HospitalInspections.org

Based on interview and record review, the facility failed to ensure the Notice of Patient Rights was acknowledged by the patient or their responsible party (RP, person authorized to have decision-making authority for the hospitalized individual) for 11 of 30 patient records reviewed.

This failure had the potential for patients and their RP to not be informed of their rights prior to making decisions regarding their care.

Findings:

A record review was conducted on 11/6/24, 11/7/24, and 11/12/24. 11 of 30 patient records had no confirmation by facility staff that the Notice of Patient Rights was received by the patient or their RP.

On 11/12/24 at 3:30 P.M., an interview was conducted with Admissions staff (Adm). Adm stated it was her responsibility to provide the Notice of Patient Rights to all new admissions. The Adm stated the patient could refuse the documents, but it was important to write down any refusals as proof the facility had provided the Notice. Per Adm, it was necessary for the facility to acknowledge the Notice had been provided in order to provide legal protection for the facility, and to ensure all patients were aware of their rights.

On 11/12/24 at 3:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was important to provide the Notice of Patient Rights in order to make patients aware of their rights while in the facility.

Per a facility document, updated 9/27/24 and titled Specialty Hospital Division Financial Process and Procedure Manual, "...the hospital will be required to process all inpatient...admissions through this process...Completing Admission Forms...explain all benefits to the patient or responsible party upon admission. Document this explanation on the documents...Ensure that all fields are completed on admission documents and that the documents are signed by the patient/representative upon admission. Notify Controller/designee when signatures cannot be obtained and document reason...Required Inpatiet Forms:...Patient Rights and Responsibilities..."

Based on interview and record review, the facility failed to ensure the Admission Agreement (AA) were obtained in a timely manner from the patients or patient representatives.

As a result, there was a potential treatments were performed without consents.

Findings:

A review of records was conducted. There were multiple AAs that had signatures obtained from the patients/representatives from one to thirteen days after admission. There were no documentations of the reasons for the delay.

On 11/7/24 at 11:15 A.M., an interview with the Admissions (ADM) staff was conducted. The ADM stated the "goal" was to have the AA signed on the same day of admission.

Per the facility's provided document titled Special Hospital Division Financial Process and Procedure Manual dated 9/27/24, "02.5 Patient Admissions ...B. Completing Admission Forms ...Ensure ...the documents are signed by the patient/representative upon admission. Notify Controller/designee when signatures cannot be obtained and document reason."

Based on interview and record review, the facility failed to ensure restraint orders for three out of 30 sampled patients (Patients 18, 19 and 20) indicated the following:

1) a date and time with the physician signature and
2) the location of the restraint.

As a result, there was a potential for errors to occur when the restraints were applied to the patients.

Findings:

1) Patient 18 was admitted to the facility on 8/20/24 with diagnoses which included acute and chronic respiratory failure with hypoxia (lack of oxygen) per the facility's Patient Registration Data.

On 11/12/24, a review of records was conducted. The document titled Restraint Care Plan (Non-violent Non-self-destructive Behavior) indicated Patient 18 had a restraint applied on 11/1/24. The Physician/LIP/AHP Assessment/Restraint Order Confirmation indicated the physician signed the order. There was no date and time documented when the physician signed the order.

Patient 19 was admitted to the facility on 9/25/24 with diagnoses which included pneumonia (lung infection) per the facility's Patient Registration Data.

On 11/12/24, a review of records was conducted. The document titled Restraint Care Plan (Non-violent Non-self-destructive Behavior) indicated Patient 19 had a restraint applied on 10/8/24. The Physician/LIP/AHP Assessment/Restraint Order Confirmation indicated the physician signed the order. There was no date documented when the physician signed the order.

Patient 20 was admitted to the facility on 8/29/24 with diagnoses which included respiratory failure with hypoxia (lack of oxygen) or hypercapnia (high carbon dioxide-a type of gas, level in the blood).

On 11/12/24, a review of records was conducted. The document titled Restraint Care Plan (Non-violent Non-self-destructive Behavior) indicated Patient 20 had mitten (a type of restraint) applied on 11/1/24. The Physician/LIP/AHP Assessment/Restraint Order Confirmation indicated the physician signed the order. There was no time documented when the physician signed the order.

