Perry County General Hospital

“Medical staff. The governing body must: CFR(s): (4) Approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 45467 Based on Staff interview, document review of the facility’s “Leadership Meeting Minutes,” dated 05/21/2024, the facility failed to have “Medical Staff Rules and Regulations,” and “Medical Staff Bylaws,” approved by the designated governing body or appointed individual legally responsible for the conduct of the Rural Emergency Hospital (REH) since it began operating as a Rural Emergency Hospital on April 1, 2024. Findings Include: An interview on 10/23/2024 at 12:02 p.m. with the Infection Control Nurse confirms the facility has not had a governing body meeting since the facility attested it meets the requirements for a REH beginning on 04/01/2024 and further confirms the facility’s “Medical Staff Bylaws” and “Medical Staff Rules and Regulations” have not been approved/adopted since the facility’s conversion to the REH. Review of the facility’s “Medical Staff Rules and Regulations,” revealed the document was unsigned and dated 2003, and review of the facility’s “Medical Staff Bylaws,” revealed the document was dated 01/25/2022. No documented evidence the facility’s governing body or appointed individual legally responsible for the conduct of the Rural Emergency Hospital (REH) has reviewed or adopted the documents for the REH beginning operation on 04/01/2024. Review of facility “Leadership Meeting Minutes” dated 05/21/2024, call to order by the Administrator, reveals “ ...we have transitioned into an REH hospital ...” No documentation the “Medical Staff Bylaws” and “Medical Staff Rules and Regulations” were presented for review and adoption by the Leadership team/governing body. During exit conference on 10/23/2024 at 1:30 p.m. with Infection Control Nurse, Administration Assistant, and Health information Management (HIM) Clerk, findings were discussed, no further documents were submitted for review.”

“Notice of rights. CFR(s): (a) (1) An REH 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: 45467 Based on staff interviews, medical record reviews, document review of Patient’s Rights Form, and review of facility’s policy and procedure, the facility failed to ensure each patient/patient’s representative received “Patient’s Rights” prior to receiving patient care for seven (7) of 20 records reviewed. Patient records #6, #11, #12, #13, #15, #16, and #19. Findings Include: An interview on 10/22/2024 at 4:01 p.m. with Registration Clerk #2 confirmed consent forms are part of registration process and each patient that arrives at the Emergency Department (ED) for services should receive and sign a consent form and receive the Patient’s Right’s Form. Review of patient #11 medical record reveals patient #11 arrived at the Emergency Department on 09/13/2024 at 1:58 p.m. for outpatient x-ray of the chest. No documented evidence of a signed consent form for evaluation and treatment. Review of patient #12 medical record reveals patient #12 arrived at the Emergency Department on 10/15/2024 at 10:48 a.m. for outpatient Laboratory Services. No documented evidence of a signed consent form for evaluation and treatment. Review of patient #13 medical record reveals patient #13 arrived at the Emergency Department on 10/14/2024 for outpatient X-ray of the abdomen. No documented evidence of a signed consent form for evaluation and treatment. Review of patient #16 medical record reveals patient #16 arrived at the Emergency Department on 06/26/2024 at 9:15 a.m. for outpatient service of Laboratory Services. No documented evidence of a signed consent form for evaluation and treatment. Review of patient #19 medical record reveals patient #19 arrived at the Emergency Department on 07/05/2024 at 10:49 a.m. for outpatient x-ray of the forearm. No documented evidence of a signed consent form for evaluation and treatment. Review of facility form “Patient Rights & Responsibility,” dated 04/22/2019 reveals, “ ...Consent: You have the right to be reasonably informed about and participate in decisions involving your health and plan of care ...You should not be subjected to any procedures without your ...informed consent ...”. Review of facility policy, Registration Department, inpatient and outpatient (IP/OP) dated 03/2002 reveals, “Procedure: Registration Consents and Handouts ...Purpose: To ensure accurate documentation of Registration Consent forms ...General Consent (assignment of Benefits and Privacy Practices), Medicare Message ...Tricare Message, Financial Information Form. Patient’s Rights and Responsibilities ...Any registration assigned to register patients during personal registration interviews ...consent for treatment ...this is signed by the patient. If the patient is not able, the form is signed by a “blood relative” ...witnessed by the registrar and dated appropriately ...”. During exit conference on 10/23/2024 at 1:30 p.m. with Infection Control Nurse, Administration Assistant, and Health information Management (HIM) Clerk, findings were discussed, and no further documents were submitted for review.”

“Records system. CFR(s): (a)(4) For each patient receiving health care services, the REH must maintain a record that includes, as applicable -- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; (ii) Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; (iii) All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and (iv) Dated signatures of the doctor of medicine or osteopathy or other health care professional. This Standard is not met as evidenced by: 45467 Based on staff interviews, medical record reviews, and review of facility’s policy and procedure, the facility failed to obtain properly executed informed consent forms for six (6) of 20 records reviewed. Patient records #6, #11, #12, #13, #16 and #19. Findings include: During an interview on 10/22/2024 at 4:01 p.m. with Registration Clerk #2 confirmed consent forms are part of registration process and each patient that arrives at the Emergency Department (ED) for services should receive and sign a consent form and receive the Patient’s Right’s Form. During an interview on 10/22/2024 at 4:07 p.m. Registration Clerk #1, confirms consent forms not being electronically available in the electronic medical record system. Review of Patient #6 medical record reveals Patient #6 arrived at the Emergency Department on 08/06/2024 at 10:30 a.m. for outpatient abdominal x-ray. No documented evidence of a signed consent form for evaluation and treatment. Review of Patient #11 medical record reveals Patient #11 arrived at the Emergency Department on 09/13/2024 at 1:58 p.m. for outpatient x-ray of the chest. No documented evidence of a signed consent form for evaluation and treatment. Review of Patient #12 medical record reveals Patient #12 arrived at the Emergency Department on 10/15/2024 at 10:48 a.m. for outpatient Laboratory Services. No documented evidence of a signed consent form for evaluation and treatment. Review of Patient #13 medical record reveals Patient #13 arrived at the Emergency Department on 10/14/2024 for outpatient X-ray of the abdomen. No documented evidence of a signed consent form for evaluation and treatment. Review of Patient #16 medical record reveals Patient #16 arrived at the Emergency Department on 06/26/2024 at 9:15 a.m. for outpatient service of Laboratory Services. No documented evidence of a signed consent form for evaluation and treatment. Review of Patient #19 medical record reveals Patient #19 arrived at the Emergency Department on 07/05/2024 at 10:49 a.m. for outpatient x-ray of the forearm. No documented evidence of a signed consent form for evaluation and treatment. Review of facility’s document, “Patient Rights & Responsibility,” dated 04/22/2019 reveals, “ ...Consent: You have the right to be reasonably informed about and participate in decisions involving your health and plan of care ...You should not be subjected to any procedures without your ...informed consent ...”. Review of facility policy, “Registration Department, Inpatient and Outpatient” (IP/OP) dated 03/2002 reveals, “Procedure: Registration Consents and Handouts ...Purpose: To ensure accurate documentation of Registration Consent forms ...General Consent (assignment of Benefits and Privacy Practices), Medicare Message ...Tricare Message, Financial Information Form. Patient’s Rights and Responsibilities ...Any registration assigned to register patients during personal registration interviews ...consent for treatment ...this is signed by the patient. If the patient is not able, the form is signed by a “blood relative” ...witnessed by the registrar and dated appropriately ...”. During exit conference on 10/23/2024 at 1:30 p.m. with Infection Control Nurse, Administration Assistant, and Health information Management (HIM) Clerk, findings were discussed, no further documents were submitted for review.”