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Based on interviews and record review (RR), the facility failed to determine one patients (P)1 decisional capacity and health care decision maker in a timely manner. Specifically P1 had an advance health care directive (AHCD) on file dated 08/01/2016. P1 was determined not to have decisional capacity while still in the emergency room (ER), but the facility did not acknowledge his wife as legal authority representative (LAR) until after a meeting was held on 07/27/21. This deficiency resulted in a lack of guidance for how the care team should proceed and caused significant stress for all family members. There was the potential the directives (wishes) P1 made in the 2016 AHCD when he had decisional capacity would not be honored.

Findings include:

1) P1 was a 65-year-old male admitted to the facility on 07/12/21 for nausea and vomiting. He had Stage 4 lung cancer with known metastasis to the throat, lungs and brain. His diagnosis included respiratory failure, bilateral pneumonia, and bilateral pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). Prior to hospitalization he lived at home with his wife and was receiving services from a hospice agency.

P1 had an Advanced Health Care Directive (AHCD) on file dated 08/01/2016 which designated his wife as the decision maker, or Durable Power of Attorney for Healthcare Decisions (DPOAHC) effective immediately. P1's end of life decisions were "I want to stop or withhold medical treatment that would prolong my life." On 07/20/21 at approximately 10:00 PM, P1 signed out of the hospital AMA and went home with his wife.

On 07/21/21 at 05:59 PM, P1 returned to the ER by ambulance requesting police be notified and another external agency because his wife was not feeding him. P1 did not have any new medical symptoms. While in the ER, P1 verbalized he wanted to change his AHCD to prolong life and change his decision maker from his wife to another family member (FM)1.

2) Review of the facility policy titled "Advanced Care Planning including: Advance Health Care Directive, Provider Orders for Life-Sustaining treatment, Comfort Measures Only" dated 02/13/20 included the following definitions:
"Advanced Health Care Directive (AHCD): An individual instruction which is for anyone 18 years of age and older and documents: a. desired goals of care b. a healthcare power of attorney (designation of agent)"
"Health Care Power of Attorney-Designation of agent: A competent person who has attained age of majority may execute an AHCD authorizing an agent to make any lawful health care decisions pursuant to HRS Chapter 327E."
"Legally Authorized Representative (LAR): an individual appointed by the patient, the courts, or by other means to make health care decisions on behalf of the patient. Example of a LAR include a guardian, Health Care Power of Attorney..."
"Capacity: A patient's ability to understand the significant benefits, risks and alternatives to proposed health care and make and communicate a health care decision.

The purpose of the policy "is to describe processes and procedures to promote optimal advance care planning for patients..." The policy included "A critical aspect of end of life care is elucidation (clarification) of patient goals in a process that: 1) reflects on a patient's goals, values, and beliefs; 2) discusses these goals, values, and beliefs in relation to possible health care choices and 3) documents and communicates the patient's treatment choices to others.

The policy said it is "meant to guide physicians, nursing, social work, and chaplaincy in supporting appropriate advance care planning throughout the Medical Center." The policy included "The expressed desires of a patient with capacity always supersedes the effect of an AHCD...identifier form." The policy states "Unambiguous verbal statements by the patient, or reliable reports thereof, shall be documented in the electronic medical record (EMR) as a verbal health care directive, ...A patient with capacity has a right to change or revoke all or part of a patient's AHCD..., including during an emergency situation "

3) Review of the facility policy "Informed consent policy & who can consent" dated 05/02/19 included the following definitions:
"Agent: Designation of Agent: An individual designated in an Advanced Health Care Directive to make a health care decision for the individual granting the power."
"Designated Surrogate: A person other than a patients agent or Guardian, who is appointed by the patient to make health care decisions on his or her behalf should he or she become incapacitated.
"Verification and identity and Authority: If the health care decision-maker is not a patient, the facility shall verify the authority of the decision-maker by obtaining documentation, where indicated, that supports the decision-makers right to make health care decisions on the patient's behalf. Questions regarding who has the authority as a decision-maker be referred to the Risk Management or Legal Services Departments."

The policy included "3. Determining Capacity when necessary, the following should be considered to determine decision making abilities that constitute capacity: Understanding, Expressing a choice, Appreciating, Reasoning. See additional guidelines. Addendum B and C." Although the Addendums (flow diagrams) are specific for surgical consent, the flow chart in Addendum B titled "Durable Power of Attorney Process" identifies step one as "Evaluation of capacity (capacity tool)," followed by step two "Does the patient have capacity?"

