Genesis Medical Center-Davenport

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47335 Based on a review of the Acute Care Hospital (ACH)’s policies and procedures, medical records, and interviews, the ACH’s administrative staff failed to ensure all patients were given all information needed in order to make an informed decision regarding the patients’ care in 1 of 10 patients reviewed (Patient #9). Failure to provide patients and/or their representative with the needed information to make informed decisions placed all patients at risk of not receiving treatment according to the wishes of the patient. Findings include: 1. Review of policy, “Patient Rights and Responsibilities/Non-Discrimination,” last revised 11/2025, revealed in part: a. “Purpose: [Hospital] supports the establishment and protection of patient rights and access to and provision of care without discrimination. To effectively provide all rights for patients...” b. “ ...Organizations must do the following: ...Inform patients of their rights and responsibilities. Provide effective communication with patients...” 2. Review of policy, “Education, Patient,” last revised 8/2025, revealed in part: a. “Patients and their family/support person will receive education specific to the patient needs as appropriate to the care, treatment and services required. Goals for patient education are to improve individual outcomes by promoting healthy behavior and to involve and enhance the confidence of patients their family/support person in their care, treatment and service decisions ...” b. “ ...Instruction may include but is not limited to: The plan for care, treatment and services ...” c. “ ...Assess patient goals for treatment and care ...” 3. Review of hospital “Huddle and weekly update,” from 2/17/26 at 2:23 PM, revealed: a. Hospital leadership instructed staff that physicians would complete a peer to peer review for placement denials. Insurance decision from the peer to peer review “will be final if not overturned then we will not go to expedited appeal.” 4. Review of Patient #9 (P9)’s medical record revealed: a. On 2/26/26 at 4:13 PM, P9 presented to the emergency department (ED) after being referred by their primary care provider for possible colon cancer and trouble finding words and remembering. b. On 2/26/26 at 9:59 PM, the hospitalist admitted P9 to the neurology unit for a diagnosis of a stroke. P9 had multiple co-morbidities, including expressive aphasia (speech difficulties), low potassium levels, sepsis, lactic acidosis (illness caused by infection and/or poor tissue oxygenation), high white blood cell count, a worsening chronic lower abdominal wound, and major depressive disorder (MDD). c. On 2/27/26 at 2:02 PM, Social Worker (SW) G discussed OT recommendations and services offered by acute rehabilitation (rehab) facilities with P9 and their spouse. d. On 3/1/26 at 11:40 AM, SW H provided P9’s hospitalization information to the acute rehab facility and inquired about starting a prior authorization with P9’s insurance for acute rehab services. e. On 3/4/26 at 8:32 AM, SW G documented P9’s insurance offering a peer to peer review. SW G forwarded P9’s information to the hospital physicians to complete the peer to peer review. f. On 3/4/26 at 10:42 AM, SW G documented the peer to peer review denied acute rehab services for P9. g. On 3/4/26 at 11:10 AM, SW G discussed discharge planning and further plans for P9 with leadership following the peer to peer review denial for acute rehab services. Leadership instructed SW G to discuss P9’s options with the therapy staff to determine if P9 required acute rehab services, or if P9 should go to a skilled nursing facility (SNF) or home with lower-level therapy services. SW G noted therapy felt P9’s needs could be best met at an acute rehab facility. h. On 3/4/26 at 11:30 AM, SW G requested guidance from leadership regarding having a discussion with P9 and their family regarding filing an expedited appeal with P9’s insurance for acute rehab services. i. On 3/4/26 at 12:19 PM, SW G documented Care Coordinator Director (CCD) instructed SW G that an expedited appeal was not recommended, and to look at SNF for P9. j. On 3/4/26 at 2:46 PM, SW G spoke with P9 regarding the insurance denial, and plan of looking at SNF for similar rehab services. SW G provided P9 with a list of SNF. P9 expressed confusion with the insurance decision, and reported P9 felt they needed acute rehab services. SW G contacted the acute rehab facility, and requested an expedited appeal on P9’s behalf. k. On 3/6/26 at 4:05 PM, SW G received notice that P9’s appeal for acute rehab services was denied by P9’s insurance. SW G notified P9 of the insurance decision. P9 decided to discharge home with outpatient services. l. On 3/6/26 at 6:36 PM, P9 discharged home with family and home health services. 