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 record review and interview, facility staff failed to inform the designated Power of Attorney for Health Care (POAHC) agent that the facility activated the POAHC for 1 of 5 patients (Patient #1) who had a POAHC activated during admission out of a total universe of 10 medical records reviewed, and facility leadership failed to develop and implement a process to ensure facility staff were aware of documentation and communication requirements and responsibilities for 1 of 1 POAHC activation process.

Findings include:

A review of the facility's policy #672 titled, "Decision Making Capacity for Adult Patients," Revision/Review Date: 02/08/2020 revealed, " ...4. Policy ...4.1 Patients are presumed by caregivers to possess decision-making capacity unless there has been a clear demonstration of lack of capacity ...4.3 Old age, eccentricity, or physical disability is insufficient to determine incapacity. 4.4 If a caregiver, family member, or loved one suspects a patient does not have decision-making capacity, a formal capacity assessment may be requested. 4.5 A formal assessment of capacity for purposes of activating a health care power of attorney document is a process where two physicians or a physician and a licensed psychologist who have personally examined the patient determine and document the patient's incapacity ...4.6 The three distinct aspects that must be present for a patient to be capable to make decisions are: the ability to receive and understand information; the ability to evaluate options; and the ability to communicate choices. Caregivers should seek assistance from experts if unsure whether these aspects are present ...4.7 Decision-making incapacity can be temporary or transient and should be assessed over time as indicated. Upon return of decision-making capacity, decision-making authority will shift from the surrogate decision maker to the patient; this shift should be properly documented in the electronic health record (EHR). 5. Procedure 5.1 If the patient lacks decision-making capacity and the patient has a Power of Attorney for Health Care: a) Two physicians or a physician and licensed psychologist will sign AHC Form S "Activating and Deactivating a Power of Attorney for Health Care" ...b) A copy of the completed, signed ...form will be given to the health care agent(s). The original of this form will be given to the Health Information Management Department for inclusion in the patient's electronic health record. c) The health care agent will make health care decisions on the patient's behalf consistent with the expressed desires of the patient (substituted judgement), if known ...Agents and caregivers will continue to include the patient in decision-making as is possible ..."

A review of the facility's policy #2689 titled, "Patient Rights and Responsibilities," Effective Date: 12/12/2019 revealed, " ...C. Patient and/or Family Involvement in Decision-making - Advance Directives and Informed Consent ...1. The patient or his/her Legal Decision-Maker and the patient representative have the right and responsibility to be involved in decision-making about the patient's care. This includes being informed about health status, diagnosis and prognosis, being involved in the development and implementation of his/her inpatient plan of care ...participating in the development of his/her discharge plan ...5. Patients and, when appropriate, their family member(s) and patient representative are informed about the outcomes of care, including unanticipated outcomes ...D. Patient Feedback ...3. Suspected patient rights violation(s) will promptly and professionally be investigated. 4. All team members are expected to demonstrate the behaviors that support the [organization name] Values and Commitments, to perform their job at a fully competent level, and to follow all organizational policies, procedures, and guidelines ..."

Patient #1's electronic medical record was reviewed on 05/25/2021 at 1:10 PM with Clinical Nurse Educator S who confirmed the following per interview:

Patient #1 was admitted to the hospital's MS4W inpatient orthopedics unit on 03/15/2021 after presenting to the Emergency Department with a chief complaint of, "Worsening pain and worsening discoloration to left foot." #1 underwent an attempted angiogram (a diagnostic test used to evaluate blockages in the blood vessels; a catheter is inserted through the blood stream to deliver dye and x-rays are taken; generally done while the patient is sedated) of the left leg on 03/17/2021 and a successful angiogram of the left leg on 03/19/2021. Patient #1 developed confusion and intermittent agitation following the angiogram on 03/19/2021, and was ultimately transferred to the facility's AAU3 (mixed acuity; Med Surg and Intensive Care) unit as a result. #1's mental status improved, and #1 was transferred back to the MS4W unit on 03/21/2021.

On 03/21/2021 at 12:08 PM, "AMG Hospitalist Service Progress Note" revealed, " ...Patient seen and examined this this (sic) morning. Confusion significantly improved ...Acute metabolic [DIAGNOSES REDACTED] - resolving ..."

