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 review of documents and interview of staff, it was determined the facility failed to ensure appropriate consent was obtained, per policy and prior to treatment, for one (1) of one (1) incapacitated adult patient who had a legal guardian on record (Patient # 2). This failure has the potential to deny the rights of all incapacitated adults to have an authorized person make treatment decisions on their behalf.

Findings include:

1. Facility policy entitled "Patient Rights and Responsibilities", effective date 4/22/15, was reviewed on 3/22/16, and revealed, in part, "Patients have the right...for the patient's guardian, next of kin, or legally authorized person to exercise to the extent permitted by law, the rights defined on behalf of the patient."

2. Facility policy entitled "Consent", last updated 10/10/13, was reviewed on 3/24/16. It states, in part, under the heading "IP (Inpatient), Observation, and ER (emergency room ) Procedure: 7. If patient is unable to sign consent and the person with the patient is no spouse, parent, guardian, or MPOA, registration should document the relationship of the person signing and reason why the patient is unable to sign."

3. Patient #2's medical record was reviewed on 3/23/16. Review of the History and Physical revealed the patient was admitted to the Medical -Surgical unit through the Emergency Department on 3/21/16. It stated she was from a group home, had a history of mental retardation and [DIAGNOSES REDACTED], and had previously been determined to lack capacity to make health care decisions. Review of the document entitled "Conditions of Admission and Authorization for Medical Treatment", dated 3/21/16, revealed a signature "B.H." with no designation of the relationship of that individual to the patient. Review of the patient's Emergency Contact information revealed the name "M.W."

4. The above record was reviewed with the Nurse Manager of the Medical-Surgical unit on 3/23/16 at 10:30 a.m. She was able to provide the document proving the individual M.W. was, in fact, Patient # 2's legal guardian, and stated the facility Case Manager had obtained this information by fax on "3/22 or 3/23". She was unable to identify the relationship of the individual B.H. to the patient. She agreed the "Conditions of Admission" document did not contain this information, did not indicate the reason the patient could not sign, and did not reveal any attempt had been made to contact the legal guardian to obtain consent.
Based on review of documents and interview of staff, it was determined the facility failed to ensure the tracking and analyzing of all adverse events. This failure leads to missed opportunities to identify systemic problems and thereby implement preventive actions to improve patient safety.

Findings include:

1. The policy entitled "Event Reporting", last revised 8/21/12, was reviewed on 3/23/16. It states, in part, "An event is an unplanned or unexpected event causing injury or the potential for injury to a patient or visitor...Other Patient Injury or Death: 8. Any unexpected death... Notify the appropriate manager/lead and then complete the Incident Report." The policy further references "Policy 072-ADM".

2. The policy # 072-ADM, entitled "Sentinel Event Reporting, Investigation and Follow-up", last revised 3/6/11, was reviewed on 3/23/16. It states, in part, under the heading "Definitions: Sentinel Event: Any event that resulted in an unanticipated death...not related to the natural course of the patient's illness or underlying condition". It further states, in part, under the heading "Procedure: 2. The appropriate incident reporting form is to be completed and immediately sent to the Risk Manager...4. An immediate investigation will be completed and all pertinent documentation and information will be gathered. 5. A thorough and credible Root Cause Analysis will be completed." Included with the policy was a copy of the facility-approved four (4) page Root Cause Analysis form to be used in the investigation of the event.

3. A brief joint interview was conducted with the facility Director of Patient Care (DPC) and the Director of Risk Management (DRM) on 3/23/16, at 9:30 a.m. When asked if the facility had had any sentinel events for either the current year or 2015, they both stated "No". When asked if the facility had experienced any unexpected deaths during that time period, they both stated, "Yes", and referred to a thirty-four (34) year old employee who had died in the facility's Intensive Care Unit on August 2015 following a scheduled gynecological surgery. The DRM stated no incident report had been filed because "we all knew about it" and added,"we did not view this as a sentinel event". She stated a meeting had occurred at the time between herself, the DPC, the Administrator and the Director of Quality, at which time a decision was made for an outside peer review "because we were all so emotional."

4. A follow-up interview was conducted with the DRM on 3/23/16 at 10:30 a.m. When asked if any internal investigation had been conducted related to the event, she replied "we all talked about it". When asked if the discussions had been documented, she stated "No". When asked if there had been a Root Cause Analysis conducted, she replied "No". She stated nursing documentation had been reviewed which revealed staff had been forced to "go to the ED (Emergency Department) for one piece of equipment during the Code", but stated no documentation of that record review had been completed. When asked if the event had been discussed in Quality meetings, Risk Management meetings or at the level of the Governing Body, she stated it had been discussed but not documented. She stated the Medical Care Appraisal Committee (MCAC) had reviewed the case, and this was documented in their minutes. She was requested at that time to provide the above documentation.

5. The minutes of the MCAC provided were dated for 10/1/15 and 12/3/15 and were reviewed on 3/23/16 in the presence of the DRM. The minutes dated 10/1/15 revealed case # was discussed, reviewed and analyzed; the minutes dated 12/3/15 revealed electronic medical record instructions were given to the medical staff. When asked if there was any documentation of the contents of the discussions noted above, she stated there was none.

6. In a brief interview on 3/24/16 at 9:30 a.m., when asked if any further documentation of the investigation, analysis, conclusions, or plans of action related to the event were available for review, the DRM provided a typed statement from the Director of Operating Room (OR), dated 8/6/15 stating the OR staff had discussed the case and had "considered the procedure uneventful". She stated no further documentation was available.

Based on review of documents and interview of staff, it was determined the facility failed to ensure an Admission Assessment was completed per policy for one (1) of ten (10) in-patient medical records reviewed (Patient # 2). Failure to assess the physical and emotional needs of the patient, as well as their possible needs for discharge planning, as soon as possible after admission, can lead to inappropriate planning of care, with possible negative outcomes for all patients.

Findings include:

1. Facility policy entitled "Documentation of Nursing Care", last reviewed 1/7/16, states, in part "The Registered Nurse shall complete the initial 'Head to toe' admission assessment and all other flow sheets appropriate to that patient. The Admission Assessment will be completed within the following Standards: Med/Surg (Medical-Surgical unit) within 24 hours".

2. Patient # 2's medical record was reviewed on 3/23/16 and revealed an admission date of [DATE] to the Medical-Surgical unit. No documentation of an admission assessment was found in the record.

3. A brief interview was conducted with the Nurse Manager of the Medical-Surgical unit on 3/24/16 at 11:20 a.m., at which time she agreed no admission assessment had been completed for Patient # 2 since her admission.