5. During an interview on 4/22/26 at 9:00 AM, SW B explained the peer to peer review process was offered before insurance formally denied the authorization for services, but was offered with the intent to deny the authorization. SW B reported the expedited appeal was the patient’s right to disagree with the insurance’s denial and request an additional review. SW B explained hospital staff would contact the patient’s insurance and request the appeal process on the patient’s behalf. SW B reported being directed by leadership that staff should consult with leadership on whether staff should offer an expedited appeal to a patient after insurance denied the request for acute rehab services. SW B explained staff were to let leadership make the decision whether the patient should appeal the denial. 6. During an interview on 4/22/26 at 9:30 AM, SW G reported the process for insurance authorizations and the appeal process changed in February 2026. SW G explained staff were directed by leadership during a weekly huddle meeting that when a patient’s request for acute rehab services were denied by insurance after a peer-to-peer review, then the process was completed and staff needed to look for lower level facilities such as SNF for the patient. SW G reported staff were instructed by leadership not to proceed with an expedited appeal process for patients. SW G explained their understanding was the peer-to-peer review happened before a patient’s insurance made an initial denial, and after the peer to peer review, patients had the right to appeal if denied. SW G reported leadership told staff the peer-to-peer was the appeal process, and the expedited appeal was a second appeal. 7. During an interview on 4/22/26 at 10:30 AM, SW H reported the current hospital process was insurance may offer a peer-to-peer review for patients wanting acute rehab services. SW H explained the physician would contact the insurance and provide the patient’s information. SW H reported if that was denied, leadership instructed staff to notify leadership of the decision, so the decision could be reviewed. SW H reported the expedited appeal process would be completed on a “case-by-case basis” if leadership felt that was the right next step for the patient. SW H explained leadership would instruct staff whether to proceed with the expedited appeal process or pursue something else for the patient such as SNF. 8. During an interview on 4/22/26 at 11:00 AM, Registered Nurse (RN) E reported receiving confusing information during a weekly huddle meeting from leadership regarding the appeal process for insurance denials. RN E recalled the discussion being about the appeal process and keeping patients hospitalized longer during the appeal process. RN E explained their interpretation from the discussion as staff should review with the patient and explain why the prior authorization was denied by the patient’s insurance. RN E reported there were discussions about only completing one appeal for patients, then pursuing SNF for patients post discharge care. RN E reported there was misunderstanding from the huddle meeting on leadership’s expectations for hospital processes regarding the appeal processes. 9. During an interview on 4/22/26 at 12:00 PM, CCD explained hospital staff send referrals to acute rehab facilities for patients who need acute rehab services following discharge. CCD reported, once the patient was accepted by the acute rehab facility, the acute rehab facility would send a request for prior authorization to the patient’s insurance for acute rehab services. CCD explained the patient’s information would be reviewed by the insurance, and once a decision was made, the acute rehab staff would notify the hospital whether the prior authorization was approved or denied by insurance. CCD reported, if the patient’s insurance denied the prior authorization, then hospital staff would inform the patient of the denial and review the appeal rights and process with the patient. CCD denied instructing hospital staff not to inform patients of their rights to appeal decisions made by their insurance and stated, “that is not our practice.” CCD did not acknowledge instructing hospital staff to only do the peer-to-peer review process and not to do the expedited appeal process. CCD explained staff always do the peer-to-peer review process first, then the expedited appeal process.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51283 Based on medical record review, review of hospital policy, legal representative interview and staff interview, the hospital emergency department (ED) staff failed to do the following for a patient that had a legal representative and was cognitively unable to direct their own care: 1) to provide notice of patient rights prior to, and before discontinuing care (see A0117); and, 2) to obtain informed consent (see A0131) from the legal representative at any time during the course of treatment and services. The cumulative effect of these system failures and deficient practices resulted in the inability of hospital staff to ensure they protected the health, safety and rights of patients. The hospital reported a patient census of 232 at the time of the complaint investigation.