HospitalInspections.org

Based on document review and interview, the facility failed to document that the Notice of Patient Rights was provided to patents or the patient's representative prior to receiving care for 1 of 10 medical records (MR) reviewed (Patient #7).

Findings include:

1. Review of the policy/procedure Patient Rights and Responsibilities (revised 6-18) indicated the following: "At the time of admission, the Admissions Representative will distribute a patient Handbook which includes a copy of the Patients' Rights and Responsibilities to each patient or the patient's representative... The patient is asked to sign for receipt of the Patient Handbook. In the absence of the Admissions Representative, the nursing staff of the admitting unit executes this function."

2. Review of the General Consent and Financial Agreement form (revised 1-18) indicated the following: "I acknowledge that I have received a copy of the (facility's name) Notice of Privacy Practices and the patient handbook advising me of my patient rights and responsibilities..." and indicated a place for each patient to sign and date the agreement upon admission to the facility.

3. Review of the MR for Patient #7 lacked documentation of a General Consent and Financial Agreement including acknowledgement of receiving of a copy of the notice of Patient's Rights and Responsibilities.

4. On 12-12-18 at 0915 hours, the Risk Manager A1 and the Compliance Integrity Officer A3 confirmed the MR for Patient #7 lacked the indicated documentation.

Based on document review and interview, the facility failed to ensure a properly executed consent for treatment was obtained from the patient or the patient's representative for 2 of 10 medical records (MR) reviewed (Patients #5 & 7).

Findings include:

1. Review of the policy/procedure Informed Consent (revised 11-17) indicated the following: "Absent an outlined exception, the General Consent and Financial Agreement... must be signed by the patient or the patient's surrogate and witnessed by a competent adult with the date and time noted on the form."

2. Review of the MR for Patient #7 lacked documentation indicating a General Consent and Financial Agreement form was signed by the patient and witnessed by a facility representative at the time of admission.

3. On 12-12-18 at 0915 hours, the Risk Manager A1 and the Compliance Integrity Officer A3 confirmed the MR for Patient #7 lacked the indicated consent form.

4. Review of the MR for Patient #5 lacked documentation indicating a General Consent and Financial Agreement form was signed, dated and timed by a facility representative that witnessed the patient signing the form.

5. On 12-12-18 at 1120 hours, staff A1 and A3 confirmed the MR for Patient #5 lacked the indicated documentation.

Based upon document review and interview, the facility failed to follow its policy/procedures and ensure a Registered Nurse (RN) supervised and evaluated the care of all patients for 3 of 10 medical records (MR) reviewed (Patients #3, 7 & 8).

Findings include:

1. Review of the policy/procedure Patient Incident Reporting Policy (revised 11-15) indicated the following: "A Safety Event Manager (SEM) report is to be completed by any employee who witnesses or has first-hand knowledge of a patient event, incident or accident that is not consistent with the routine operations of the Hospital... A general list of events that would require a SEM report includes, but is not limited to... f) Patient leaving Against Medical Advice (AMA)."

2. Review of the MRs for Patients #3, 7 and 8 indicated each patient left the facility AMA.

3. Review of facility incident reports for the period surrounding the three patient admissions failed to indicate an incident report was prepared by the RN associated with the episode of care.

4. On 12-12-18 at 1315 hours, the Risk Manager A1 confirmed the facility lacked the indicated documentation.

Based upon document review and interview, the facility failed to follow its policy/procedure and ensure the results of weekly Interdisciplinary Team Conference (ITC) care planning were shared with each patient or patient's representative for 2 of 10 medical records (MR) reviewed (Patients #9 & 10).

Findings include:

1. Review of the policy/procedure Team Conference/Team Conference Report/ Care Plan (revised 12-15) indicated the following: "The care plan is an interdisciplinary plan that represents the patient goals developed by the interdisciplinary team as identified through evaluation as well as those goals identified by the patient and/or family, which focus on achievement of the anticipated rehabilitation outcome... This interdisciplinary plan will be reviewed on a weekly basis, at a minimum, in conjunction with discharge planning though the course of the patient's stay... Following each team conference, the Care Coordinator and/or Physician will discuss its content with the patient, and when needed, the family..."

2. Review of the MR for Patient #9 indicated the patient was admitted to the facility on 11-12-18 with severe receptive and expressive language deficits and severe cognitive deficits resulting from a motor vehicle crash (MVC) on 9-5-18. The MR indicated ITC care planning was conducted on 11-15-18, 11-20-18, 11-27-18, 12-4-18 and 12-11-18 and lacked documentation indicating the patient's representative or family member was contacted after each meeting by the Physician and/or Care Coordinator to discuss the results including the patient's progress towards their discharge goals, changes in status and related revisions in the care plan and/or expected discharge date.

3. On 12-12-18 at 1430 hours, the Social Worker A16 confirmed the MR for Patient #9 lacked documentation indicating the incapacitated patient's representative was contacted for the purpose of discussing the weekly results of ITC care planning and the patient's progress towards their discharge goals.

4. Review of the MR for Patient #10 indicated the patient was admitted to the facility on 10-19-18 with cognitive deficits, confusion and agitation resulting from a motorcycle crash (MCC) approximately 2 months prior to admission. The MR indicated ITC care planning was conducted on 10-23-18, 10-30-18, 11-6-18, 11-13-18 and 11-20-18 and lacked documentation indicating the patient's brother and legal guardian was contacted after each weekly meeting to discuss the results of ITC care planning and the patient's progress towards their discharge goals.

5. On 12-12-18 at 1530 hours, the Social Worker A16 confirmed the MR for Patient #10 lacked documentation indicating the patient's representative was contacted after the weekly ITC meetings on 10-30-18, 11-6-18, 11-13-18 or 11-20-18 until the day of discharge on 11-23-18.