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Based on document review and interview, it was determined that the Hospital failed to promote the rights of patients by failing to inform the patient's power of attorney (POA) of a patient's health status change. As a result, it was determined that the Condition for Participation 42 CFR 482.13, Patient Rights, was not met.

Findings Include:

1. The Hospital failed to ensure that the patient's POA was informed of the patient's change in health status. See deficiency at A-131.

Based on document review and interview, it was determined that for 1 of 4 (Pt #2) clinical records reviewed, the Hospital failed to ensure the patient's power of attorney (POA) was informed of the patient's change in health status and transfer to the Intensive Care Unit (ICU).

Findings include:

1. On 3/8/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 presented to the Hospital's Emergency Department (ED) on 1/09/22 by ambulance with a chief complaint of altered mental status (AMS). Pt. #2 was admitted to the Hospital's Telemetry Unit-6 North. Pt. #2 expired on 1/18/22 at 9:14 AM. The clinical record included:

- An Illinois Durable Power of Attorney for Health (name of Pt.#2) dated 8/9/2020, naming (Pt.#2's son) as POA, signed by Pt.#2.

-A critical care/pulmonology physician's note on 1/11/22 at 3:35 PM included, " ... found in hypoxic respiratory failure today, CXR shows pulmonary edema related to pleural effusion ... ordered BIPAP (bi-level positive airway pressure-mask connected to machine/oxygen that helps with breathing), Lasix (medication used for fluid retention) ..."

- A pulmonology physician's note on 1/17/22 at 5:56 PM, included, "(Pt. #2) was seen and examined today, worsening gas exchange and renal failure. Transferred to ICU for close monitoring, on BIPAP ... lungs coarse, bilateral breath sounds with rales ... CXR: pulmonary edema, plans: BIPAP ..."

-A pulmonology physician's note on 1/18/22 at 8:30 AM, included, " ... responded to code blue ... no pulse ... CPR started, emergency intubation 7.5 ETT (endotracheal tube-inserted through the oral cavity to help breath) placed first attempt, good color, pulse returned ... full vent (ventilation) ..."

- The clinical record lacked documentation that a physician contacted (Pt. #2's) son/POA when Pt #2 was transferred to the ICU due to change/worsening of Pt. #2's condition and when Pt #2 coded.

2. On 3/10/2022, the Hospital's "Medical Staff Rules and Regulations" (revised 6/2020) were reviewed and required, " ... 1-3. Responsibility. A member of the Staff is responsible for the medical care and treatment of each patient in the Hospital ... and for transmitting reports of the condition of the patient to... relatives of the patient ..."

3. On 3/10/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" (revised 3/2019) was reviewed and required, " ... 2. Designate an authorized representative ... to exercise, to the extent permitted by law ... if the patient is found to be either medically incapable of understanding the proposed treatment or procedure or unable to communicate his/her wishes. The patient's rights include being informed of his/her health status, being involved in care planning and treatment ..."

4. On 3/10/2022 at approximately 11:30 AM, an interview was conducted with the Medical Director of 6 North (MD#3). MD#3 stated that when there is a change in the patient's condition or plan of treatment, it is the physician's responsibility to contact the patient's family or POA and discuss the changes and options. MD#3 stated that when a patient experiences a code blue and has to be intubated and can no longer speak for themselves, the physician must contact and document in the clinical record that the family or POA were notified of the patient's change in condition.

5. On 3/10/2022 at approximately 12:00 PM, an interview was conducted with MD #4 (Pt.#2's Attending Physician). MD#4 stated that when a patient's condition changes and can no longer make medical decisions, it is the responsibility of the physician to contact the patient's family or POA. MD#4 stated that when Pt.#2 coded, a physician should have contacted the son (POA).