HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to ensure that patients were given notice of rights for one (1) of eight (8) patients (Patient # 3).

The findings include:

On August 28, 2019 at 2:00 p.m., the clinical record review for Patient # 3 revealed Patient # 3 was admitted on August 18, 2019 (and had been a patient at the facility for 10 days). The triage note dated 08/18/2019 at 3:15 a.m. read "Pt arrived to ED via EMS from group home unresponsive. Medics state home states pt has been increasingly more unresponsive as the day went on. Also states pts recent stay in hospital."
There was documentation reading "08/18/2019 Unable to sign or verify info due to condition, no family present. 2nd attempt (initials)."
There was no documentation that the patient received notice Patient Rights.

An interview with Staff Members # 3 and # 15 on August 28, 2019 at 2:05 p.m. revealed "I don't see that form."

The facility policy titled "Conditions of Admission form in Registration Packet" received from Staff Member # 3 on August 28, 2019 at 2:10 p.m. read in part "If the patients' mental or physical condition inhibits or precludes his or her decision making capacity, determine if there is a family member or substitute decision maker reasonably available to sign (in VA spouse may sign). Document all efforts in the Hospital Account notes. The registrar will leave the COA (Conditions of Admission) form status as blank, and will document information in the Hospital Account notes. The patient account will then fall onto a workqueue for additional follow up. In the event that the patient is still "in-house", the registrars will make 3 separate attempts to obtain the signature. After the 3rd unsuccessful attempt to obtain COA, the registrar will change the form status to "Unable to Obtain", along with documenting all efforts."

An interview with Staff Member # 15 on August 28, 2019 at 2:15 p.m. revealed "[His/her] family (Patient # 3) come to visit everyday."

An interview with Staff Member # 14 on August 28, 2019 at 3:25 p.m. revealed "The registrar should make three (3) attempts and document these attempts. The registrar will continue to try after the three (3) attempts because it will remain in the "workqueue". The "workqueue" is list of patients that have missing information that the registrar needs to continue to try to obtain. The "workqueue" continues to notify the registrar daily. It is available to all registrars when they log on to the system. There are five (5) other patients along with Patient # 3 in the workqueue now."

The facility failed to follow their policy to make and document three (3) attempts to inform the patient, family member or substitute decision maker of patient rights on admission.

Based on document review and interview, it was determined that the facility failed to ensure that the facility staff obtained informed consent for treatment for one (1) of eight (8) patients (Patient # 3).

The findings include:

On August 28, 2019 at 2:00 p.m., the clinical record review for Patient # 3 revealed Patient # 3 was admitted on August 18, 2019 (and had been a patient at the facility for 10 days). The triage note dated 08/18/2019 at 3:15 a.m. read "Pt arrived to ED via EMS from group home unresponsive. Medics state home states pt has been increasingly more unresponsive as the day went on. Also states pts recent stay in hospital."
There was documentation reading "08/18/2019 Unable to sign or verify info due to condition, no family present. 2nd attempt (initials)."
There was no documentation that informed consent to treatment was obtained.

An interview with Staff Members # 3 and # 15 on August 28, 2019 at 2:05 p.m. revealed "I don't see that form."

The facility policy titled "Conditions of Admission form in Registration Packet" received from Staff Member # 3 on August 28, 2019 at 2:10 p.m. reads in part "If the patients' mental or physical condition inhibits or precludes his or her decision making capacity, determine if there is a family member or substitute decision maker reasonably available to sign (in VA spouse may sign). Document all efforts in the Hospital Account notes. The registrar will leave the COA (Conditions of Admission) form status as blank, and will document information in the Hospital Account notes. The patient account will then fall onto a workqueue for additional follow up. In the event that the patient is still "in-house", the registrars will make 3 separate attempts to obtain the signature. After the 3rd unsuccessful attempt to obtain COA, the registrar will change the form status to "Unable to Obtain", along with documenting all efforts."