Further review of the medical record revealed a document titled, "Activating and De-Activating a Power of Attorney for Health Care," with a label placed in the top right corner of the document including Patient #1's name, date of birth, and medical record number. The top section of the document was titled, "Power of Attorney for Health Care Statement of Incapacity." The first line in this section of the document revealed, "I have personally examined (blank line) [patient's name] and certify that the patient meets the statutory definition of incapacity, in that the patient is unable to receive and evaluate information effectively or to communicate decisions to such an extent that the patient lacks the capacity to manage his or her health care decisions." The line in which the patient's name was to be written was left blank. The document was signed by Hospitalist R on 03/23/2021 at 9:52 AM and the second signature was signed by another Hospitalist on 03/23/2021 at 11:14 AM.

The activation form was completed 2 days after documentation was found indicating #1's mental status had improved.

There was no supporting documentation found indicating intention to activate or the activation of the POA. The activation form did not have Patient #1's name written on the form, and it was unable to be determined when, or by whom, the patient label was placed on the form.

On 03/23/2021 at 2:29 PM, after the POA activation form was signed by Hospitalist R, "AMG Hospitalist Service Progress Note," completed by R, revealed, " ...Patient seen and examined this morning. AOx3 (alert and oriented to person, place, and time) today...Acute metabolic [DIAGNOSES REDACTED] - resolved ..."

Further review of the daily physician progress notes revealed Patient #1 remained awake, alert, and oriented to person, place, and time. There were no further episodes of confusion documented by physicians.

Review of the nursing flowsheet titled, "Physical Assessment" revealed on 03/23/2021 at 8:27 PM, "Mental Status" is documented as, "WDL (Within Defined Limits)," and "2 - Behavior fluctuates." Further review of the flowsheets revealed no significant changes in mental status assessments throughout the remainder of the admission, with documentation that #1 was, "Confused at times," "Easily redirectable," and "Forgetful at times."

There was no evidence found that Patient #1's family, the Vascular Surgeon, Social Workers, Psychiatrist, Hospitalists, or nursing staff demonstrated concern regarding Patient #1's mental status or that Patient #1 lacked the capacity to make his/her own health care decisions.

There was no documentation found in Patient #1's medical record to support: 1) An assessment was requested or completed to evaluate #1's ability to make his/her own medical decisions; 2) Discussions were had with Patient #1 and/or family, including A, regarding the potential need for POA activation; 3) That Patient #1 and Patient #1's personal representative (A) were notified of the activation.

There was no additional documentation found in Patient #1's medical record completed by physicians, Psychiatry, nursing, or Social Work to indicate that Patient #1's Power of Attorney (POA) was activated or that any other members of Patient #1's care team - including nursing, social work, Vascular Surgeon, Psychiatry, or other consulting disciplines - were notified or aware of the POA activation.

#1 was discharged to a rehabilitation facility on 04/05/2021.

The POA activation form was not scanned in to Patient #1's medical record until 04/06/2021 at 1:05 PM, 2 weeks after the POA activation was signed and 1 day after Patient #1 was discharged from the hospital.

On 04/12/2021, Patient #1 was readmitted to the facility for complications from the surgical procedure performed during the previous admission. There was no documentation found in the medical record from 04/12/2021 through 04/15/2021 that indicated facility staff were aware that Patient #1's POA had been activated.

On 04/15/2021 at 3:42 PM, "Initial SW/CM (Social Work/Case Management) Assessment/Plan of Care Note," completed by Social Worker I revealed, "...Patient does have a Power of Attorney for Healthcare. Document is activated. Agent is [A] ...Soc. (Social) Services notified of case ...Writer is familiar with pt from [his/her] last hospitalization ...Pt's POA document was activated during [prior] hospitalization but pt appears to be doing much better at this time and appears that they may be able to deactivate POA document per pt's agent [A]. Writer did speak to [A] today to discuss discharge planning. Per [A], [s/he] was unaware that pt's POA document was activated during [#1]'s last hospitalization . [A] stated that [s/he] does not feel that it is necessary any longer and would like to have the document deactivated. Writer explained that I would send a message to [Hospitalist] and see what [s/he] says ..."

Further review of the medical record revealed steps were taken to deactivate the POA at that time. Patient #1's POA was deactivated on 04/16/2021. The deactivation document was scanned in to #1's medical record on 04/19/2021 at 10:04 AM.

Patient #1 was discharged back to the skilled nursing facility on 04/19/2021 at 3:12 PM.