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 51283 Based on medical record review, review of hospital policy, legal patient representative interview and staff interviews, the hospital’s administrative staff failed to have a system in place that directed emergency department (ED) staff on when to utilize other hospital services to meet the emergency needs of patients for 1 of 20 sampled patients (Patient #19). (See A1103) This failure resulted in Patient #19, a patient that lacked the cognitive abilities to self-direct their care and recognize environmental hazards, discharging from the ED alone and taking a cab to an incorrect address. The patient was missing for approximately 14 hours, from 7:34 PM on 11/14/24 until 11:00 AM on 11/15/24, with temperatures that reached a low of 32 degrees Fahrenheit at 7:00 AM on 11/15/24. The cumulative effect of this system failure and deficient practice resulted in the hospital staff’s inability to ensure the patient was safely discharged from the hospital. The hospital reported a patient census of 232 at the time of the complaint investigation.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51283 Based on medical record review, review of hospital policy, legal representative interview and staff interview, the hospital staff failed to inform the legal representative of a patient of the patient’s rights in advance of furnishing and discontinuing care for 1 of 20 sampled patients (Patient #19). Failure to inform the legal representative, a durable power of attorney for healthcare decisions (DPOA), of Patient #19’s rights prior to care, during care or at the discontinuation of care, resulted in Patient #19, a patient with Alzheimer’s dementia and without the capacity to understand their rights and make informed decisions, receiving care and treatment without the benefit of understanding the consent the patient provided for those services. Findings include: 1. Review of the hospital’s policies revealed the following: a. Advance Directives (Living Will and Durable power of Attorney for health care), last reviewed 4/2023. POLICY:”...supports the patients ’ rights to make legally valid informed decisions about future medical treatment ... an Advance Directive will only be used when a patient is unable to make decisions for oneself ...” DEFINITIONS: “...Durable Power of Attorney (POA) For Health Care: A document through which a competent adult names another as the “attorney-in-fact” or “agent” to make health care decisions when the patient becomes unable, and which may provide specific instructions for the agent ...” PRACTICE/PROCEDURE: “... Patients who have executed an Advance Directive will be encouraged to present the hospital with a copy and discuss this with their practitioners ...” b. Patient Rights and Responsibilities/ Non Discrimination, reviewed last 10/2024. POLICY:”... affirms the rights of the patient, recognizes the unique health care needs of the individual, and provides considerate and respectful care to all. Patients and families who are well informed, participate in treatment decisions, and communicate openly with physicians and other health professionals ...” PRACTICE/PROCEDURE: “... rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you or your legally designated representative have the right to...obtain from physicians and other direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis ... receive appropriate pain management for acute, chronic and terminal conditions ...expect reasonable pain control ...make decisions about the plan of care prior to and during the course of treatment ...have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designation of a surrogate decision maker with the expectation that the intent of that directive will be honored to the extent permitted by law and organizational policy ....rights and responsibilities shall be communicated at the time of admission in a form that is understandable to the patient or their legally designated representative ...” 2. Review of the medical record for Patient #19 revealed the following: a. On 11/14/2024 at 3:03 PM RN Staff F documentation revealed, Patient #19 with a history of Alzheimer’s dementia presented to the ED via ambulance services for chest pain. b. On 11/14/24 (no time documented) ED Physician Staff C documented the following for history of present illness: “The patient presents today with concerns for chest pain. The patient does have a past medical history of dementia. Per EMS (emergency medical services) report, the patient had chest pain for about 30 minutes prior to arrival. Currently denies any chest pain. Patient complained of abdominal pain during the nursing assessment,and denies any abdominal pain currently. Patient ‘s only complaint is pain around the IV (intravenous) site...Additional review of system information: unable to obtain from patient due to: dementia... Active Problems: Alzheimer’s Dementia, auditory hallucinations..visual hallucination, hypertension (HTN- high blood pressure)... incontinence (inability to control bladder/bowel function), Intraparenchymal hemorrhage of brain (brain bleed).” c. On 11/14/2024 at 4:12 PM, Patient #19 signed consent to treat forms. d. On 11/14/2024 at 7:34 PM, RN Staff F documented Patient #19 discharged home. 3. During an interview on 12/9/2024 at 2:24 PM, RN Staff P confirmed Patient #19 had an active DPOA on file. 4. During an interview on 12/11/2024 at 10:47 AM, ED Physician Staff C reported it would be the expectation that the DPOA should have been consulted, and informed of events that led up to the hospitalization, care provided, and discharge given Patient #19 Alzheimer’s Dementia. Staff C recalled Patient #19 did not have a DPOA with them at the time they arrived at the hospital, and was unaware if there was any communication between the DPOA and the assigned nurse on duty. 5. During an interview on 12/09/2024 3:22 PM, ED/RN Nursing Manager Staff A reported an inability to locate documentation of Staff F attempting to reach Patient #19’s DPOA. Staff A reported a hospital care coordinator could have been used (to assist with discharge) when a person was confused, and hospital staff were unable to reach the family member. 