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Based on interview and record review the facility failed to ensure the required patient information and consents were signed by the patient or designated power of attorney in 7 of 13 patient records reviewed (ID# 1,9,10,11, 12, 13). There is no documentation that the patient received the required documents on admission.

Finding Indicate: No policy was presented.

Record review of admission paperwork reviewed from patient (ID#1, 9, 10, 11, 12, 13) revealed the following:
Patient (ID#1) Authorization for Release of Information; and Acknowledgement of Notice of Privacy Practices consent were obtained via telephone, on 08/16/21 and not signed or acknowledged by the patient or family.

Patient (ID# 9) Patient Choice Form, telephone consent was obtained 04/17/2023 by staff (ID#57) who signed the spouse's name on the form.

Patient (ID#10) Medicare Benefits Workshop was obtained on 04/13/2023 at 1335 and the Authorization Release of Information, Election of Lifetime Reserve Days, Acknowledgement of Notice of Privacy Practices, on 04/13/2022 by staff (ID# 62) and was not signed or acknowledged by two nurses.

Patient (ID#11) Patient Choice Form, telephone consent was obtained 03/23/2023 by staff (ID#57) who signed the sister's name on the form.

Patient (ID#12) Authorization for Release of Information, Acknowledgement of Notice of Privacy Practices, Important Message from Medicare, Medicare Benefits Worksheet, Election of Lifetime Reserve Days, telephone consent was obtained 04/14/2023 by staff (ID#63) who signed the patient's name to the form.

Patient (ID#13) Important Message from Medicare, Election of Lifetime Reserve Days, Acknowledgement of Notice of Privacy Practice, Authorization for Release of Information dated 03/20/2023 at 1300 was obtained by staff (ID#63) who signed the patient's name to each form.

Interview on 04/19/2023 at 1330 with quality (ID# 53) who stated, two signatures are required when completing telephone consents, and nurses should sign the consent for the patient.


23032

Based on interview and record review, the facility failed to ensure failed to ensure consents were signed by the practitioner according to the the Medical Staff Rules & Regulations for 2 of 5 current sampled patients ( Patient # 6, 7)

Findings included:

Review of the facility 'Medical Staff Rules & Regulations', dated January 2018, showed: Informed Consent: Both the patient and the practitioner shall sign the consent form affirming that the practitioner has personally informed the patient. Space shall be provided on the form for the practitioner to document that was explained to the patient and that the patient understood and agreed to the proposed treatment.

Findings included:

Record review of five (5) current patient medical records showed:

Patient # 7:

Review of Patient # 7's medical record showed a form titled "Disclosure and Consent Medical and Surgical Procedures," dated 1/19/2023 . The form showed "peripherally inserted central catheter (PICC) line placement" listed as the procedure Patient # 7 "voluntarily consented and authorized." There was no practitioner's signature on this procedure consent.

Further review showed a consent for administration of blood and/or blood products. There was a lined space provided labled:" Physician's Signature." There was no physician signature on this consent. These lack of physician signatures was verified by Staff-D, RN.

Patient # 6:

Review of Patient # 6's medical record showed a form titled "Disclosure and Consent Medical and Surgical Procedures," dated 4/13/2023 . The form showed "peripherally inserted central catheter line placement" listed as the procedure Patient # 6 "voluntarily consented and authorized." There was a lined space provided tabled " Physician's Signature."

During an interview on 4/20/2023 at 11 AM, with Staff -D, RN , she stated there should be signatures by the practitoners on the consents.

Based on record review and interview, the facility failed to establish an effective policy and procedure regarding Advance Directives and Medical Power of Attorney (MPOA). The facility failed to ensure its policies clearly designated responsible staff to obtain copies (as applicable) , of patients' Advance Directive and/or MPOA. [citing Patient # 2]

Findings included:

TX003881163

Review of facility policy titled " Leadership/ Administration Advance Health Care Directives, " dated 12/2022, showed:

- Documentation in the medical record will note whether or not the patient has an advance directive [ * policy does not specify which staff will do this].

- A supervising healthcare provider who knows of the existence of an advance directive, or designation of a surrogate (decision maker) must promptly record this in the medical records .

- Patients who indicate that have an advance directive or Physician Order for Life Sustaining Treatment (POLST) and persons who have indicated they have been a designated agent will be asked to give the hospital a copy of the advance directive or POLST to be placed in the patient's medical record. [ * policy does not specify which staff will do this].

