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Based on interview and record review, the facility failed to enforce its policies for obtaining a witness, for a patient who refused to sign conditions of admission and consent for outpatient care and patient Bill of Rights forms (Patient ID #1)

Findings Included:

a) Interview with patient access director Staff ID #63 on 7/18/23 at 2:35 pm, she confirmed that when a patient is confused and/or refuses to sign consents for treatment, patients bill of rights and/or admission registration forms, the registrar should obtain a witness signature documenting this encounter.

Record review of patient ID #1 electronic medical record with Staff RN ID #52 on 7/18/23 at 12:30 pm revealed emergency department physician note which stated patient ID #1 was "confused."

Record review of Patient ID #1 "Conditions for Admission and Consent for Outpatient Care" form which included Patients rights and responsibilities with Patient Access Director Staff ID #63 on 7/18/23 at 2:40 pm, she confirmed that registrar staff ID #63 had written "pt refuse to sign" in all blanks on the form and had electronically signed the form on 4/11/23 at 01:13 am. She confirmed he had handwritten his first name in the blank which was labeled "Additional witness signature and title: (required for patients unable to sign without a representative or Patients who refuse to sign) at the same time. SHe confirmed this was not considered a "witness."

Record review of facility policy "Procedure for Registration Forms and Signatures", effective 02/08/2018, stated "Documentation requirements when a patient is unable to sign: A physician or 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 or licensed clinical person's signature ad title including first and last name. Registrars are not required to document the patient is unable to sign on the consent, other registration forms or in the system notes. The witness signature area, when signed with a second witness signature and title, indicates a patient's inability to sign with a representative present." The policy further stated "E. Patient refuses to sign: No treatment should be rendered to the patient if the patient refuses to sign the consent form. In this situation, (2) witness signatures and titles are required as defined in the witness signature and Title section of this policy. In addition, the registrar should notify their supervisor or manager."

Based on interview and record review, the facility failed to provide notice of its grievance decision to the complainant, per the facility's grievance policy, for 1 of 3 sampled complainants with documented grievances (Patient ID# 1).

Findings Included:

Telephone Interview with complainant for TX00459602 on 6/20/2023 at 5:25 pm, complainant stated "I spoke to the risk person (name unknown) at the facility to discuss patient's loss of jewelry on arrival to ED a few weeks ago and I never heard anything back."

Interview with Director of Patient Safety ID #56 on 7/18/23 at 11:35, he confirmed he had spoken with the complainant regarding the above issue. He stated that following the investigation and grievance committee meeting, the resolution had been mailed to the patient. He stated that the grievance response is mailed to the patient due to HIPAA protection concerns. He confirmed there had been no follow-up specifically with complainant.

Record review of facility's grievance log identified Patient ID #1 with a grievance labeled "Property and Security" filed on 6/8/2023 by phone call from complainant. The log reflected "Resolution 6/15/2023" and date resolution was mailed "6/15/2023."

Record review of facility's grievance closure letter, addressed to patient ID #1 with patient's home address was reviewed on 7/18/2023 at 11:40 am with Patient Safety Director Staff ID #56. He confirmed the resolution had been mailed to the patient, and not the complainant.

Record review of facility's "Patient Complaints and Grievances Management" policy, last reviewed 04/2021 stated "In resolution of the grievance, a written notice of decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

Based on a record review and interviews, the facility failed to ensure the transfer of all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

Findings included:

Review of physician's history and physical with Staff RN ID #52 on 7/18/23 at 12:30pm revealed "History: Past medical history. Reports hypertension."

Review of patient's electronic medical record with Staff RN ID #52 on 7/18/23 at 12:40pm revealed patient had three episodes of systolic blood pressure > 170 which prompted administration of hydralazine (blood pressure medication) dosing.

Review of physician's discharge summary with Staff RN ID #52 on 7/18/23 at 12:30 pm revealed that diagnosis of hypertension (high blood pressure), intermittent blood pressure elevations or prn treatments were not mentioned anywhere on the discharge summary.

Review of electronic MIDAS system with Case Management Director Staff ID #55 on 7/18/23 at 1:35 pm revealed that attachments for patient ID# 1 had been uploaded by case manager Staff ID #58 to the terminal facility for placement consideration. She confirmed there was no evidence of a comprehensive medication record being sent.

Review of facility policy "Discharge Planning and Care Coordination", last reviewed 12/2022, stated "Upon discharge, the patient's condition and status of current patient problems are assessed and documented in the medical record .... Document all assessments, interventions and follow up in the medical record." It further stated "The hospital transfers or refers patients, along with necessary medical information, to appropriate facilities, agencies or outpatient services as needed for follow up or ancillary care. Necessary medical information must be provided not only for patients being transferred, but also for those being discharged home."

Interview with Case Management Director Staff ID #55 on 7/18/23 at 1:40 pm. She stated that the case managers were responsible for uploading history and physical, all consult notes, all recent therapy notes, labs and/or imaging, and current medication record into the MIDAS system for review by facility's considering a patient for admission.

Interview with Assistant Chief Medical Officer Staff ID #66 on 7/18/23 at 1:55 pm. He confirmed that he would expect the discharge summary to reflect accurate diagnosis and course of care. He confirmed that high blood pressure, and the need for intermittent treatment with medications, should be included. He reviewed admission history and physical, electronic documentation of a call placed to a physician staff ID #66 for blood pressure 189/117 and confirmed that an order for hydralazine 10 mg every 6 hrs as needed for systolic blood pressure > 170 and systolic blood pressure > 110 was placed. He confirmed the discharge summary had no mention of blood pressure changes or treatments.