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Based on medical record review, policy review, and staff interview, the hospital failed to ensure consent forms were properly signed and witnessed. This affected one of ten medical records reviewed including Patient #6. The facility census was 37.

Findings include:

On 07/01/15 the hospital policy, Informed Consent For Treatment, dated 11/14/11, was reviewed for consent information. The policy documented consent for treatment was required for each patient admitted to the hospital unless admitted involuntarily. The policy also documented consent for psychotropic medications must be signed by the patient/guardian, or verbal/written consent given before the first dose of any psychotropic medication. If verbal consent was obtained by a legal representative, two witness signatures would be required on the form for consent verification.

On 07/01/15 the medical record for Patient #6 was reviewed. The consent form for psychotropic medications documented verbal consent obtained by the patient's legal guardian, Advocacy and Protective Services, Inc (APSI) on 04/14/15 and 04/22/15, but lacked a second witness to the verbal consents.

On 07/01/15 at 11:00 AM, Staff A confirmed the lack of a second signature on Patient #6's consent for psychotropic medications.

Based on record review, staff interview and policy review, the hospital failed to update the interdisciplinary care plan and document patient participation. This affected one of ten medical records reviewed including Patient #6. The facility census was 37.

Findings include:

On 07/01/15 the hospital policy, Multidisciplinary Treatment Plan, revised 02/18/15 was reviewed. The policy documented the initial multidisciplinary plan of care would be held within 72 hours of admission. The interdisciplinary team would review progress and revise the plan as necessary at least weekly and would include documentation of patient and/or significant others/guardian's participation in the treatment team meetings.

On 07/01/15 the medical record for Patient #6 was reviewed including the interdisciplinary treatment plan of care and treatment plan updates. Patient #6 was admitted on 04/07/15. The master multidisciplinary treatment plan, dated 04/07/15 documented problems, objectives, and interventions for issues including mood/behavior, nutrition, victim of violence/trauma, and fetal alcohol syndrome. The initial treatment plan was signed by Patient #6 and the disciplinary team over the 72 hour period ending on 04/10/15.

The first documented treatment plan update was dated 04/22/15, 12 days after the initial treatment plan was completed. The treatment plan updates dated 04/22/15 and 04/29/15 both lacked documentation or signatures of Patient #6's and/or the guardian's participation in the treatment team meetings. The treatment plan update on 04/29/15 failed to include the visitation restrictions and rationale placed on Patient #6 on 04/24/15.

On 07/01/15 at 11:00 AM, Staff A confirmed the treatment plan update was not completed within a week of the initial treatment plan, the two treatment plan updates failed to document patient participation, and the treatment plan was not updated to include the visitation restrictions.