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.

CLEAR VISTA HEALTH & WELLNESS 3364 KOLBE ROAD LORAIN, OH 44053 Jan. 18, 2018
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and staff interview the facility failed to ensure the completion of the form "Authorization to Release and Obtain Protected Health Information" in accordance with it's policy for nine of ten (Patient #'s 1, 2, 4, 5, 6, 7, 8, 9 and 10) records reviewed and failed to ensure one patient (Patient #7) was involved in making decisions regarding his/her care. The current census at the time of the survey was 22.

Findings include:

Review of policy # CS-19 Effective date 04/01/15, "Authorization to Release and Obtain Protected Health Information (PHI)" was completed on 01/18/18. Bullet point #1 under Procedures reads, "A form titled "Authorization to Release and Obtain Protected Health Information (PHI)" is requested of all patients referred to the hospital for all persons with whom the treatment staff may need to communicate patient information." Bullet point #2 reads, "the form is reviewed with the patient for any questions and fully completed as indicated."

1. The medical record review for Patient #1 was completed on 01/17/18. Patient #1 was admitted to the facility on [DATE]. During the record review, the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

Interview with Staff A on 1/17/18 at 11:30 AM confirmed the form should be in the patient's record and signed.

2. The medical record review for Patient #2 was completed on 01/18/18. Patient #2 was admitted to the facility on [DATE] and discharged on [DATE]. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

3. The medical record review for Patient #4 was completed on 01/18/18. Patient #4 was admitted to the facility on [DATE] and discharged on [DATE]. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

4. The medical record review for Patient #5 was completed on 01/18/18. Patient #5 was admitted to the facility on [DATE] and discharged on [DATE]. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

5. The medical record review for Patient #6 was completed on 01/18/18. Patient #6 was admitted to the facility on [DATE] and discharged on [DATE]. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

6. The medical record review for Patient #7 was completed on 01/18/18. Patient #7 was admitted to the facility on [DATE] and discharged on [DATE]. During the record review the form titlted, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

7. The medical record review for Patient #8 was completed on 01/18/18. Patient #8 was admitted to the facility on [DATE] and remains an inpatient at the time of the survey. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

8. The medical record review for Patient #9 was completed on 01/18/18. Patient #9 was admitted to the facility on [DATE] and remains an inpatient at the time of the survey. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

9. The medical record review for Patient #10 was completed on 01/18/18. Patient #10 was admitted to the facility on [DATE] and remains an inpatient at the time of the survey. During the record review the form titled, "Authorization to Release and Obtain Protected Health Information" was not signed by the patient, nor the patient's representative.

On 01/18/18 at 2:10 PM Staff A confirmed the above findings during interview.

A medical record review was completed for Patient #7 on 01/18/18. This patient had an involuntary admission date of [DATE] for advanced dementia with recent behavioral exacerbation, confusion, disorientation, increased agitation and hallucinations.

The Voluntary Admission form was signed by the patient and witnessed by a staff member on 12/07/17. However, there were no signed consents by the patient for Advanced Directive Acknowledgement, photography and medication, or receipt of the handbook which contained patient rights and complaint/grievance process. The Important Message for Medicare form lacked evidence of receipt by the patient.

The consent forms for treatment contained documentation at the top of the forms as follows: "Unable to sign." However, this documentation lacked a date and author of who wrote the statement on the top of the forms.

On 01/18/18 at 2:15 PM, Staff A confirmed these findings. Staff A stated the patient was very confused at the time of admission and was unable to sign the consents for treatment at that time. However, Staff A stated staff should have presented these consents and information for care at the time the patient signed the Voluntary Admission form on 12/07/17. The patient remained in the facility until discharged on [DATE].

Staff A confirmed staff failed to follow the policy titled Informed Consent, revised 07/2017, which contained the following: "5. All written consents, including admission to the hospital and medication consents, are signed by the patient/guardian, witnessed by a staff member, and kept in the chart as part of the permanent medical record."