HospitalInspections.org

Based on record review and interview the facility failed to inform patients of their rights in advance of furnishing or discontinuing care for 5 of 10 patients (Patients (Pts. #1,3,7,8,and 9) in a sample of 10 records reviewed.

Findings include:

Review of facility policy, titled, "Patient Bill of Rights," effective 7/9/2019, stated, "All patients and/or patient representatives presenting for any type of medical service within the organization will be made aware of and /or offered a copy of The Patient Bill of Rights. Documentation of this discussion will be completed within the Electronic Health Record."

A review of patient #1 medical record revealed that the notice of the patient's bill of rights being provided to
Pt. #1 was not documented in the medical record.

During an interview on 3/3/2022 at 8:15 AM, RN F confirmed there was no admission consent or notice of rights documented in Pt. #1 medical record. RN F stated, "We try to connect with family, but didn't in this situation."

Review of facility policy titled, "Important Message -Medicare Beneficiary Protocol, approval date of 5/2019, stated," The Important Message (IM) CMS-R-193 notice must be issued to all Medicare Part A recipients by the hospital within 2 days of admission to inpatient services or with any change in status from outpatient or observation to inpatient. ....The follow up copy must be delivered as far in advance as possible but NOT MORE than 2 days prior to discharge."

A review of patient #3, #7, #8, and #9 medical records revealed the Important Message was NOT issued prior to change in service or discharge from the facility.

In an interview on 3/3/2022 at 10:45 AM with RN F, when asked about the Important Message being given, RN F stated, "It's not documented as given."

In an interview on 3/3/2022 at 11:15 AM with RN V , when asked about the Important Message being given and where it is documented, RN V stated, "There was no Important Message evident in the records and it wasn't documented that it was given."

Review of facility policy titled, "Informed Consent" effective date of 3/3/2020, stated, "If a patient lacks decision-making capacity, the patient cannot validly sign the consent form, and a consent should be obtained by an individual who is empowered to act on his/her behalf." Under Duration of Consent: "1. Hospital Admission and Medical Treatment consent: Given by the patient/patient representative at time of admission to the hospital; covers routine care administered during the entire hospitalization."

Review of Pt. #1 medical record revealed no consent for admission/hospitalization to the facility. Pt. #1 was admitted on 01/06/2022.

Review of Pt. # 9 medical record revealed a certificate of incapacitation effective 06/14/2021. Pt. #9 signed the Important Message from medicare form on 2/6/2022.

Review of Pt. # 6 medical record revealed revealed a certificate of incapacitation effective 04/07/2021. Pt. # 6 signed the Important Message for Medicare on 01/12/2022.

In an interview on 3/3/2022 at 11:15 AM with RN F, when asked if Pt. #9 and Pt. #6 were incapacitated and signed the Important Message from Medicare, RN F stated, "Yes, that is correct." When asked RN F how can patients sign consent forms if they are incapacitated, RN F stated, "That is a fair question."

Based on record review and interview the facility failed to develop a policy to create a process for ensuring the implementation of additional precautions to mitigate the transmission and spread of COVID-19 for unvaccinated staff and failed to develop contingency plans for staff who are not fully vaccinated for COVID 19. This has the potential to impact all patients at the facility.

Findings Include:

Review of Facility Policy, titled, "Business Health COVID-19 Vaccination Policy," effective date of 11/16/2021 revealed no process or additional precautions to mitigate the transmission and spread of COVID-19 from unvaccinated staff and no contingency plan for staff who are not fully vaccinated for COVID 19.

In an interview with RN Q on 3/2/2022 at 9:20 AM when asked about COVID precautions, RN Q stated, "I have an exemption, I'm not vaccinated." when asked what extra precautions are needed, RN Q stated, "I'm doing what I was doing, nothing different right now, I might have to do weekly testing, they were supposed to let us know by March 1st, but I haven't heard anything."

In an interview with RN Manager J on 3/2/2022 at 9:30 AM when asked about COVID precautions, RN J stated, "I have a waiver." When asked what extra precautions are needed for unvaccinated staff, RN J stated, "Hand hygiene, social distancing, if we are sick then we stay home. Currently not weekly testing, but possibly in the future."

In an interview with RN F on 3/3/2022 at 10:45 AM when asked about the vaccine policy and the missing elements as stated in the regulation, RN F stated, "We don't have a contingency plan for unvaccinated staff that is defined, that is something we would need to do. We don't have defined testing parameters due to the low incidence in our county. There are no additional precautions unvaccinated staff need to take at this point, we are doing the social distancing and universal masking. There is no defined contingency plan for staff not fully vaccinated."