HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 15 medical records reviewed, it was determined the facility did not ensure that (1) patients are informed of their diagnoses and (2) patients participation in the development and implementation of their plan of care is documented in the medical record. (Patient #3).

Findings include:

A review of medical record for Patient #3 revealed the following: Patient was admitted to the facility on March 30, 2016 with a complaint of abdominal pain and was diagnosed with Diverticulitis with possible abscess formation. Perforation of the bowel was identified on April 1, 2016 and drainage of the abscess was contemplated at that time. The patient's treatment consisted of antibiotic therapy and bowel rest. The patient was discharged from the facility on April 2, 2016, but there was no documented evidence throughout the medical record that a physician informed the patient of her diagnosis and the treatment plan.

During an interview conducted on October 14, 2016 at 11:30 AM with Staff B, Director of Professional Practice, she stated that it is the facility's policy to discuss each patient's diagnoses and care with the respective patient. She confirmed the finding that this discussion was not documented in the patient's medical record.

These findings were shared with Staff #A, the Director of Regulatory Affairs on October 14, 2016 at 3:15 PM.