HospitalInspections.org

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Based on Medical Record review, document review, and interview, in four (4) of eight (8) Medical Records, the Admitting Staff did not follow Policies to obtain appropriate signatures of acknowledgement or receipt of information for: (A) "An Important Message from Medicare" (IM), (B) "Identification of Caregiver and Authorization for Release of Medical Information to the Identified Caregiver" (ICARMI), and (C) "Authorization to Designate a Representative to an Adverse Determination" (ADRAD).

This failure may not have ensured that patients and/or their representatives had the information necessary to exercise their rights.

Findings for A:

The facility's Policy and Procedure titled "Discharge Notices: Important Message from Medicare" last revised 01/04/16 stated "The Admitting Department registrar will obtain the signature of all admitted Medicare beneficiaries ... on the IM. When the beneficiary is unable to comprehend or incapable of receiving the notice, the registrar will give the IM to the beneficiary's representative. The representative must sign and date the notice and indicate his/her relationship to the beneficiary ... [if] the beneficiary's representative is not directly available, the registrar will call the representative and convey the information. Documentation includes the name of the person contacted, the date and the telephone number called...."

A Memorandum from Staff Y to all Admitting Registrars dated 11/13/12 stated "...if patient is unable to sign [the IM form], indicate why on the form.... If the patient is unable to sign, but is able to understand the form, then you would indicate 'patient unable to sign due to [blank]; form was explained'. Then witness it and place with chart...."

Patient #8's Medical Record identified that the IM Letter lacked a patient or representative's signature. In lieu of a signature, the IM stated "verbal consent" on the signature line. No reason why a signature could not be obtained, who obtained the verbal consent, or witness signature were documented.

The same lack of patient or representative signature was found in the Medical Records for Patients #11, #18 and #22 for the review period of 02/02/17 to 02/03/17.

These findings were confirmed by Staff P on 02/02/17 at 11:40AM and acknowledged by Staff L on 02/03/17 at 1:15PM.

Findings for B and C:

An interview with Staff P on 02/03/17 at 1:45PM revealed the "Identification of Caregiver and Authorization for Release of Medical Information to the Identified Caregiver" (ICARMI) and the "Authorization to Designate a Representative to an Adverse Determination" (ADRAD) Consent Forms are used to determine whether a patient has a representative and who that representative is [New York State Proxy Law]. Staff P stated these Consent Forms apply to the General Consent Policy.

The facility's Policy and Procedure titled "General Consent for Hospital Services / Treatment" last revised 06/06/16 stated "...If the patient is unable to sign consent and is not accompanied by a legal representative, the Admitting Representative or Registrar will document "Patient unable to sign due to (Reason). The reason why the patient is unable to sign must be clearly documented. The Admitting Representative or Registrar will then sign, date and time on the witness line."

Patient #8's Medical Record identified that the "Identification of Caregiver and Authorization for Release of Medical Information to the Identified Caregiver" (ICARMI) and the "Authorization to Designate a Representative to an Adverse Determination" (ADRAD) Consent Forms lacked a patient or representative's signatures. In lieu of signatures, the "Identification of Caregiver and Authorization for Release of Medical Information to the Identified Caregiver" (ICARMI) and "Authorization to Designate a Representative to an Adverse Determination" (ADRAD) stated "verbal consent" on the signature line. No reason why a signature could not be obtained, who obtained the verbal consent or witness signature were documented.

The same lack of patient or representative signature was found in the Medical Records for Patients #11, #18 and #22 for the review period of 02/02/17 to 02/03/17.

These findings were confirmed by Staff P on 02/02/17 at 11:40AM and acknowledged by Staff L on 02/03/17 at 1:15PM.
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Based on Medical Record review, document review, and interview in six (6) of seven (7) Medical Records reviewed, the facility did not ensure that the Medical Records were complete. This was evident by the lack of documentation justifying the reason for the 1:1 (one to one) observation of a patient, and the lack of documentation on the 1:1 Observation Flow Record (OFR).

These lapses in documentation has the potential to adversely affect the provider's ability to monitor and provide appropriate patient care.

Findings:

Review of Patient #24's Medical Record identified the following: on 01/31/17 the patient expressed to the Nurse that she wanted to kill herself. The Nurse notified the Physician, and a 1:1 observation was ordered, and was initiated at 3:00PM. The only Nursing Note documented at 9:46PM stated "1 to 1 observation in place and maintained". The Note lacked justification for placing the patient on 1 to 1 observation. Also the 1:1 OFR lacked documentation by staff in the Daily Behavior Section from 3:00PM to 11:00PM.

Review of Patient #3's Medical Record on 02/01/17 identified lapses in documentation on the 1:1 Observation Flow Records. The Records lacked observation dates, behavior observations of the patient, and staff signatures for varying shifts and days.

The same lapses in documentation for patients on 1:1 observation were found in the Medical Records of Patients #4, #14, #16 and #17 for the review period of 11/04/16 to 02/01/17.

These observations were made in the presence of Staff R who acknowledged that the Nurse should have documented the reason for placing the patient on a 1:1, and the staff should have documented the dates, observations, and daily behavior observations for patients being monitored on 1:1.

The facility's Policy and Procedure titled "Patient Observation: 1:1 / 2:1" last revised August 2016 contained the following statements: "The Registered Nurse (RN) will document in the Nursing Progress Notes at a minimum of once per shift including the patient behavior (decrease or absence) ... the Nursing Assistant / Security Staff will utilize the appropriate Flow Record / Behavioral Observation Tool (days / nights)."

The facility's training material titled "Patient Observation", undated, stated the following under 1:1 / 2:1 observation: "Patient Observation Progress Note is required each shift by the RN ... a brief description of the patient's overall behavior for the time frame ... indicate the patient's status: ex improved, remains agitated, requires constant verbal cues."