HospitalInspections.org

Based on facility policy review, medical record review and staff interview, the facility failed to ensure patients and/or their designated representative were informed and updated regarding the treatment plan, changes in condition or discharge plans for four of ten sampled patients (Patients #1, #2, #4, and #5). The facility's census was 35.

Findings include:

Review of the facility policy titled, Treatment Plans, revision date 05/2018, revealed procedures included active participation of the patient and/or legal guardian, POA (power of attorney). Documentation in the policy revealed updates would be provided with the development and any changes to the treatment plan, and the signature of the patient or representative on the treatment plan would serve to signify their awareness and understanding.

Review of the facility policy titled Scope of Service, effective date 04/01/2018, revealed those included in the treatment planning process include the patient, physician, social worker, nursing, activity therapist, and when appropriate the patient's family, caregivers or other significant support system. Review of the section for Discharge and Post Discharge Planning Process revealed discharge criteria and expected length of stay are established upon admission, but reviewed and revised as necessary. The social worker assists in discharge planning and includes family, as indicated, and communication with other providers to promote continuity of care. Review of the section Progress Notes revealed the notes "clearly document the course of treatment for the patient and family" and include "(9.) family/ caregiver involvement in treatment planning and intervention," documentation in the progress notes.

Review of the facility policy for Discharge Planning, Policy # NU.62, effective 06/15/16 and revised 07/09/2017, revealed the social worker or registered nurse facilitate discharge planning by (section b. subtext v.) "notifying patient and family of the date transfer will occur with patient's consent."

1. Review of the medical record for Patient #1 revealed a stay at the facility from 07/01/19 to 07/05/19 for treatment of change in behavior, and increased aggression. Patient #1 had a history of depression and dementia, widowed and residing in an assisted living facility. The patient was admitted to the psychiatric hospital for stabilization and safety. Review of the facility complaint log revealed Patient #1's representative contacted the facility patient advocate on 07/18/19 with a concern about not having any information about the plan to discharge Patient #1. Review of a 07/05/19 discharge note, revealed no notification of the patient's discharge was documented.

Review of Patient #1's treatment plan dated 07/01/19 revealed concerns had been identified with behavior including aggression, fall risk, cognitive deficits affecting activities of daily living, and a physical function decline for which therapy was assessing. Review of the signature page for the treatment plan revealed neither Patient #1's representative nor Patient #1 had been informed of the plan.

2. Review of the medical record for Patient #2 revealed a stay at the facility from 05/31/19 to 06/11/19 for treatment of major depressive disorder and visual hallucinations. Review of a treatment plan dated 06/07/19 revealed the facility had identified concerns including a need for medication changes, a nutrition deficit, blood pressure management, and behavioral health related to anxiety. There was no patient nor patient representative signature or documentation of their notification. Review of the facility complaint log revealed on 06/03/19 Patient #2's family complained they were unaware of the planned treatment for Patient #2. The facility's patient advocate contacted the family to address the concerns, but no documentation on the treatment plans indicated their involvement.

3. Review of the medical record for Patient #4 was completed on 08/27/19. Patient #4 was admitted to the facility on 06/13/19 with manic behavior and increased aggression. Review of the patient's medical record revealed Treatment Plan Reviews dated 06/28/19, 07/03/19, and 07/08/19 that were not signed by the patient, nor was it documented the patient refused to sign.

4. Review of the medical record for Patient #5 was completed on 08/28/19. The patient was admitted to the facility on 06/21/19 with a chief complaint of confusion and depression, and the patient was discharged on 07/05/19. The patient had a POA.

Patient #5 had a fall by rolling out of bed on 06/25/19. Review of the Post Fall Evaluation revealed the physician was notified. A voicemail was left with the patient's POA, but no documentation was found or provided as to whether there was any follow up to the voicemail message left for the POA regarding the fall.

Patient #5 had incomplete Treatment Plan Reviews not signed by the patient or clinicians involved. The Multidisciplinary Treatment Plans for the patient did not include the signatures of the patient or the patient's POA.