4) Reviewed P1's medical records on 09/28/21 which revealed the following:
07/20/21 at 12:15 PM, Advanced Practice Registered Nurse (APRN)1's note prior to AMA: "Focused (P1) on wanting to get in touch with his attorney to amend his will. ...Alert, some confusion noted during conversation...Fixated to attend to legal matters...Given episodes of confusion, agitation, team would benefit from consulting psychiatry for formal capacity assessment. MD3 to order consult." APRN1 "reviewed P1's current AHCD with him.... Assisted patient (P1) in making a phone call to his attorney .... Patient informing attorney that he would like him to come to the hospital to change certain things in his will. Also wanted attorney to come to evaluate his "lucidity." Informed patient that capacity assessment would be arranged inpatient with hospital psychiatry team. Arranged for patient to identify details of his will that he would like addressed and that we would call his attorney back to arrange a visit after capacity assessment." The APRN discussed P1's AHCD with him in great detail. "Patient read and re-read the scenarios (of condition) several times and agreed that he would not want to prolong his life in these situations. Patient however, not able to apply these situations to his own life at present."

07/20/21 at 02:25 PM Hospitalist (MD)3 documented: "Reportedly called 911 on nursing staff this morning. States wants to be cured of his underlying disease. ...Agitated/Anxious appearing and Paranoid. ...Stage 4 Lung cancer with brain metastasis...Patient displaying erratic behavior, verbally abusive with staff/wife, ...forgetful an tangential with conversation. Query whether the patient is able to make decisions regarding his care at this time.

07/20/21 at 05:24 PM Psychiatric (MD)4's note included: "Psychiatry consulted to assess for decisional capacity to accept/refuse hospice care. ...At this point probably best to focus on palliative care rather than hospice/decisional capacity given patients wish to prolong life."

07/20/21 at 10:00 PM P1 left the hospital AMA
07/21/21 at 05:59 PM P1 returned to the ER by ambulance and readmitted.

07/21/21 at 06:34 PM, the psychiatrist's (MD)2 consult note in the ER included P1 had "stage 4 lung cancer with brain metastasis with psychiatric history of anxiety and dementia... Patient also reportedly stated he came to get away from his wife. Psychiatry consulted for safety assessment and to evaluate for capacity to refuse admission (patient later agreed to hospitalization). ...Of note, patient left AMA yesterday. ...consulted for capacity to accept/refuse hospice care. Patient apparently suspicious about prognosis and team. He refused psychiatric medication and expressed interest in palliative care. ...States wife has been holding him "captive" and that she has been trying to "starve" him for his inheritance. He states he has felt this way for "months". ...He currently lives with his wife but desires to live with one of his FM's instead. He denies other paranoid thoughts... When asked if he were interested in psychiatric medication that could possible help alleviate paranoid thoughts, he politely declined. ... unspecified anxiety. Also considering delusional disorder. ...Psychiatry initially consulted for capacity to refuse admission, but patient now agreeable to admission after discussion with family member and social work. ...Due to evolving nature of capacity, capacity evaluation can be performed by psychiatry when need arises."

07/21/21 at 07:19 PM, the Emergency Physician (MD)1 notes: "Psychiatric/Behavior: Positive for agitation, confusion, dysphoric mood (can be causes that aren't related to underlying diseases i.e. grief reaction), hallucinations and sleep disturbance. ...The patient is nervous/anxious." The note documented; "History of adjustment disorder with depressed mood. Patient was evaluated by psych as an inpatient. Patient has been refusing palliative care assistance or hospice care. Psychiatry was consulted for evaluation and management. At 10:30 PM MD1 documented; "Per psych team, patient has capacity to request AMA discharge."

On 07/21/21 at 10:34 PM while in the ER, with the assistance of the Social Worker (SW)1, P1 initiated a new AHCD. The new directive P1 drafted included he wanted to prolong his life and wanted artificial nutrition and hydration. P1 hand wrote "I do not want ...Hospice to be involved in any of my care ...I do not want my wife to be involved in my medical decisions or care." The AHCD identified other FM's, not his wife as DPOAHC agents. The original document was given to the family to take home to get notarized or to have signatures witnessed and return the document to the hospital.

