The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on hospital admission documentation, observations, interviews, and record review, it was determined the hospital staff failed to assure the consent forms signed by, or for, Patient Identifier numbers (PI) #2 and #3, were signed by a person designated by the patient as their representatives; And failed to assure that PI #12's designated legal representative was informed of changes in the patient's condition or treatment options.
This deficient practice affected three of nine sampled in-patients.

Findings Include:
The hospital's "Conditions of Admission" statement is written in small print and includes:
"1. Authorization for Disclosure of Medical Information: I, the undersigned as the patient or his/her representative, in consideration for the treatment provided by...(name of hospital associated services) to patient hereby authorized and request...(name of hospital service) or any other professionals who provide care treatment or services to patient to release to my insurance company(ies) or their authorized representative or other appropriate agency(ies) such medical, diagnostic or therapeutic information (including any treatment for emotional illness; alcohol or drug abuse, communicable disease, or sexually transmitted disease) as may be necessary to determine or validate the undesigned's benefit entitlement or to process payment of claims for health care services provided to the patient...also authorized to release to my physician(s), or persons authorized to bill for them, such information as necessary for billing purposes including, without limitation, all records and information pertaining to my medical treatment including any treatment...
2. Consent to Hospital Care: I am presenting myself for admission to the hospital and I voluntarily consent to the rendering of such care including diagnostic procedures and medical treatment, by authorized agents and employees of the hospital, and by its medical staff, or their designees, as my in their professional judgement be deemed necessary or beneficial. I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my conditions. I realized that during the course of my care ...(hospital name), or follow-up care, it maybe necessary for the...Hospital or my attending physicians to make available to other health car providers, copies of my medical records for information relating to my care, and I consent to such releases, And, I have been notified that if these documents are sent electronically, this may possibly breach my confidentiality issues with the released contents.
3. Personal Valuables: It is understood and agreed that the hospitals maintains a safe for the safekeeping of money and valuables and the hospital shall not be liable for the loss or damage to any money, jewelry, glasses, dentures, furs, fur coats, and for garments or other articles of unusual value and small compass, unless placed therein, and shall not be liable for the loss or damage of any other personal property, unless deposited with the hospital for safekeeping.
Assignment of Insurance Benefits: In the event the undersigned is entitle to hospital benefits of any type whatsoever arising out of any policy of insurance insuring patient or any other patty liable to patient, said benefits are hereby assigned to Hospital for application on patient' bill, and is agreed that the hospital may receipt for any such payment and such payment shall discharge the said insurance company of any and all obligations under the policy to the extent of such payment, the undersigned and or patient being responsible for charges not covered by this assignment.
5. Financial Agreement and Payment Guarantee: Both undersigned patient and the guarantor(s) agree that consideration of the services rendered to the patient, they thereby individually obligate themselves to pay the charges of the hospital in accordance with the regular rates and terms of the Hospital. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate.
6. For Medicare/Medicaid Beneficiaries Only: I certify that the information given by me in applying for payment under Titles XVIII & XIX under the Social Security Act is correct. I request the payment of authorized benefits be made on my behalf for any services furnished me by, or in ...Hospital, including physician services. I authorize any holder of medical records or other information about me to release to the health care financing administration and agents any information necessary to determine these benefits or related services.
7. I have been informed that ...produces a Facilty Directory for Admissions only. This list may include: the patient's name, the patient's location within the facility (room number, ER, OR, etc), a general description of the patient's condition and the patient's religious affiliation.
I ( ) DO CONSENT ( ) DO NOT consent to be listed on the facility director.
8. I understand that ...(hospital name and services) utilizes an extensive system of video cameras throughout their facilty, Cameras monitor public hallways, waiting rooms, and parking lots as well as closed patient care areas such as obstetrical, surgical hallways and the endoscopy suite.
9. The undersigned certified that he/she has read the foregoing, and is the patient, or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms. All guarantors certify that they have read the foregoing and accept its terms.
10. under Federal Law, ...(hospital name and health services) is required to report certain diseases and/or conditions to the Alabama Department of Public Health, or the Centers for Disease Control and Prevention, this includes but is not limited to the following: Human Immunodeficiency Virus (HIV), Tuberculosis, Viral Meningitis, Hepatitis A, B, and C.
Patient...Witness...Date...Guarantors...Relationship to Patient
Name of Patient...Date..."

On 4/27/2011 at 10:38 AM CST, PI #2, an alert and oriented patient (over the age of 70) was observed and interviewed. PI #2 stated, and family members at the bedside confirmed, that she (PI # 2) was admitted to the hospital from the emergency room (on 4/18/11).
A review of PI# 2's medical record revealed three different consent forms were signed with PI# 2's name. Each form had a different types of writing (penmanship). On the "Conditions of Admission" form PI# 2's name was printed (dated 4/18/2011), someone printed two letters (initials) in the witness section of the form, and PI# 2's "daughter" signed as "Guarantors" on the form.
The "AUTHORIZATION FOR EMERGENCY TREATMENT" form (also dated 4/18/2011) had PI# 2's name written on the form with three letters (or initials) in parentheses beside the PI# 2's name. The witness section had three letters (initials) signed in a different penmanship (no signature on the witness section).
The form 4/18/11 form entitled "An Important Message From Medicare About Your Rights" was signed with PI# 2's name in a third penmanship (writing different from the aforementioned forms).

On 4/28/2011 at 11:30 AM, PI # 2 was questioned about the different signatures on the consent forms. PI #2 looked at the forms and and stated she signed the 4/18/2011 form entitled "An Important Message From Medicare About Your Rights" PI# 2's daughter (who was visiting with the patient) looked at the forms and stated she (daughter) signed the "Conditions of Admission" form (dated 4/18/2011). According to PI# 2's daughter, she was instructed (by an unknown emergency department staff member) to print PI# 2's name on the "Conditions of Admission" form (dated 4/18/2011) and sign her name as the Guarantor. Neither PI# 2, nor her daughter, could identify who signed or initialed the "AUTHORIZATION FOR EMERGENCY TREATMENT" form.

On 4/27/2010 at 10:45 AM CST, PI #3 was observed lying in bed, confused and calling out incoherently for Albert or Alvin. PI # 3 did not respond to the surveyors greeting or questions.
A review of PI# 3's medical record revealed PI# 3 (over [AGE] years old) and was transferred and admitted to the hospital from a long term care facility on 4/23/2011. PI# 3's diagnoses include Alzheimers and Psychosis. On 4/23/2011, staff documented the patient was "unable to sign" the "Conditions of Admission" form. Staff documented and identified family member as the emergency contact for PI# 3. There was no documentation indicating the hospital staff attempted to obtain consent to initiate and or continue the medical treatment of PI# 3.

On 4/27/2010 at PM, PI # 12 was observed on medical care provided to PI # 2 and PI # 3, and hospital staff failed to ensure that PI #12's living will and power of attorney (POA) were included in the medical record, addressed in the plan of care, or that PI# 12's designated legal representative was afforded the opportunity to participate in, or refuse, continued medical treatment for PI# 12, after the patient's health status began to decline