HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 5 (Pt. #1, #6, and #8) clinical records reviewed, the Hospital failed to ensure the patients and/or families were informed of their health status.

Findings include:

1. On 05/18/2021, at 9:30 AM the Hospital's policy titled, "Patient Rights," (reviewed 04/2020) was reviewed and included, " ...The Hospital has mechanisms in place to ensure the following: A) The right to participate in the development of his/her plan of care. B) ...The patient's rights include being informed of his her health status, being involved in care planning and treatment and being able to request or refuse treatment ..."

2. On 05/18/2021 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted 01/27/2021 at 3:43 PM with a diagnosis of syncope (sudden temporary loss of consciousness) and was discharged on 02/03/202021 at 1:42 PM. The Nurses Note dated 01/29/2021, at 6:28 PM included, " ...Son contacted writer requesting his mother/pt. (Pt. #1) to be discharged ...explained no discharge order. Pt's son stating he is concerned due to (MD #1-Attending Physician) not returning any of his calls ...Will page MD #1 regarding pt's son's request and nursing supervisor made aware of son's concerns ..."The clinical record for Pt. #1 failed to include documentation from MD #1 that plan of care, patient condition and diagnosis were discussed with Pt. #1 and/or family.

3. On 5/18/2021 at approximately 11:00 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 5/3/2021 with diagnosis of dysphasia (difficulty with swallowing). The Physician's (MD #1) Progress notes dated 5/5/2021 through 5/8/2021 were reviewed and lacked documentation that MD #1 discussed with Pt. #6 and/or family patient condition, diagnosis, and treatment plan.

4. On 5/18/2021 at approximately 11:15 AM, the clinical record of Pt. #8 was reviewed. Pt #8 was admitted on 5/14/2021 with a diagnosis of Pneumonia (infection in lungs). The Physician's Progress notes dated 5/15/2021 through 5/17/2021 were reviewed and lacked documentation that (MD #1) discussed with Pt. #8 and/or family the patient's condition, diagnosis, and treatment plan.

5. On 5/18/2021 the Hospital's Patient Grievance Log from 12/1/2020 through 5/18/2021 was reviewed. There was a Grievance listed for Pt. #1 regarding concerns with Attending Physician's (MD #1) communication.

6. On 5/19/2021 at 10:15 AM an interview was conducted with MD #1. MD #1 stated, "I communicated with (Pt. #1's) son 2-3 times ...I informed the son that (Pt. #1) had an acute MI (Myocardial Infarction-Heart Attack) and I declined to transfer the patient because she was not stable for transfer... MD #1 stated, "I told the son about her diagnosis...I did not document well..." MD #1 was asked about documentation for Pt. #6 and #7, and MD #1 stated that he did not document his discussions about his findings and or treatment plans. MD #1 stated that he should document this information in the clinical record.