On 07/21/21 at 10:54 PM, SW1 documented: "Met with pt. 1:1 per pt. request to discuss AHCD. Pt would like to change his DPOAHC and AHCD to place other FM's as his decision maker and remove his wife. LCSW (licensed Social Worker) reviewed AHCD from [sic] with pt and FM2 ... Pt stated multiple times he does not want his wife as decision maker or involved in his health care decisions. Pt is deathly afraid of being d/c (discharged) home with wife or that wife will come to hospital and try to take him home. Pt does not want any medical info shared with wife, Pt requesting to have life prolonged at this time (as reasonable). Pt would like artificial nutrition and hydration, ... Pt wants his HC (Health Care) decision makers power to take effect immediately. Pt completed "surrogate decision" making form to take effect immediately until FM's return pts signed AHCD. Pt discussed a "no info" with FM's and are considering completing forms so that wife is not able to call and or receive medical updates ot [sic] information about pt. ...Family aware that psych (psychiatrist) MD2 saw pt tonight and deemed pt to have capacity. ...RN updated on surrogate decision maker form, copy placed in chart. New AHCD (copy placed in chart). And pt request for no info (completed), family given code. ..." MD2's consult note did not document P1 had capacity.

On 07/21/21 prior to leaving the ER, P1 signed a form to be a no information status. The form states "A no information status means the facility will not provide information about your presence at the hospital to any caller or visitor unless they provide the correct password. This will include family and friends. Please understand that a NO information status includes all of the protections below:
All caller and visitors will be told that we do not have a patient by your name, unless they provide the correct password. If family/friends call information or the nursing station directly, staff will not share any information with your family/friends over the telephone (unless they provide the correct passcode). Your name will not appear on the patient listing that our Information Desk uses...Telephone calls will only be transferred to your room if your caller provides your room number and asks to be transferred to that specific room number-your call provides the correct password. You may call out."

On 07/21/21 [this date was corrected from 07/23/21], at 11:17 PM the admitting hospitalist (MD6) completed the facility Health Care Decision Maker form that documented P1 "to lack sufficient ability to understand the significant benefits, risks and alternatives to proposed health care or to communicate a health-care decision..." This form identified FM1 to be the patient designated decision maker.

On 07/21/21 at 11:52 PM MD6's history and physical (H&P) included; "Comes (P1) to the ER with concerns of abuse at home from his wife. He reports his wife has been "keeping me locked up in a room" and "not been giving me water. ...He left AMA today (actual time 07/20/21 at 10:00 PM) from hospital where he was initially here for N/V (nausea/vomiting). Pt does not want his wife to be updated on his condition and does not want her visiting him. He only wants his family (brothers and sisters) to have updates only in his presence and his case is not to be discussed without him present." There was no documentation in the H&P regarding P1's evaluation of capacity.

On 07/23/21 at 01:14 PM APRN1: APRN1 "recommended that family talk amongst themselves and with patients' wife (as she has been primary support for last 10 years,) While patient is currently a NO INFO patient, his wife had previously been heavily involved ... Patient has requested he be a NO INFO and not to talk with this wife prior to being determined to not have capacity so no conversations have occurred with the wife but she has been calling the operator multiple times a day trying to check on patient. ... P1 deemed unable to make medical decisions."

LATE ENTRY for 07/28/21 by APRN1: "...met with leadership to discuss patient and decision makers. It was determined that we should be honoring patient's AHCD that is scanned into chart from 2016. This AHCD lists his wife at [sic] decision maker and a FM as alternate. PPC (Palliative Care) SW and PPC APRN (APRN1) to contact patients FM1 prior to previously scheduled meeting to update him of this change and that he will no longer be making medical decisions for patient."

On 07/28/21 at 01:35 PM MD7: "Per meeting with palliative care team and hospital leadership, patient's wife is the designated health care decision maker...I spoke to patients wife and discussed plan of care."

On 07/29/21 at 02:14 PM SW1: PPC SW advised that patients FM2 had come to bedside yesterday evening and was asking patient to sign documents. ...Unit staff advised that patient should not be signing anything..."

5) On 09/28 at 10:00 AM during an interview with the palliative care APRN1 assigned to P1, she said she saw P1 while she was in the ER and at first he didn't remember her from the day before. When asked about P1's capacity, the APRN said what she saw in the psychiatry chart was he did not have capacity. She said there was a draft of the new AHCD in the chart and that she "needed guidance" regarding the two AHCD's and contacted Risk Manager for assistance. The APRN went on to say she had about three care conferences with FM1 and got to know him. FM1 told her he had not been involved with P1's life for awhile and hard for him to step in. He told us he was nervous about being the decision maker and that they hadn't been aware P1 had been sick.