6. During an interview on 12/09/2024 at 4:51 PM, RN Staff F reported that Staff F arranged for the cab for Patient #19 at time of discharge from the ED. Staff F explained that if a person presented to the ED with Alzheimer’s Dementia, a family member or power of attorney would have been contacted on that person’s behalf. RN Staff F reported reaching out to the DPOA of Patient #19 at the time of discharge. However, when asked to show in the record where Staff F documented this information, Staff F was unable to find documentation in the medical chart supporting this phone call attempt. 7. During an interview on 12/9/24 8:13 AM, the DPOA for Patient #19 disclosed Patient #19 was hospitalized at the same hospital about 2 weeks prior to this ED visit (11/14/24) for memory care issues. Patient #19 was oriented to person only, and required frequent prompting to follow commands.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 51283 Based on medical record review, review of hospital policy, legal representative interview and staff interview, the hospital staff failed to allow the legal representative of a patient to make informed decisions regarding the medical the patient received in the emergency department (ED) for 1 of 20 sampled patients (Patient #19). Failure to allow the legal representative for Patient #19, a durable power of attorney for healthcare decisions (DPOA), make informed decisions regarding the patient’s care and discharge resulted in Patient #19, a patient with Alzheimer’s dementia and without the capacity to make informed decisions, being inappropriately and unsafely discharged from hospital emergency department (ED) services. Findings include: 1. Review of the hospital’s policies revealed the following: a. Advance Directives (Living Will and Durable power of Attorney for health care), last reviewed 4/2023. POLICY:”...supports the patients ’ rights to make legally valid informed decisions about future medical treatment ... an Advance Directive will only be used when a patient is unable to make decisions for oneself ...” DEFINITIONS: “...Durable Power of Attorney ( POA) For Health Care: A document through which a competent adult names another as the “attorney-in-fact” or “agent” to make health care decisions when the patient becomes unable, and which may provide specific instructions for the agent ...” PRACTICE/PROCEDURE: “... Patients who have executed an Advance Directive will be encouraged to present the hospital with a copy and discuss this with their practitioners ...” b. Patient Rights and Responsibilities/Non Discrimination, reviewed last 10/2024. POLICY:”... affirms the rights of the patient, recognizes the unique health care needs of the individual, and provides considerate and respectful care to all. Patients and families who are well informed, participate in treatment decisions, and communicate openly with physicians and other health professionals ...” PRACTICE/PROCEDURE: “... rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you or your legally designated representative have the right to...obtain from physicians and other direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis ... receive appropriate pain management for acute, chronic and terminal conditions ...expect reasonable pain control ...make decisions about the plan of care prior to and during the course of treatment ...have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designation of a surrogate decision maker with the expectation that the intent of that directive will be honored to the extent permitted by law and organizational policy ....rights and responsibilities shall be communicated at the time of admission in a form that is understandable to the patient or their legally designated representative ...” 2. Review of the medical record for Patient #19 revealed the following: a. On 11/14/2024 at 3:03 PM RN Staff F documentation revealed Patient #19 presented to the ED via ambulance services for chest pain. b. On 11/14/24 (no time documented) ED Physician Staff C documented the following for history of present illness: “The patient presents today with concerns for chest pain. The patient does have a past medical history of dementia. Per EMS (emergency medical services) report, the patient had chest pain for about 30 minutes prior to arrival. Currently denies any chest pain. Patient complained of abdominal pain during the nursing assessment,and denies any abdominal pain currently. Patient ‘s only complaint is pain around the IV (intravenous) site...Additional review of system information: unable to obtain from patient due to: dementia... Active Problems: Alzheimer’s Dementia, auditory hallucinations..visual hallucination, hypertension (HTN- high blood pressure)... incontinence (inability to control bladder/bowel function), Intraparenchymal hemorrhage of brain (brain bleed).” c. On 11/14/2024 at 4:12 PM, Patient #19 signed consent to treat forms. d. On 11/14/2024 at 7:34 PM, RN Staff F documented Patient #19 discharged home, “disposition accompanied by self, mode of departure ambulatory, disposition outcome improved.” 