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Based on document review and interview, facility staff failed to notify a hospital provider of the existence of an advanced directive and failed to communicate to a receiving hospital the existence of an advanced directive for 1 of 10 medical records reviewed (P2).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, facility staff failed to notify a hospital provider of the existence of an advanced directive and failed to communicate to a receiving hospital the existence of an advanced directive for 1 of 10 medical records reviewed. (P2)

Findings include:

1. Facility policy titled, "Advanced Directives in Hospital", PolicyStat ID 13517664, last revised 06/2021, indicated under PROCEDURE: 10. The patient's hospital provider will be notified of the existence of an Advance Directive. 11. If the patient is transferred, referred or discharged to another organization, the existence of any Advance Directives for care is communicated to the receiving organization.

2. Review of P2 MR from H2 (Psychiatric Hospital) indicated an advance directive dated 5/7/25, P2 was designated to be a DNR (Do Not Resuscitate) with comfort measures only (allowing a natural death). This document was signed by P2's child and P2's doctor on 5/7/25. This document indicated P2's child was his/her Healthcare Power of Attorney. P2's MR lacked documentation of a provider notification of P2's advance directive as required by facility policy.

Transfer documentation dated 5/26/25 at 12:50 pm indicated P2 was transferred to H3 (Acute Care Hospital) d/t (due/to) mental status changes. Transfer documentation indicated P2 was a full code.

3. Review of P2 MR from H3, Discharge Summary documentation dated 6/6/25 indicated P2 arrived at H3 on 5/26/25 at 1:11 pm. P2 was subsequently intubated on 5/26/25 for airway protection related to hypoxia and decreased level of consciousness.

4. Interview on 8/22/25 at approximately 10:10 am with A2 (Chief Executive Officer) confirmed the advance directive was present in the medical record of P2. A2 confirmed he/she could not determine when P2's advanced directive was received by H1. A2 confirmed P2's full code status was not updated to a DNR (Do Not Resuscitate) status when P2's advance directive was received and should have been.

Based on document review and interview, facility nursing staff failed to notify a medical provider in a timely manner of a patient's change in condition requiring emergency medical treatment and/or transfer to higher level of care for 2 of 10 medical records reviewed (P1, P2); failed to notify a medical provider of an unwitnessed patient fall within a timely manner for 1 of 10 medical records reviewed (P1).

Findings include:

1. Facility policy titled,"Change of Condition", PolicyStat ID 12197218, last revised 05/2021, indicated under POLICY: It is the policy of the hospital that providers will be notified of patients that have changes in their condition in a timely manner. Nursing staff will document these changes, provider notifications, and an interventions and/or orders regarding the change of condition in the patient's medical record. PROCEDURE: 2. The nurse will evaluate the patient and notify the provider with findings. 3. Findings, provider notification, and any interventions and/or orders received will be documented. The change of condition will continue to be monitored and provider updated as needed. 4. A sample list of possible changes in condition would include but not be limited to: b. Falls. c. Change in mental status.

2. Facility policy titled, "Provider Communication", PolicyStat ID 92275841, last revised 01/2025, indicated under POLICY: Licensed nursing staff are responsible for notifying providers of any changes in patient conditions that may negatively impact treatment or medical well-being. Communication ensures timely interventions to support patient safety and care. PROCESS: 2. Notification Process: Primary Notification: Notify the in-house medical and/or psychiatric provider immediately. Document the notification and result in the patient's chart. On-Call Notification: If the in-house provider is unavailable, notify the on-call provider. Document the notification and result. Escalation to Medical/Psychiatric Director: If the first provider cannot be contacted or fails to respond within 15 minutes, place a second call to the same provider. If no response is received within an additional 15 minutes, contact the second listed provider. Allow 15 minutes for the second provider to respond. If neither the in-house nor on-call provider responds, escalate the issue to the Medical/Psychiatric Director.

3. Review of P1's MR post fall huddle form documentation dated 5/26/25 at 2:35 am, indicated P1 was found on the hallway floor after an unwitnessed fall. P1 was with his/her wheelchair and sustained approximately 1 inch skin tear to the right elbow. Provider notification time was documented as 4:27 am. P1's MR indicated change in condition notification to medical provider was completed at approximately 8:00 am. P1's MR lacked documentation of immediate nursing interventions used to stabilize the patient.

4. Review of P2's MR nursing note dated 5/26/25 at 8:00 am indicated P2 was found resting in bed, eyes closed, and difficult to arouse. At 8:30 am N1 tried to get P2 up but his/her mental status was declining. At 10:00 am N1 called NP1 notifying the provider of the change in condition. Transfer time was documented as 12:50 pm on 5/26/25.

5. Interview on 8/21/25 at approximately 1:15 pm with N1 (Registered Nurse) confirmed he/she was the primary nurse for both P1 and P2 on 5/26/25 at the time of their transfers to H2 (Acute Care Hospital). N1 indicated was not the primary nurse for P1 when he/she had an unwitnessed fall. N1 confirmed provider notification related to change in condition was to be as soon as possible, but was not for P1. N1 confirmed his/her documentation times on 5/26/25 for P2 were correct, but could not recall why there was a delay in notifying NP1 (Nurse Practitioner) of P2's decline in mental status and/or a delay in calling emergency medical transportation.

6. In interview on 8/21/25 at approximately 2:00 pm with NP1 (Registered Nurse) confirmed provider notification should have been as soon as possible for both P1 and P2's change in conditions on 5/26/25, but was not notified until a later time.

7. Interview on 8/22/25 at approximately 2:00 pm with N2 (Registered Nurse) confirmed he/she was the primary nurse for P1 when he/she had an unwitnessed fall on 5/26/25 at approximately 2:30 am. N2 could not confirm a reason for the delay in provider notification related to P1's fall. N2 confirmed notification of the medical provider should have been as soon as possible but wasn't.

8. Interview on 8/22/25 at approximately 3:15 pm with A5 (Director of Nursing) confirmed nursing staff are trained to notify providers if there is any change in condition as soon as possible. Confirmed provider notification for P1 and/or P2's change condition was not completed in a timely manner and should have been.

Based on document review and interview, nursing services failed to complete incident reports related to emergent transfers in 2 instances (P1, P2)

Findings include:

1. Facility policy titled,"Incident Reports", PolicyStat ID 13033981, last revised 01/2023, indicated under PROCEDURE: Time Frame for Completing an Incident Report: A. After providing for the needs of the individuals involved, hospital staff must complete and submit an incident report as soon as possible. Preferably, the report should be submitted before leaving the hospital at the end of the work shift, but no later than twenty-four (24) hours from the time the even occurred.

2. Facility incident report log was reviewed for the months of 1/1/25-8/22/25. This log lacked a filed incident report related to P1's change in condition requiring emergent transfer to H3 on 5/26/25, and lacked filed incident report related to P2's change in condition requiring emergent transfer to H3 on 5/26/25.

3. Interview on 8/21/25 at approximately 1:15 pm with N1 (Registered Nurse) confirmed incident reports are to be completed on all patients who are transferred emergently.

4. Interview on 8/22/25 at approximately 3:15 pm with A5 (Director of Nursing) confirmed incident reports related to P1 and P2's emergency medical transfer was not completed by N1.