6) On 09/28/2021 at 03:00 PM during an interview with the Social Services Manager (SSM), she said she had been involved in one meeting on 07/27/21 with Risk Management, Legal and the Palliative Care team about P1's Health Care Directive. The SSM said "the guidance was that the directive (AHCD) given to the family in the ER was not valid. It did not have witnessed signatures or notary, so we needed to honor the one signed in 2016 rather than the one prepared in ER." When quiered if P1's competency was an issue, the SSM said "it was not competency, but signatures." She went on to say when the wife became the overall decision-maker, she then drove the visitation list and did not allow visitors.

7) On 09/29/21 at 10:30 AM during an interview with the Risk Management (RM), she said "someone from the palliative care team notified me about the case, most notably about the second advance care directive and the no information implemented against the wife when he came into the ER." The RM said they had a meeting on 07/27 and that she was notified a day or two before that, which gave her time to review the chart. She said since it was about the AD, she "decided to bring legal in." The RM said "We reviewed the records from the previous admission when he went AMA and returned less that 24 hours later. P1 changed everything and wanted a second directive initiated. He made his decision maker another FM. We reviewed everything as a group and discussed the two documents (ADs). The physician and APRN filled in the gaps in his clinical situation." The RM said MD6 documented P1 lacked capacity a couple of hours after he designated a FM as the new decision-maker. The RM said "what was significant for me and legal was in his case nothing had significantly changed an hour or two prior to MD6 said P1 lacked decisional capacity. His mental status was the same. We did not make a final decision at that time because legal wanted to review it with the head of legal. Clinically, it didn't make sense and we all agreed we felt uncomfortable with the new directive and should honor the 2016 one with the dynamics going on. It was very concerning and his illness was progressing. Legal department felt we should be honoring the 2016 one. This had a significant impact on who would be visiting and other things. A secondary reason was the new document was not completed appropriately. It did not have witnessed signatures or a notary."

8) On 09/28/21 at 12:00 PM during an interview with SW2, she said she was present when APRN1 provided FM1 a medical update on P1 and background of what had been going on the past few years. FM1 was unaware of P1's diagnosis or medical condition. SW2 said "FM1 said he felt like he got called off the bench like in a baseball game because he hadn't had a conversation with P1 for several years."

9) When capacity was not determined or clear prior to allowing P1 to draft a second AHCD and appoint new decision makers, it created unnecessary stress on P1's wife as well as the FM's who unexpectedly got appointed as decision makers. Until the facility determined they needed to honor the original ACHD with P1's wife as the decision maker, P1's FM's had been actively involved in his care/discharge planning. During that time, his wife was not given any information or allowed to visit. After the hospital determined they should be honoring the original AD 2016, the FM's were notified the wife would now be the decision maker.

Inquired if there were any complaints or grievances filed by either P1's wife or other FM's and was provided a file initiated on 07/23/21. The issue was identified as a complaint with the description: "It was brought to advocates attention that the patients (P1) wife was on the phone with operator for some time, then admin (administrative) secretary for a lengthy amount of time requesting to be transferred to her husband. Advocate reviewed the chart and it was noted the patient is a "No Info." Informed the patient's wife that we do not have any information for patient by that name. The caller insisted that the patient was in the hospital. Again, and again reiterated to the caller that we are sorry as we do not have any information for a patient by that name. She continues and was upset. Advocate explained that again we are sorry and that advocate would be ending the call (continued to escalate over the phone). The caller ended up hanging the phone.

On 09/29/21 reviewed an email SW1 sent to FM1 on July 30th at 02:42 PM. The email was responding to questions and concerns FM's had after P1's wife was made the decision maker. They were concerned how P1 would react when his wife came to visit as he had previously said he was afraid of her and wanted to be able to get information regarding his status. It is unknown exactly when FM's were told about the change.

On 09/30/21 at 09:45 AM during an interview with the Clinical Operations Manager (COM) for social work, she said P1's FM's came to her office and wanted to know what was going on. The COM said she asked them to wait in the lobby so she could contact someone who knew about the situation. The COM said she also notified Risk Management. She went on to say "they wanted answers. I conveyed to them about the no information and explained couldn't share anything with them. She said they were insistent wanting to continue to question her and said they deserve to know and had been involved since the beginning. The COM contacted security and the FM's left with them.

