Every finding on record at West Georgia Medical Center, Inc.

Observed in Record Review. In 5 of 7 patient records reviewed, to assess the informed consent process, it was noted that the organization did not ensure the Hospice Election and Consent Form(s) were completed as required. For example, a review of the Hospice Election and Consent Form revealed that patients were not informed of their financial responsibility prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services. For example, a review of the medical record(s) for Inpt#2, RRHV#1, RRHV#2, RRHV#3, and RRHV#4, revealed that the West Georgia Hospice Election Statement, section titled Hospice Philosophy and Coverage of Hospice Care, did not include the amount of financial responsibility and was signed by the patient or the patient's caregiver. This observation was reviewed with the Clinical Manager.

Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRNHV#6, the following goal statement was noted, “Patient will be free of anxiety”. The goal statement did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the Clinical Manager.

Observed in Building Tour. The organization did not ensure that fire protection features were designed and maintained to minimize the effects of fire, smoke, and heat. For example, during the building tour of Hospice Inpatient Building - Hallway #2, it was noted that the smoke door had a gap between the bottom of the door and the floor that was larger than 3/4 of an inch. This observation was reviewed with the Clinical Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.