HospitalInspections.org

43018

Based on record review, interview, and facility policy and procedure review, the facility failed to honor patient rights for notification of patients' designated emergency contact in 3 out of 4 sampled patients, (Patient #1,Patient #2,and Patient #5) when the patients had a change of condition that required transfer to another facility for a higher level of care.

Findings:
Patient # 1:
A review of the Facility Medical Record for Patient #1 was completed. Patient #1 had an admission diagnosis of Coronary Artery Disease, Dementia, Gastroesophageal Reflux, hypertension, permanent pacemaker and a brief psychotic disorder. A review of the Face sheet indicated that patient #1 wife was listed as the emergency contact notification/legal representative.

A review of the Nursing shift note for Patient #1 dated 1/19/2020 at 9:50 PM read: Patient returned from hospital via stretcher at 9:50 PM. Patient remains alert to self, calm cooperative. Pt is monitored on 1:1. ARNP( Advanced Registered Nurse Practioner) notified of patient return. Will continue to monitor. There is no family notification present in the chart.

Patient # 2:
A review of the facility Medical Record for Patient #2, was admitted on 12/27/2019 with admission diagnoses of: Unspecified psychosis, Congestive Heart Failure, Diabetes Mellitus and Hypertension. A review of the facility medical record, indicated that (Patient #2 wife's name) was listed as the Emergency contact.

Further review of the nurses notes shows that Patient # 2 was re-admitted to the facility on 01/06/2020 and 01/18/2020, each time patient # 2 had an episode where he needed to go to a higher level of care, or when returned to the facility, the wife was not notified.

A review of the RN Shift Assessment nurses note section for Patient #2 dated 12/29/19 at 8:30 AM read: "Assessments per flowsheet. Patient is lethargic. VSS (Vital Signs Stable) on 2 Liters per nasal. Physician notified of change in status. Orders obtained to send to ER. "Entry at 6:30 PM reads: "staff spoke with ER, patient admitted to PCU (Progressive Care Unit) for AMS (Altered Mental Status) changes and for further evaluation." No further entries. No documentation of family notification was found within the note

During a review of the facility Medical Record for Patient #2 a nursing note dated 1/18/20 at 9:51 AM, read: "Observed patient with eyes closed, respirations even and unlabored, skin warm/dry to touch, vital signs within normal limits for patient, yet patient is not able to arouse with verbal or tactile stimuli, report that patient did not eat dinner last night or breakfast this AM. Observed patient with oxygen at 2 liters per minute via nasal cannula with oxygen saturation 92-93%. physician aware, orders to send out for medical clearance,called for transport, safety and comfort maintained will monitor." Nursing note dated 1/18/20 at 10:15 AM read: "Patient left on stretcher No documentation of family notification was found within the note.

A Record review of "Case Management Discharge Summary Note" for Patient #2 dated 3/10/2020 at 10:24 AM and denoted as "late entry for 12/29/2019" read: "Family Contact upon Discharge: Per the nursing note dated for 12/29/2019, there is no indication as to whether or not the charge nurse contacted patient wife (Patient #2 wife's name) to inform her that patient was being sent out to ER or that patient ended up being admitted there." Signed by Staff N on 3/10/2020 at 10:27 AM.

Patient # 5:
A review of the Facility Medical Record for Patient #5 shows an admission diagnosis of psychotic disorder with unspecified neurocognitive disorder, Hypertension, Prostatitis, dehydration, fecal impaction and falls. A review of the Face sheet indicated that Patient #5 emergency contact/legal representative was his daughter.

A review of the Nursing shift note for Patient #5 dated 5/15/2020 at 1:15 AM read: Patient found during rounds on floor in room, on floor with ST (skin tear) to left elbow, laceration to forehead and slight pain to left hip. Patient sent to ER. Review of the RN shift assessment note for There is no family notification present in the chart. There was also no note in chart showing that the ARNP notified family change in condition or that patient # 5 transferred to the ER.

Interviews:
During an interview on 6/25/2020 at 3:45 PM with Staff Q Registered Nurse, she states, "If the patient is stable but needs a medical evaluation which may require transport out of the facility, I will notify family and documentation is made in the chart of what happened, the facility staff who were notified and a note about family contact."

During an interview on 6/25/2020 at 10:30 AM, the interim DON (Director of Nursing) reviewed the nursing notes in the above charts and acknowledged the absence of documentation regarding notification of the patient representative for Patient #2 regarding his transfer to the emergency room/hospital on 12/29/2019, 1/6/2020 and 1/18/2020 and for Patient #1 and Patient #5. "The nurse is expected to notify the family/emergency contact at that time as well as document the situation in the patient's medical chart. Specifically, the time patient was sent out and well as a progress note. I do not see evidence that the families were notified of the transfers to the emergency room in the chart. All families should be notified when we send a patient out to the Emergency Room at the time we send them. An acceptable time for notification of a family is as soon as the patient has been stabilized or as soon as they are transported out of the facility. The nurses have not followed our policies and procedures for notification of the emergency contacts."

During an interview on 6/26/2020 at 8:00 AM, Staff R, Registered Nurse states nurses will contact the doctor for a patient who requires medical attention and transport to hospital. If a doctor writes an order to transfer the patient to the hospital, the nurse notifies the front desk and supervisor as well as completing paperwork for transfer. The nurse or charge nurse will notify family and should do that at the time of transfer. States, "Everything that happens will be documented in the patient's chart."

During an interview on 6/26/2020 at 9:42 AM, Staff S states when an order is written for the transfer of a patient with a change in condition requiring a higher level of care, she notifies her supervisor, the front desk and she will notify the emergency contact. If the patient has a POA ( Power of Attoney), she will give more detailed information to them. She also completes the SBAR( Situation, Background, Assessment and Review) and writes a nursing note in the patient's medical chart.

Polices:

Review of The facility's policy tiled " Practices/Rights, effective date 01/15/2018 was reviewed and read: Your rights: When it comes to health information you have certain rights. This section explains your rights and some of our responsibilities to help you.
Choose someone to act for you.
-If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

Review of the facilities policy titled "Nursing Documentation Policy # NUR 4:023" effective date 3/1/2018 was reviewed and read:
Policy: It is policy that nursing staff will maintain required ongoing documentation on all pertinent objective data regarding the patient's condition. The notes should include implementation of treatment plans, the patients observed responses to treatments interventions expressed in behavioral terms and include the identification of any new problems that emerge during the course of treatment.
Procedure:
2. A nursing staff member will be assigned to each patient and is responsible for documentation which reflects all patient care issues occurring during the hours of staff assignment.
5. Narrative nursing notes should include but are not limited to:
-any abnormalities, interventions to treat the abnormality and response to the intervention
-any changes in patient status
-new orders received
-any communication between healthcare staff and family members or significant others.