During an interview with Case Management Manager F on 05/25/2021 at 9:42 AM, when asked about the POA activation process, F stated the Physicians conduct an assessment of the patient and identify the need for activation. The Physician notifies a peer or Psychologist and contacts the patient's designee. Two providers sign the activation form, and the document is given to the HUC, Social Worker, Nurse, or Case Manager. F stated the Social Worker then contacts the patient's designee and asks how the designee would like to receive a copy of the document. The Social Worker then completes the template in the electronic health record that populates the storyboard to reflect the patient has an activated POA. When asked if s/he recalled any instances in which a POA was activated without the designee or any other clinical staff being notified or aware, F stated, "I'm aware of a case. The form was signed by 2 physicians, but the form didn't get to Medical Records and the banner bar was not updated." F stated s/he, "Spoke to the attending and [s/he] didn't remember activating it for that patient." F stated the patient's designee was not notified at the time of the activation, and that it was, "A number of days that the designee was not aware. [S/He] found out just prior to discharge."

During an interview with Social Worker I on 05/25/2021 at 11:10 AM, when asked whose responsibility it was to notify family of a POA activation, I stated, "The doctor." When asked about Patient #1, I stated, "[A] wasn't aware that the doctors talked about activating the POA. [S/He] was surprised that it was activated because the patient was better. [S/He] wanted the POA to be deactivated. I updated the doctor and the POA was deactivated prior to [#1's] discharge."

During an interview with RN L on 05/25/2021 at 10:06 AM, L stated the Social Workers were responsible for notifying the designated agent and documenting the activation of a POA.

During an interview with Social Worker H on 05/25/2021 at 10:58 AM, when asked whose responsibility it was to notify the designated agent of a POA activation, H stated, "It depends," and, "It's a team approach." H stated that it could be Social Work, the physician, or nursing. H stated that the Medical Records staff were responsible for updating the "banner bar" in the patient's electronic medical record to indicate the POA was activated.

During an interview with Quality Director B on 05/25/2021 at 11:24 AM, B stated that s/he became aware of the situation when s/he received the complaint from the accrediting organization, on 04/26/2021. B stated, "We were not aware of this at all before then." B stated that the facility immediately launched an investigation, including completion of, "A full gap analysis and risk assessment." J stated the outcomes from the investigation included a need to review the scanning process and how the template is updated to reflect POA activation on the banner bar. B stated that there were not clearly defined responsibilities for staff in the process.

B also stated that during the course of the investigation, it was discovered that there, "Used to be a warning box that popped up any time someone accessed the record," which indicated that a POA was activated, and that staff would be required to, "Acknowledge" the warning before going further into the record. B stated that it was discovered that this function was removed in January, 2021, as part of an electronic health record, "Upgrade."

During an interview with 4th Floor Manager G on 05/25/2021 at 1:00 PM, when asked if staff receive education on Advance Directives and POA activation, G stated that staff do not receive annual or periodic education on Advance Directives or POA activation. G stated new staff receive information on how to access and find Advance Directive information upon orientation, and that, "Learning assessments are done to determine education needs" on an annual basis. G stated, "It [education on Advance Directives or POA activation] wasn't determined to be a need. It was not included on the 2020 or 2021 assessments."

During an interview with Patient Access Representative O on 05/26/2021 at 9:34 AM, O stated, "Sometimes we need to search for the actual activations because there seems to be glitch where the POA activation might be scanned, but [the banner bar] might not be updated. It happens a fair amount of times where the banner bar says, 'Received' or something else, but not, 'Activated.'" When asked if the "glitch" had been reported, O stated, "I talked to my old supervisors about it, but it never went anywhere. We were told to either go in and look for it or just go by what the system says."

During interviews with Day Surgery RN N on 05/26/2021 at 9:28 AM and ED RN P on 05/26/2021 at 9:43 AM, when asked how they would know if a POA was activated, both N and P stated that there was a "Pop up" that would notify staff of an activated POA, and that box would need to be acknowledged each time the record was accessed, before staff could document further. N and P did not indicate an awareness that the "Pop up" warning box functionality had been removed in January, 2021.

During an interview with RN Q on 05/26/2021 at 9:51 AM, when asked how s/he would know if a patient had an activated POA, Q stated, "There used to be a big pop up that you would have to acknowledge, but that went away. I would just review what the banner bar says."

Facility staff interviewed were unable to demonstrate a clear understanding of documentation and communication responsibilities regarding the POA activation process, and were unable to demonstrate a consistent understanding of confirming POA activation status within the facility's electronic medical record.