3. During an interview on 12/9/2024 at 2:24 PM, RN Staff P confirmed Patient #19 had an active DPOA on file. 4. During an interview on 12/11/2024 at 10:47 AM, ED Physician Staff C reported it would be the expectation that the DPOA should have been consulted and informed of events that led up to hospitalization, care provided, and discharge, given Patient #19 Alzheimer’s Dementia. Staff C recalled Patient #19 did not have a DPOA with them at the time they arrived at the hospital. Staff C was unaware if there had been any communication between the DPOA and the assigned nurse on duty. 5. During an interview on 12/09/2024 3:22 PM, ED/RN Nursing Manager Staff A reported an inability to locate documentation of Staff F attempting to reach the DPOA for Patient #19. 6. During an interview on 12/09/2024 at 4:51 PM, RN Staff F reported that Staff F arranged for the cab for Patient #19 at time of discharge from the ED. Staff F explained that if a person presented to the ED with Alzheimer’s Dementia, a family member or power of attorney would have been contacted on that person’s behalf. RN Staff F reported reaching out to the DPOA of Patient #19 at the time of discharge. However, when asked to show in the record where Staff F documented this information, Staff F was unable to find documentation in the medical chart supporting this phone call attempt. RN Staff F reported Patient #19 had Alzheimer’s Dementia, was not safe to ride in a cab alone. 7. During an interview on 12/9/24 8:13 AM, the DPOA for Patient #19 disclosed the patient was hospitalized at the same hospital about 2 weeks prior to this ED visit (11/14/24) for memory care issues. Patient #19 was oriented to person only, and required frequent prompting to follow commands. The DPOA reported they purchased a new home, and Patient #19 would not have been able to recall the correct new address. Patient #19’s DPOA reported when Patient #19 was found the next day (on 11/15/24) at 11:00 AM, the weather was cold, and Patient #19 did not have a coat with them.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 51283 Based on medical record review, review of hospital policy, legal patient representative interview and staff interviews, the the hospital emergency department (ED) staff failed to provide integrated services, within the hospital’s capabilities, including utilizing a care coordinator/social worker, to meet the emergency needs of patients for 1 of 20 sampled patients ( Patient #19). The failure of ED staff to provide integrated services to meet the emergency needs of patients resulted in Patient #19, a patient that lacked the cognitive abilities to self-direct their care and recognize environmental hazards, discharging from the ED alone and taking a cab to an incorrect address. The patient was missing for approximately 14 hours and was at risk for serious harm and/or death. Findings include: 1. Review of the ED and Hospitals policies revealed the following: a. Advance Directives ( Living Will and Durable power of Attorney for health care), last reviewed 4/2023. POLICY: “ ...supports the patients ’ rights to make legally valid informed decisions about future medical treatment ... an Advance Directive will only be used when a patient is unable to make decisions for oneself ... “ DEFINITIONS: “ ...Durable Power of Attorney ( POA) For Health Care: A document through which a competent adult names another as the “ attorney-in-fact “ or “ agent “ to make health care decisions when the patient becomes unable, and which may provide specific instructions for the agent ... “ PRACTICE/PROCEDURE: “ ... Patients who have executed an Advance Directive will be encouraged to present the hospital with a copy and discuss this with their practitioners ... “ b. Patient Rights and Responsibilities/ Non Discrimination, reviewed last 10/2024. POLICY: “ ... affirms the rights of the patient, recognizes the unique health care needs of the individual, and provides considerate and respectful care to all. Patients and families who are well informed, participate in treatment decisions, and communicate openly with physicians and other health professionals ... “ PRACTICE/PROCEDURE: “ ... rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you or your legally designated representative have the right to...obtain from physicians and other direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis ... receive appropriate pain management for acute, chronic and terminal conditions ...expect reasonable pain control ...make decisions about the plan of care prior to and during the course of treatment ...have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designation of a surrogate decision maker with the expectation that the intent of that directive will be honored to the extent permitted by law and organizational