HospitalInspections.org

Based on document review and interview, the facility failed to ensure the right to formulate an advance directive was documented for 1 of 9 patients who were either inpatient or outpatient at the facility. (Patient #5).

Findings include;

1. A review of Patient #5's medical record indicated the following:
a) The patient was admitted on 4/18/19 at 1:34 p.m. to the emergency department.
b) The medical record lacked documentation that the patient was informed of his/her right to formulate an advance directive.

2. During an interview with N26, (Director of Emergency Department) on 7/24/19 at 2:57 p.m., he/she verified that the nursing staff in the emergency department do not ask or document related to the advance directives of a patient. A18 also verified that registration staff do not document when they ask a patient if they have an advance directive. He/she verified that the registration staff only scan in the information to the patient's medical record if there is an advance directive.

3. During an interview with N11, (Executive Director of Quality and Risk Management) on 7/24/19 at 3:11 p.m., he/she verified that there is nothing that prompts the registration staff to document advance directive information and no consistent process or policy for registration to document if the patient has an advance directive or not.

Based on document review and interview, the facility failed to ensure its policies governing health care services were developed and reviewed at least annually by one or more members of the medical staff and professional healthcare personnel for two (2) policies (Transfer of Patients by EMS, and Mobile ICU or Helicopter and Informed Consent).

Findings include:

1. The policy/procedure Policy Management (reviewed 1-19) indicated the following: "Hospital-wide policies, procedures, protocols or guidelines... must be approved/reviewed by: at least one senior leadership staff member... or a director with overarching responsibility for the departments impacted, or the department director from each impacted department... Patient care/medical care policies, procedures or protocols must be reviewed by at least one physician... At a minimum, policies, procedures, protocols and guidelines will be reviewed on an annual basis."

2. Review of the policy/procedure Transfer of Patients by EMS, Mobile ICU or Helicopter (approved 10-18) indicated approval by the Director of Emergency Department A12 and the Medical Surgical Department Director A20 and lacked documentation indicating review and/or approval by a medical staff physician within the past year.

3. On 7-24-19 at 1005 hours, the Chief Executive Officer A1 confirmed the policy/procedure lacked documentation of annual approval by a medical staff physician.

4. Review of the policy/procedure Informed Consent (approved 2-19) indicated approval by the former Chief Nursing Officer A21 and the former Director of Surgery A22 and lacked documentation indicating review and/or approval by a medical staff physician within the past year.

5. On 7-24-19 at 1700 hours, staff A1 and the Executive Director of Risk and Quality A3 confirmed the policy/procedure lacked documentation of annual approval by a medical staff physician.

Based on document review and interview, the facility failed to maintain its list of all contracted services and ensure the list included the nature and scope of services provided for 180 of 188 contracted services (anesthesia equipment factory maintenance, radiologic C-arm equipment factory maintenance, food service equipment factory maintenance, electronic medical record support services, medical gases, pest control, surgical sterilizer factory maintenance, etc.).

Findings include:

1. Review of the list of contracted services provided on 7-22-19 failed to indicate a description of the scope and nature of each service listed under the designated column titled 'Description' for the simple majority of service providers.

2. On 7-22-19 at 1635 hours, the Chief Executive Officer A1 and the Director of Performance Improvement A4 confirmed the list of contracted services lacked documentation indicating the scope and nature of each service for the majority of listed providers.

Based on document review and interview, the Quality Improvement (QI) program failed to ensure all departments and services participated in its 2018 annual program review for one (1) department (surgical services).

Findings include:

1. Review of the Quality Improvement (QI) Plan (approved 2-19) indicated the following: "All services with direct or indirect impact on patient care quality shall be reviewed under the QI program... in conjunction with the Hospital Quality Review Committee (HQR) as described in [sections] A-J below... B. Hospital-wide QI Activities... Each department participates in hospital quality improvement by... evaluating at least annually the effectiveness of the quality improvement including progress, recommendations for improvement, and projected plan for the following year."

2. Review of the 8-8-18, 11-14-18, 2-13-19 and 5-8-19 HQR meeting minutes lacked documentation indicating a 2018 program review was completed for surgical services.

3. On 7-24-19 at 1045 hours, the Executive Director of Risk and Quality A3 confirmed the HQR meeting minutes lacked documentation indicating the department of surgical services completed a 2018 annual program review and no other documentation was available.

Based on document review and interview, the facility failed to ensure all residents were informed in writing of all items and services that are included in the nursing facility services and the items and services offered by the facility and for which the resident may be charged, and the amount of those charges at the time of admission for 2 of 2 resident medical records (MR) reviewed (Resident's #61 & 62).

Findings include:

1. Review of the policy/procedure Referrals, Transitional Care (approved 12-18) indicated the following: "Upon admission or by the next business day, the business office will provide to the patient the Transitional Care payment agreement and the Patient Rights and retain copies of the signature sheets to be scanned into the EHR (electronic health record) under the consents section of the media tab."