A physician order by telephone for the patient's discharge was received on 07/05/19 and a progress note was completed by the registered nurse on 07/05/19. The progress note revealed the patient was to be discharged from the facility that morning via ambulance. The discharge paperwork was given to the patient, according to the progress note. The progress note lacked evidence the POA was contacted regarding the patient's discharge from the facility.

The findings regarding the lack of documentation of patient and/or patient representative in regard to the patients' treatment plans and collaborative communication about the progress, including discharge plans were confirmed in an interview with Staff A, B, C and D on 08/28/19 at 12:12 PM.

This deficiency substantiates Substantial Allegation OH00105952.

Based on facility policy review, medical record review and staff interview, the facility failed to ensure patients and/or their designated representative were informed and updated regarding medication changes, especially administration of psychiatric medications which required informed consent for four of ten sampled patients (Patients #1, #2, #4, and #5). The facility census was 35.

Findings include:

Review of the facility policy titled Informed Consent for Medication, Policy Stat ID 5993145, revised 05/2018, revealed the "signature shall be dated, timed and signed by the person witnessing the legal representative's signature" and section 3. (h) date and time of the informed consent form is signed by the patient or patient's legal representative, (j) signature and professional designation of person witnessing the consent.

1. Review of Patient #1's medication administration record revealed there were medications that required informed consent including Seroquel (antipsychotic), Trazadone (sedative and antidepressant), Namenda (cognition enhancing medication), Depakote (anticonvulsant), and Aricept (cognition enhancing medication). Review of the facility's medication consent form for Patient #1 revealed a time was documented at 12:54 PM, and Patient #1's representative's (power of attorney/POA) name was written on the form and a nursing signature for witnessing the POA's verbal acknowledgement for the medication consent. The form had no date documented. Review of the medication administration record (MAR) revealed Patient #1 received medications requiring informed consent on 07/01/19, 07/02/19, 07/03/19, and 07/04/19.

2. Review of the medical record for Patient #2 revealed a stay at the facility from 05/31/19 to 06/11/19 for treatment of major depressive disorder and visual hallucinations. Review of Patient #2's medication consent and medication administration record revealed the medication consent record had two dates, 05/31/17 and 05/31/18, and the patient's signature. Review of the consent documentation revealed medications including Donepzil (cognition enhancing medication), Risperdal (antipsychotic), Ativan (anti-anxiety), and Trazadone (sedative and antidepressant) required consent. Review of the medication administration record (MAR) dated 05/31/19 to 06/09/19 revealed Patient #2 received medications including Benztropine (antitremor), Risperidone (antipsychotic), Donepezil, and Lorazepam (sedative), which required informed consent per documentation on the MAR.

3. Review of the medical record for Patient #4 was completed on 08/27/19. Patient #4 was admitted to the facility on 06/13/19 with manic behavior and increased aggression. Review of the medical record revealed the patient was given Lithium (antipsychotic) 300 mg by mouth twice daily on 06/14/19, 06/15/19, and 06/16/19 before the Medication Consent was signed on 07/03/19.

4. Review of the medical record for Patient #5 was completed on 08/28/19. The patient was admitted to the facility on 06/21/19 with a chief complaint of confusion and depression, and the patient was discharged on 07/05/19. The patient had a Power of Attorney (POA).

Review of Patient #5's medication list upon admission included Paxil 40 mg (antidepressant) and Lamictal 200 mg (prevent and control seizures). A physician order dated 06/25/19 revealed to stop Paxil and start Risperdal 0.5 mg (antipsychotic) by mouth twice a day and Zoloft 50 mg (antidepressant) by mouth daily. A physician order dated 07/01/19 revealed a verbal telephone order to increase the Risperdal to 1 mg by mouth twice a day and Zoloft to 100 mg by mouth daily, but the medical record lacked documentation the POA was updated regarding the increase of dosages. A medication consent was signed by the patient on 06/21/19 for Trazodone (antidepressant), but the patient's POA did not sign the consent, nor was there documentation the POA was notified of the medication. The medication was given on 06/25/19, 07/01/19, and 07/03/19.

The findings regarding the lack of documentation of patient and/or patient representative in regard to informed consent was confirmed in an interview with Staff A, B, C and D on 08/28/19 at 12:12 PM.

This deficiency substantiates Substantial Allegation OH00105952.