An interview with Staff Member # 15 on August 28, 2019 at 2:15 p.m. revealed "[His/her] family (Patient # 3) come to visit everyday."

An interview with Staff Member # 14 on August 28, 2019 at 3:25 p.m. revealed "The registrar should make three (3) attempts to obtain consent to treatment and give notice of patient rights and document these attempts. The registrar will continue to try after the three (3) attempts because it will remain in the "workqueue". The "workqueue" is list of patients that have missing information that the registrar needs to continue to try to obtain. The "workqueue" continues to notify the registrar daily. It is available to all registrars when they log on to the system. There are five (5) other patients along with Patient # 3 in the workqueue now."

The facility failed to follow their policy to make and document three (3) attempts to obtain informed consent to treatment from the patient, family member or substitute decision maker.

Based on document review and interview, the facility staff failed to ensure the History and Physical for one of eight (1 of 8) patients (Patient #7) was correctly documented prior to surgery.

The findings include:

The review of Patient #7's medical record was conducted on 8/28/19 with Staff Member #9. The following information was from the medical record review:
Patient #7 was admitted on 11/20/18 for left shoulder open rotator cuff repair/nerve block.
The History and Physical (H&P) for Patient #7 was completed on 11/16/18. The section of the medical record titled, "Anesthesia Encounter" section, "Events" documents the surgeon arrived in the pre-op area at 7:35 A.M. on 11/20/18. The H&P update was documented occurring on 11/20/18 at 7:30 A.M., which was five (5) minutes prior to the surgeon's arrival in the pre-op area where Patient #7 was located.

Anesthesia was documented as starting at 7:38 A.M. on 11/20/18. On 11:20/18 at 7:47 A.M. Patient #7 underwent a nerve block and general anesthesia.

The above information was shared with Staff Member #10 on 8/28/19 at approximately 2:00 P.M. Staff Member #10 stated, "[He/She] (the surgeon) could have been in post-op documenting the update because pre-op is sometimes so crowded." Staff Member #10 was asked if the documentation indicated the surgeon saw the patient prior to surgery. Staff Member #10 stated, "No, but we try to start surgery on time." "Our staff will document the cause of the delay." Staff Member #10 confirmed that the time documented on the H&P Update was "7:30".

The hospital Medical Staff Rules and Regulations were provided by Staff Member #7. Under Section 5.2.5 of this document, it read "History and Physical Update Requirements - For a medical history and physical examination that is completed within 30 days, an update documenting any changes in the patient's condition is completed within twenty-four (24) hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services."

The above findings were shared with Staff Members #1, #3, #7 and #22 at the end of day conference on 8/28/19.

Based on document review and interview, the facility staff failed to ensure information related to a patient's response to anesthesia was noted and passed on to the staff performing anesthesia on the day of surgery for one (1) of six (6) patients (Patient #1).

The findings include:

Patient #1's medical record review on 08/28/19 at 2:00 pm revealed:

History and Physical assessment (H&P) documentation written by Staff Member #4 on 11/24/18 stated, "Adverse effect of anesthesia on date 12/2013, passed out after waking from a seizure severe headaches every procedure since."
H&P by Staff Member #4 continued and stated under Allergies and Reactions- "[Patient #1] states that 10/1 surgery [he/she] passed out from anesthesia."

Documentation Titled, "Anesthesia Preprocedure Evaluation" written on 11/28/18 at 9:36 AM was reviewed and under "Anesthetic History" read, "No history of anesthetic complications."

Staff Member #21 (Anesthesiologist) was interviewed on 8/29/19 at 9:20 AM. Staff Member #21 stated, "Anesthesia will go through all patients with nursing during pre-admission testing before surgery. The chart then remains in anesthesia office available to review as needed until surgery takes place. Important information is flagged usually as well as conveyed by nurses."

Staff Member #21 failed to review documentation, including the H&P by Staff Member #4, reflecting Patient #1's adverse reaction.