cleaned between soiled and cleaned patient meal delivery by Nutrition Department staff-3 times a day at a minimum, or as needed." Review of the facility's policy titled: "Food and Nutrition Department Infection Control/Prevention with a most recent revision date of April 2, 2025 reads in part:"...2. Food Carts: b. Carts are cleaned and sanitized after each use. Carts are also washed on a scheduled basis."

Staff Member #8 could not verify that the meal delivery cart had been cleaned.