2) Patient 18 was admitted to the facility on 8/20/24 with diagnoses which included acute and chronic respiratory failure with hypoxia (lack of oxygen) per the facility's Patient Registration Data.

On 11/12/24, a review of records was conducted. The document titled Restraint Care Plan (Non-violent Non-self-destructive Behavior) indicated Patient 18 had a "limb/soft" restraint applied on 11/1/24. There was no documentation of the location of the restraint.

Patient 20 was admitted to the facility on 8/29/24 with diagnoses which included respiratory failure with hypoxia (lack of oxygen) or hypercapnia (high carbon dioxide-a type of gas, level in the blood).

On 11/12/24, a review of records was conducted. The document titled Restraint Care Plan (Non-violent Non-self-destructive Behavior) indicated Patient 20 had mitten (a type of restraint) applied on 11/1/24. There was no documentation of the location of the restraint.

On 11/12/24 at 10:45 A.M., an interview with the Director Of Nursing (DON) was conducted. The DON stated there should be a date and time when the doctor signed the order for restraints. The DON stated the staff needed to complete the order. The DON stated the staff could restrain the wrong hand and there could be a risk of decannulation (accidental removal of the tracheostomy tube (a tube that was placed in a surgically-created airway to help the patient breathe). The DON stated the expectation was the physician needed to date and time the order. The DON stated it may not be considered an order if it was incomplete.

The facility's policy and procedure titled Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated 6/23 was reviewed. There was no information noted regarding documentation of restraint orders.

Based on interview and record review, the facility failed to ensure pain was assessed or reassessed in a timely manner after medication administration for two of 30 sampled patients (Patients 17 and 24).

This failure had the potential to impact the patient's health during hospitalization.

Findings:

Patient 17 was admitted to the facility on 10/3/24 with diagnoses which included urinary tract infection per the facility's Patient Registration Data.

On 11/7/24, a joint record review with the Director Of Nursing (DON) was conducted. Patient 17's Medication Admnistration Record (MAR) indicated the following:

a) On 10/28/24 at 4:44 P.M., Patient 17 had a pain score of 8 (numeric rating scale 0-10), pain medication was administered, no pain reassessment conducted.

b) On 10/30/24 at 12:31 P.M., Patient 17 was administered pain medication without pain assessment score documented. At 1:31 P.M., Patient 17's pain score was documented as 0.

On 11/7/24 at 11:08 A.M., an interview with the DON was conducted. The DON stated the staff should have documented the pain assessment/scale and reassessment after the medication administration.

Patient 24 was admitted to the facility on 7/8/24 with diagnoses which included respiratory failure per the facility's Patient Registration Data.

On 11/12/24 a joint record review with the DON was conducted. Patient 24's Medication Administration Record (MAR) indicated the following:

a) On 11/4/24 at 8:36 P.M. Patient 24 had a pain score of 9 and oral pain medication was administered. A pain reassessment was not conducted until 10 P.M.

b)On 11/5/24 at 8:12 P.M., Patient 24 had a pain score of 6, oral pain medication was administered, no pain reassessment conducted.

c)On 11/12/24 at 6:33 A.M., Patient 24 had a pain score of 6, oral pain medication was administered. A pain reassessment was not conducted until 8 A.M.

On 11/12/24 at 1:50 P.M., an interview with the DON was conducted. The DON stated pain reassessment should be conducted after 30 minutes for intravenous (IV) and 1 hour for oral pain medication administration.

Per the facility's policy and procedure titled Pain Management Plan dated 6/23, "...PROCEDURE 1. Assessment of Patients a. The Registered Nurse performs a pain assessment...when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient medical record...d. Ongoing Assessments/Reassessments by licensed nursing staff:..iv. Reassessment of pain relief interventions...1) Recommended timeframes for reassessment of effectiveness of pain relief may include: a) 30 minute reassessment- IM injection and IV medication b) 1 hour reassessment- oral medication..."