HospitalInspections.org

Based on medical record review, facility policy and interview, it was determined the facility failed ensure attendance to treatment team meetings for 2 of 10 (Patients #2 and 6) sampled patients.

The finding included:

1. Based on facility policy and procedure, "Patient Rights" documented,"Patients have the right to participate in the development of their individual program plans and to receive sufficient information about proposed and alternative interventions and program goals to enable them to participate effectively and ability to request or refuse treatment...If the patient is unable to participate, the patient's representative by the state will be allowed to participate in the development, implementation of the inpatient treatment plan, outpatient treatment plan, discharge plan and management plan, and made informed decisions regarding care...."

2. Medical record review for Patient #2 and # 6 revealed the "Initial Family Meeting" form for patient or other representative to sign was blank under the signature section. Indicating the patients and/or families were not attending team meetings to help in goal planning.

3. During an interview in the conference room on 8/1/11 at 2:10 PM, the Nurse Consultant verified the above findings.

Based on medical record review and interview, it was determined the facility failed include the specific treatment modalities utilized for 5 of 10 (Patients #1, 2 3, 4, and 5) sampled patients records reviewed.

The findings included:

1. Medical record review for Patients #1, 2 3, 4, and 5 revealed the treatment plans were not individualized with modalities and focus. The plans also failed to indicate the staff who were to provide treatment.

2. During an interview in the conference room on 8/1/11 at 1:01 PM the Nurse Consultant verified the above finding.