2. Review of the document titled Transitional Care Program Patient Rights and Responsibilities (revised 12-17) indicated the following: "Each patient admitted to [name of facility] for skilled care in the Transitional Care Program has... 2. The right to be fully informed, prior to or at the time of admission and during stay (sic), of services available in the facility, and of related charges including any charges for services not covered under Titles XVIII or XIX of the Social Security Act, or not covered by the facility's basic per diem rate... 13. Be informed of hospital rules and regulations through the Patient Guest Guide and other means."

3. On 7-24-19 at 1700 hours, staff A3 confirmed the business office is responsible for providing each Transitional Care resident with a copy of the Transitional Care payment agreement and confirmed no documentation indicating the items and services included and/or not included in the nursing facility charges that may be charged to the resident was available.

4. Review of the MR for Resident #61 indicated the patient was admitted to the Transitional Care unit on (Saturday) 4-27-19 at (approximately) 2242 hours and lacked documentation indicating a notice of the Transitional Care payment agreement (including a list of the items and services included in the basic nursing facility rate and the items and services not included in the basic facility rate and chargeable to the resident) was provided or a signed receipt obtained.

5. On 7-24-19 at 1605 hours, the Chief Executive Officer A1 and the Educational Coordinator A14 confirmed the above.

6. Review of the MR for Resident #62 indicated the patient was admitted to the Transitional Care unit on (Saturday) 6-1-19 at 1241 hours and lacked documentation indicating a notice of the Transitional Care payment agreement was provided or a signed receipt obtained.

7. On 7-24-19 at 1730 hours, the Executive Director of Risk and Quality A3 confirmed the above.

Based on document review and interview, the facility failed to develop and maintain its policies and procedures to investigate all allegations of resident abuse, neglect, exploitation and/or mistreatment including injuries of unknown source and ensure all allegations and/or event were a) reported within 2 hours of the allegation of abuse or event involving serious bodily injury to the administrator and within 24 hours if not involving abuse and/or serious bodily injury and b) thoroughly investigated while preventing further potential abuse, neglect or mistreatment during the investigations for one occurrence.

Findings include:

1. On 7-24-19 at 1535 hours, the Executive Director of Quality and Risk, staff A3 was requested to provide any policy/procedures indicating a process for investigating all allegations of patient or resident abuse, neglect, exploitation and/or mistreatment including injuries of unknown source whether by staff, other patients, or visitors and/or indicating a process for preventing further potential abuse, neglect, or mistreatment during the investigation and none was provided prior to exit.

2. On 7-24-19 at 1700 hours, the Executive Director of Risk and Quality A3 confirmed the facility policy/procedures lacked documentation indicating a process for ensuring all allegations involving resident abuse, neglect, exploitation and/or mistreatment including injuries of unknown source were immediately reported and thoroughly investigated and included a process for preventing further abuse, neglect or mistreatment during the investigation and confirmed no other documentation was available.

Based on document review and interview, the facility failed to ensure the informing of visitation rights was documented for 7 of 9 patients who were either inpatient or outpatient at the facility. (Patients #1, 4, 5, 6, 7, 8 and 9).

Findings include;

1. A review of a current "Patient/Visitor INFORMATION GUIDE" provided by N10 (Chief Executive Officer) indicated the following on page #12: ...Visitation...You have the right to choose who may visit you during your hospital stay, subject to certain clinical restrictions or limitations on such rights, and to deny or withdraw from such consent at any time. In the event you are unable to designate who can visit, your representative may do so on your behalf..."

2. A review of Patient #1's medical record indicated the following:
a) The patient was admitted on 7/23/19 at 11:33 a.m. to the obstetrics unit.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

3. A review of Patient #4's medical record indicated the following:
a) The patient was admitted on 5/24/19 at 11:35 p.m. to the medical/surgical unit.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

4. A review of Patient #5's medical record indicated the following:
a) The patient was admitted on 4/18/19 at 1:34 p.m. to the emergency department.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

5. A review of Patient #6's medical record indicated the following:
a) The patient was admitted on 5/29/19 at 9:50 p.m. to the emergency department.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

6. A review of Patient #7's medical record indicated the following:
a) The patient was admitted on 6/11/19 at 9:30 a.m. to the outpatient surgery department.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

7. A review of Patient #8's medical record indicated the following:
a) The patient was admitted on 6/12/19 at 9:00 a.m. to the outpatient surgery department.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

8. A review of Patient #9's medical record indicated the following:
a) The patient was admitted on 4/21/19 at 7:46 p.m. to the medical/surgical unit as observation status and inpatient status on 4/22/19 at 2:00 p.m.
b) The medical record lacked documentation that the patient or (the patient's support person, where appropriate) was informed of his/her visitation rights and/or received the "Patient/Visitor INFORMATION GUIDE".

9. During an interview with N10, on 7/24/19 at 5:08 p.m., he/she verified that there was nothing in policy to instruct staff to document when they would provide a patient the "Patient/Visitor INFORMATION GUIDE" that contained the visitation rights and that there was no specific note documented in the patients' medical record that the patients received the "Patient/Visitor INFORMATION GUIDE" or was informed of their visitation rights.