HospitalInspections.org

Based on interview and record review, it was determined the hospital did not ensure that each patient or his or her representative was informed of their health status, were involved in care planning and treatment, and were able to request or refuse treatment. Specifically, 5 of 5 family members were not involved in the patient's care planning and treatment. Additionally, 10 out of 10 patients did not have treatment plans signed by the patient or the patient's family. As well as 2 of 2 patients interviewed that were cognitive enough to be interviewed stated they were not involved in their care planning and treatment. (Patient Identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10)

1. Family emergency contacts of patients 1, 4, 5, 7, and 9 were interviewed. All five family contacts that were interviewed stated the hospital did not go over the patient's treatment plan and that the hospital did not notify them of any changes in the patient's condition.

2. Patient 1 was admitted on 6/8/23 with a diagnosis of dementia.

Patient 1 was interviewed on 6/12/23 at 10:30 AM. He stated the hospital was not good at communicating and did not feel like he was involved in his treatment plan.

Patient 5 was admitted on 6/9/23 with a diagnosis of Neurocognitive disorder.

Patient 5 was interviewed on 6/12/23 at 10:45 AM. He stated no one had communicated anything to him about his treatment plan. He stated someone asked him about one medication and that was it.

3. The hospitals treatment plan policy was reviewed and revealed the following:

"Treatment plans and reviews are discussed with the patient and/or their family/POA/Guardian. The patient will be given the opportunity to read the plans, offer any comments and sign the review upon request."

"There is a treatment plan attendance form for each family member to sign in each treatment team meeting they attend, that is signed by all who attend and filed in the patient's hard chart."

There was no documented evidence in 10 out of 10 patient charts that the patients or the patients' families signed treatment plans. All signature lines for the patient and patient families were left blank.

On 6/14/23 at 11:26 AM, the hospital administrator was asked about their treatment plan policy and why none of the patient treatment plans were signed. He stated they no longer did that, it was something they did pre-covid. He was asked about the patients and family members that stated they were never spoken to about treatment plans. The administrator stated the social worker mostly goes over the treatment plan with family and patients. He stated they might not say the words treatment plan when discussing it with the patient or family.

On 6/14/23 at 10:46 AM, the hospital's social worker was interviewed. She was asked where it was documented that the treatment plan was discussed with the patient and/or family. She was not sure where it was documented. She stated she was new; she would need to find out and get back to us. She stated she would call families with updates but was not always the best at documenting it.