HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the parent or guardian was able to participate in the minor patient's treatment plan/plan of care for 2 (P[patients] P1 and P4) of 11 (P1-P11) patients reviewed by not informing them of changes in health status, incidents, or issues on the unit. This deficient practice could result in a minor patient's parent or guardian being unaware of changes in health status, incidents or issues on the unit during the minor patient's hospitalization that are necessary to allow them to fully participate in the patients' care planning process.

The findings are:

A. Record review of the facility's policy and protocol titled "Communication & Discharge Planning by Discipline Protocol" revised 03/31/24, revealed, under the "Nursing" section "Contact parent/guardian/support if patient is having issues on unit (codes, illness, etc.). In addition, document any phone calls from parent/guardian/support in the record. Document this on the [facility initials] Nursing Notes."

B. Record review of P1's medical record, the document "[facility initials] Nursing Notes," dated 04/14/2024, incident time "1730" (5:30 pm), revealed "Altercation c [with] peer pt [patient] punched wall c [with] R [right] hand result in obvious deformity to wrist area EMS [emergency medical service] transport to [initials of outside hospital]." Further review of medical record revealed the record did not contain any documentation of parent or guardian notification of incident or transport to the outside hospital.

C. Record review of the facility's Incident Log dated 01/01/24 through present, revealed incident number 24-103000, involved P1, type of incident, "Non-suicidal Self Injurious Behavior" "Outcome: Fracture", intervention/treatment "Emergency Room," Incident date 04/14/2024 incident time "1630" [4:30 pm], the record did not contain any documentation that the parent or guardian was notified of the incident.

D. Record review of P1's medical record, the document titled "Treatment Plan Review-Inpatient", dated 05/03/2024, time 9:30 am, revealed the record did not contain any references to the 04/14/2024 incident. P1's parent signature box states "Participated via phone"; with the parent's quote "I want him to reduce thoughts and behaviors of self-harm". P1's parent does not appear to be aware of the incident causing an injury to P1's right hand.

E. Record review of P4's medical record, the document titled "[facility initials] Nursing Notes", dated 04/28/24 time "2100" (9:00 pm), revealed "[name of P4] reported sexual inappropriate touch by [name of other child] three days in a role [sic]. Appropriate measures taken to address this issue and it was reported to Dr. [name of physician]." The record did not contain any documentation that the parent or guardian was notified of the incident.

F. Record review of the facility's Incident Log dated 01/01/24 through present, revealed an incident number 24-117046, involved P4, type of incident "Sexual Boundary Verbal/Physical Non-Aggressive Breach" "No injury" incident date "04/28/2024" incident time "2100" (9:00 pm): "Pt reported that [name of other child] has been 'smacking him in the buttock 3 days in a row'. [They] said it started after some of the girls on the unit mentioned that [they] has a nice buttocks. It was reported to me by [name of employee] because [they] witnessed it." The record did not contain any documentation that the parent or guardian was notified of the incident.

G. Record review of P4's medical record, the documents titled "Treatment Plan Review-Inpatient", revealed a treatment plan dated 04/24/2024 wet signed by the parent; and a treatment plan dated 04/26/2024 verbally signed by the parent. There was no treatment plan update following the 04/28/2024 incident. The record did not contain any documentation that the parent or guardian was notified of the incident. P4 was discharged on 05/01/2024.

H. During an interview with Staff (S)2 Facility Risk Manager, S2 confirmed that the parent or guardian should be notified of any changes in a minor patient's condition, any incident or illness, and it should be documented in the nursing notes.