Review of the policy shows it did not define the follow-up process, including responsible staff , for obtaining a copy of a patient's advance directive, POLST, or MPOA.

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Patient # 2:

Record review of Patient # 2's medical record, admit date 4/9/2023, showed a form titled "Psychosocial History," dated 4/9/2023. This form had a section at the top left that listed the following documents : Advance Directive / Living Will; Financial POA; Medical POA. "Yes" was checked for both Medical and Financial POA.

During an interview on 4/20/20223 at 11:30 AM with Staff C, Director of Quality Management, she was unable to locate a copy of the Medical POA for Patient # 2 in her medical recorded. Staff C said that the case management department completed the "Psychosocial History" and documented the presence of advance directives/ or POAs. She was unsure if case management or nursing staff was responsible for the follow up to obtain any needed copies of the documents.

Review of case management policy titled " High Risk Screening," dated January 2023, failed to show reference to "Psychosocial History " Form or advance directives or MPOA.

During interviews conducted on 4/19/2023 between 9:30 and 10 AM with RN nursing staff showed the following:

RN Staff E- admitting nurse responsible for follow-up of patient stated they have an advance directive or MPOA.

RN Staff F- registration staff or nursing; both responsible for obtaining copies of advance directive or MPOA.

Based on observation, record review and interview review the facility did not ensure the patients have orders for treatment in three of five patients' records (pt.# 10, 12, 13) reviewed.

Finding Include: Facility policy, reviewed April 2022, "Medical Record Documentation Requirements LTCH and IRF, that stated:
All entries into the medical record must be legible, signed, dated, time accurate and complete.

Telephone orders ... must contain all components of a valid written order. It must contain the name of the physician who issues the order as well as the name/credentials of the person who received the order.

Restraint Orders: A face-to-face assessment of the patient by the attending physician is documented daily following initiation of restraint and before renewal of restraint orders.

Observation and record review of the following patients and patient charts on 04/19/2023 at 1200 revealed patient:
(Patient ID#10) was admitted on 04/13/2023 and did not have a restraint order 04/16/2023 in the medical record.
Patient (ID#12) admitted 04/12/2023 and observed to have had a foley at the bedside. The record review on 04/19/2023 revealed no orders in the chart.
Patient (ID#13) admitted 03/29/2023 and record review of the chart 04/06/2023 revealed no foley order in the chart.

Interview on 04/19/2023 at 1220 with CNO (ID#52) who stated she did not see the orders for the following patients (ID#10, 12, 13).


23032

Based on interview and record review, the facility failed to ensure that 1 of 5 discharged patient medical records records was complete [Patient #2].

Patient # 2 's medical record failed to show a complete H & P and a Discharge Summary.

Findings included:

TX00388163

Record review of facility "Medical Staff Rules & Regulations, "dated January 2018, showed:

Medical Records and Orders:

1. the attending practitioner will be responsible for the preparation of a complete and legible medical record...it shall contain medical history...

b. the content of a history and physical ( H & P) must include: chief complaint, description of present illness, past medical history, as appropriate... a physical examination and Review of Systems...Treatment Plan

c. The Review of Systems shall include a review of the following categories:..(2) Skin..

Patient # 2:

Record review of Patient # 2's medical record showed she was a 58 year old female admitted to the facility on 5/6/2021 with admitting diagnosis of respiratory failure / ventilator-dependent. She had a history of CVA ( cerebral vascular accident /" stroke") , ESRD ( end stage renal dsease), and Diabetes.

Review of initial nursing assessment, dated 5/6/2023 showed a Stage 3 pressure ulcer to the sacrum.

Review of admission H & P, dated 5/5/2023, failed to show that integument / skin was listed in the Physical Examination components or assessed by the admitting physician. There was no mention of a Stage 3 pressure ulcer to the sacrum . No evidence that wound care was included in the "Assessment and Plan."

Review of nursing wound care notes on 5/24/2023 showed pressure ulcer to sacrum; and ulcers to left ischium and left heel.

Surveyor was unable to review physician's description of patient's "Hospital Course, " as there was no Discharge Summary located in Patient # 2's medical record.

During an interview on 4/20/2023 at 2 PM with Staff-C, Quality Director, she verified the issues with the incomplete H & P and the absence of the Discharge Summary for Patient # 2.