Based on record review (RR) and interviews, the facility failed to ensure one patient (P)1 received the appropriate diet. Specifically was discharge against medical advice on 07/20/21. He was on a full liquid diet during that admission. P1 was readmitted on 07/21/21 and ordered a solid cardiac diet. Although he expressed to the nursing staff he could not eat solid foods, the diet did not get changed until after family members expressed concern. In addition, P1's care plan was not updated in a timely manner to include aspiration precautions. As a result of this deficiency, P1 was at risk of choking or aspiration.

Finding include:

1) P1 was admitted from 07/12/21 and discharged when he left against medical advice (AMA). He had Stage 4 lung cancer with brain metastasis and had been admitted for nausea and vomiting. During that admission he was on a full liquid diet. P1 signed AMA on 07/20/21 at approximately 10:00 PM.

RR conducted P1's medical records completed on 09/29/21. RR revealed:
07/19/21 at 10:43 AM (first admission) an inpatient swallow evaluation was completed by the Speech Language Pathologist (SLP)1. Notes in the report said "P1 was on hospice care and was mostly on a liquid diet....Pt was referred to Speech Pathology services on 07/18/21 for a swallow evaluation with indication : "dysphagia (a condition with difficulty in swallowing food or liquid)." P1's baseline diet was "Pt stated he primarily drank ice water, Gatorade, and Ensure. He endorsed that some food "made him feel like he was going to choke. ...Pt (P1) actually demonstrated no signs of aspiration with trials of thin liquids that he was willing to take. He was also able to swallow pureed solid item, albeit limited amount." The SP recommendations included dysphasia therapy and "Continue with full liquid diet, with type-in's of certain food items allowed that pt indicated he would be willing to try "Cream of wheat cereal, oatmeal, creamed soups (in addition to items on a full liquid diet tray). Recommendations for safety included positioning recommendation: Ensure alertness prior to PO intake;Sit up during PO intake;No laying down after meals for 1 hour Precautions/Restrictions: Small bites, Small sips..."

07/19/21 at 12:45 PM (first admission) the Advanced Practice Registered Nurse (APRN)1 note included; "...Observed patient attempted to some water and immediately began coughing and choking. Reports [P1] that he was leading a fairly independent life until about 3 weeks go. He began having difficulty swallowing (he is unsure why) resulting in the need for a full liquid diet."

2) P1 returned to the ER and readmitted. His admission orders included a cardiac solid diet.

Review of P1's medical records done on 09/28/21. The RR revealed the following:
07/22/21 03:48 PM APRN1 saw P1 while he was still in the Emergency Department and documented "Observed to drink water and immediately gasp for air and begin coughing.
07/25/21 03:01 PM Registered Nurse (RN)4: Refuse to eat solid foods and swallow pills. Suppose to be chopped."
07/25/21 07:51 PM RN4: "...Discussed with pt's FM concerns - changed diet to ensure Chopped/Mechanical soft."
07/26/21 12:00 PM, APRN1: "Discussed with patient and sister that another swallow eval will be completed to determine the most appropriate diet/food choices. In the meantime, I informed them I have adjusted his oral medications to be crushed and served with mechanical soft foods (easy to swallow and chew)"

07/26/21 01:50 PM SLP: "Pt (P1) was referred to Speech Pathology services this morning, 7/26/21, for clinical swallow evaluation with indication: "choking or coughing on liquids or food." Per nurses report to this SLP, pt was on a p.o. (oral) diet prior to being made NPO today. He was on a cardiac diet with mechanical soft chopped solids and thin liquids. When family noticed the food items on his tray, they questioned why he was receiving those items that were too large for pt to bite/chew. This prompted pt to be made NPO and the swallow evaluation." SLP also documented "Swallow Problems Related to: Impaired Cognition." The SLP recommended: "Solids: Minced Liquids: Regular thin." The same safety precautions were recommended that were recommended in the swallow evaluation on the first admission completed on 07/19/21 with the addition of "Meds crushed and mixed with applesauce or pudding."
07/27/21 02:35 PM SLP: "Received phone call from pt's family member (FM)1, this morning and phone call from pt's FM2, just now. ...Obtained collateral information from them regarding pt's swallow function and p.o. textures, if any, pt was eating/drinking. Both FM's endorsed that they were concerned about the food pt received on his meal trays (i.e. bagels) earlier on during this current admission. They requested that pt's food be chopped due to concerns with his swallowing. ...Explained rationale for the minced solids."