policy ....rights and responsibilities shall be communicated at the time of admission in a form that is understandable to the patient or their legally designated representative ... “ c. Patient Transport Service, reviewed date 4/24. POLICY: “ .. transport services provides established patients with non-ambulance transport for medically necessary services ... “ PRACTICE/PROCEDURE “ ... Patient transportation requests must be arranged through Care Coordination ... “ 1. Review of the hospitals medical record for Patient #19, revealed the following: a. On 11/14/2024 at 3:03 PM RN Staff F documentation revealed, Patient #19 with a history of Alzheimer’s dementia presented to the ED via ambulance services for chest pain. b.On 11/14/24 (no time documented) ED Physician Staff C documented the following for history of present illness: “The patient presents today with concerns for chest pain. The patient does have a past medical history of dementia. Per EMS (emergency medical services) report, the patient had chest pain for about 30 minutes prior to arrival. Currently denies any chest pain. Patient complained of abdominal pain during the nursing assessment,and denies any abdominal pain currently. Patient ‘s only complaint is pain around the IV (intravenous) site...Additional review of system information: unable to obtain from patient due to: dementia... Active Problems: Alzheimer’s Dementia, auditory hallucinations..visual hallucination, hypertension (HTN- high blood pressure)... incontinence (inability to control bladder/bowel function), Intraparenchymal hemorrhage of brain (brain bleed).” c. On 11/14/2024 at 7:34 PM, RN Staff F documented Patient #19 discharged home, “disposition accompanied by self, mode of departure ambulatory, disposition outcome improved.” 2. During an interview on 12/9/24 8:13 AM, the DPOA for Patient #19 disclosed the patient was hospitalized at the same hospital about 2 weeks prior to this ED visit (11/14/24) for memory care issues. Patient #19 was oriented to person only, and required frequent prompting to follow commands. The DPOA reported they purchased a new home, and Patient #19 would not be able to recall the correct new address. The DPOA for Patient #19 reported when the patient was found the next day in a parking lot of a local grocery store at 11:00 AM, the weather was cold, and Patient #19 did not have a coat with them. 3. During an interview on 12/09/2024 at 4:51 PM, RN Staff F reported that Staff F arranged for the cab for Patient #19 at time of discharge from the ED. Staff F explained that if a person presented to the ED with Alzheimer’s Dementia, a family member or power of attorney would be contacted on that person’s behalf. RN Staff F, reported reaching out to Patient #19 DPOA at the time of discharge. However, when asked to show in the record where Staff F documented this information, Staff F was unable to find documentation in the medical chart supporting this phone call attempt. RN Staff F confirmed integrated services within the ED were not utilized to assist with safe discharge. RN Staff F reported Patient #19 had Alzheimer’s Dementia, was not safe to ride in a cab alone. 4. During an interview on 12/09/2024 3:22 PM with ED/RN Nursing Manager Staff A, was unable to locate documentation of Staff F attempting to reach Patient #19’s DPOA. Staff A reported a care coordinator can be used when a person is confused, and the family member is unable to be reached. 5. During an interview on 12/11/2024 at 10:47 AM, ED Physician Staff C, reported it would be the expectation that the DPOA should have been consulted, and informed of events that lead up to hospitalization, care provided, and discharge, given Patient #19 Alzheimer’s Dementia. Staff C recalled Patient #19 did not have a DPOA present at the time they arrived at the hospital, and was unaware of any communication between the DPOA and the assigned nurse on duty. 6. During an interview on 12/4/24 4:04 PM, ED Medical Director Staff M, reported if a person was not alert, or oriented, or answering questions appropriately, the family or POA should have been involved. 7. During an interview on 12/11/2024 at 4:23 PM, RN Care Coordinator Staff U reported they worked out of an office in the ED. Staff U reported being responsible for assisting with finding placement for patients that needed to go to another facility, as well as assisting with other emergent situations. The hospital did not staff social workers in the ED, but hospital social workers had also helped with emergent situations in the ED. Staff U explained there was a trigger from the nursing assessment built into the electronic system that alerted care coordination staff of when they needed to provide services. The assessment trigger was associated with cognitive impairment. Staff U confirmed they were not consulted for Patient #19; the electronic notification system did not trigger. Staff U expressed being unaware that the cognitive impairment trigger only alerted care coordination staff for patient’s with cognitive impairment due to drug and alcohol use. The system did not trigger for any other form of cognitive impairment. Staff U reported a provider could also write an order for the care coordination services.”