3) On 09/29/21 at 08:00 AM during an interview with the SLP, she said she called and spoke with FM1 about P1's diet. SLP said FM1 had seen the bagel on the tray and was concerned. SLP said she apologized for this and discussed the swallow evaluation with FM1. SLP said she "can't speak to why or how it [bagel] got there." The SLP explained minced foods and cut much smaller than chopped foods. The SLP went on to say aspiration precautions usually include crushing medications. When inquired if she documents in the patient care plan, the SLP said the recommendations should cross over into the care plan

4) During an interview with the Quality Director (QD), inquired if the SLP's recommendations were in P1's care plan. She said they do not automatically cross over into the nursing care plan, but were located in the "Patient Care Summary," and some would also be written as orders.

5) Review of the Nursing Care Plan did not include the SPL recommendations, but were located in the Patient Care Summary "Speech Recommendations" filed 07/29/21 at 10:03 AM. Recommendations included:
"Solid Consistency Minced"
"Recommended Liquid Consistency Regular thin"
"Aspiration Supervision Requirements" "Intermittent [patient needs to be encouraged to eat.]"
"Aspiration Medication Administration Requirements: Meds Crushed [patient sometimes likes his pills crushed well and put in juice]"

6) On 09/29/21 at 10:00 AM during an interview with AP said she had about three care conferences with P1's FM1 and recalled a conversation FM1 saw P1 was getting whole pills and asked to have the medications crushed. APRN1 said she changed the order to crush meds at that time.

7) On 09/29/21 at 12:00 PM during a phone interview with RN1, she said she spoke with FM1 after a bagel was found on P1's tray. RN1 explained there were two ways to put orders in the computer, and she recalled the first time the order was suppose to be changed (from regular to chopped) it was entered into the electronic record incorrectly. The order "chopped foods please" was entered in the comment area and that doesn't change the order. RN1 said "FM's needed some reassurance so she put the new order in the computer in front of them."

8) Review of Diet and other pertinent orders revealed the following:
07/21/21 at 11:46 PM Admission Orders by Hospitalist (MD)6 : "Cardiac Diet (solid)"
07/23/21 at 05:13 PM by MD3: Cardiac Diet, "Comments; Chop foods please"
07/25/21 at 06:34 PM entered by RN4 Cardiac Diet; Chop foods please
07/26/21 at 09:30 AM by MD3 NPO (nothing by mouth)
07/26/21 at 09:30 AM by MD3 Speech, Clinical Swallow Evaluation
07/26/21 at 02:44 PM by SLP: Discontinue NPO, Cardiac diet.
07/26/21 at 09:30 AM by MD3 Aspiration Precautions 1. Feed only when awake/alert 2. Sit up 90 degrees for all meals and medications 3. Stay up 30 minutes after a meal. 4. Have suction at bedside 5. Give oral meds one at a time
07/29/21 at 02:42 PM by Dietician Regular Diet [minced texture with thin liquids]

Based on record review (RR), and interviews the facility failed to ensure all entries in one patient's (P)1 medical records were complete. Specifically, R1's against medical advice (AMA) form did not include the risks of leaving AMA, or contain a progress note from the physician (MD)5 who discussed the discharge with P1. In addition, the Health Care Decision Maker form had a correction to the date which was not amended according to legal standards or facility policy. As a result of these deficiencies, the medical records were incomplete and did not contain sufficient information that promotes continuity of care among providers.

Findings include:

1) P1 was a 65 year old male admitted to the facility on 07/12/21. He had Stage 4 lung cancer with brain metastasis. His diagnosis included respiratory failure, bilateral pneumonia, and bilateral pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). On 07/20/21 at approximately 10:00 PM, P1 was discharged AMA because he wanted to go home to die.

2) A review of P1's medical records from his first admission (7/10/21- 07/20/21) was completed on 09/29/21. The RR revealed the following:

07/20/21 11:23 AM Registered Nurse (RN)2's Care Plan Addendum included: "D [data]: "You're trying to kill me" Difficult to reorient. Patient on the phone, calling 911--requesting operator to send police to his wife's home, to contact his lawyer and to call his office. Patient alert and oriented x1 [Knows name and can recognize significant others. Not oriented to place, time or situation]. A [Action]: ...APRN to consult psych (psychiatry) to assess patient's competence. Per MD3, patient has an Advanced health Care Directive that states if he has a condition that can't be improved, he does not want to escalate care. ...R [Response]: Patient's wife reporting that patient was violent when she visited, that she would not be by to visit today. Addendum: Patient made repeated attempts to call 911. Became very upset when psych team came to evaluate patients competency. "You can see by talking to me that I make sense." Patient blaming RN, saying that he will include RN in his legal complaint because RN allowed "unauthorized" doctors in his room. Wife came to visit. Pt. initially happy to see patient [sic] "Hi Sexy." but later accused his wife of wanting to kill him. Wife acknowledged that patient is confused and that this is not his normal behavior."
07/20/21 02:30 PM, Hospitalist (MD)3 progress note regarding Decision Making Capacity read; "Patient displayed erratic behavior, verbally abusive with staff/wife, calling 911 on staff this AM, paranoid about medications administered in hospital. Forgetful and tangential with conversation, Query whether the patient is able to make decisions regarding his medical care at this time. Psych consulted for evaluation."

07/20/21 05:24 PM Psychiatric (MD)4 consult note: Reason for consult was "capacity for medical decision making" Notes included "..Psychiatry consulted to assess for decisional capacity to accept/refuse hospice care. ...At this point probably best to focus on palliative care rather than hospice/decisional capacity given patients wish to prolong life. ...
Unstable, Irritable during interview. Patient able to communicate choice of wanting to have continued medical care and refusing hospice. However, team did not evaluate patient's capacity to refuse hospice care as patient clearly stating his choice for treatment with goal to prolong life."

07/20/21 07:26 PM RN2's notes: Patient insistent on leaving the hospital against medical advice. Psych team came to see patient to weigh in on patient's competency. Psych did not leave a note. ...MD4 will speak with psych and get back to patient.

07/20/21 09:30 PM, P1 signed a "Leaving Against Medical Advice" paper form. The form included an area to write in the specific risks of leaving the physician discussed with the patient. RN3 wrote in this area "MD4 spoke to the patient." RN3 dated and signed the form as a witness but did not document the time it was completed.

07/20/21 10:00 PM RN3's notes: "...MD5 was notified that the patient wanted to leave. He/she spoke to the patient about leaving."

MD5 did not document a progress note regarding the 07/20/21 phone conversation with P1. It is unknown what the content of the conversation was or if MD5 explained the risks of leaving AMA to P1.

MD3's discharge summary created on 07/21/21 at 01:00 PM read; "The patient signed AMA on the evening of 7/20/21 after discussion with the overnight staff/covering physician. The patient's wife was updated and agreed to take the patient home."

Review of the facility policy titled Admission/Transfer/Discharge Policy dated 10/10/19 states "A patient who desires to leave the hospital without medical approval MAY NOT be detained unless it's determined that the patient is unable to make informed decisions about their healthcare. An event form is filed and the patient is requested to sign a release." The policy said "Physician will discuss with patient the risks of leaving against medical advice and document this discussion fully in medical record." MD5 did not document the discussion in the medical record he/she had with P1 prior to him leaving AMA. There was no event report filed with any further details.

2) A review of P1's second admission (07/21/21- expired 08/10/21) was completed on 09/28/21. The RR revealed a document (Healthcare Decision form) MD6 completed when he examined and determined P1 "to lack sufficient ability to understand the significant benefits, risks and alternatives to proposed health care or communicate a health care decision." This legal document determined P1 to not have decisional capacity and appointed the decision maker for his health care. The date MD6 signed the document was 07/23/21, but the date had a single line marked through the 23, and changed to 21 so the date read 07/21/21. There were no initials of the individual that made the correction.

Review of the facility policy Legal Health Records revised date 03/16/18 stated documentation content will be complete and "shall include all facts and pertinent information related to an event, course of treatment, patient condition , and/or response to care." The policy also states "all entries shall be dated and timed." The policy directs the medical staff including physicians "For corrections, draw a line through the original entry is such a way that the original entry remains legible. Initial the cross-out. ...Make the necessary change. Date and authenticate the amendment if made at a time other than the original entry. Include a reason for the amendment to the record if significant changes were made.