HospitalInspections.org

Based on record review and interviews, the facility failed to involve a patient's legal guardian in the ongoing treatment plan and decisions in one of two medical records reviewed of patients with legal guardians (Patient #1).

Findings include:

Facility policies:

The Informed Consent Policy read, the patient or his/her representative (as allowed under State law) has the right to make informed decisions regarding his/her care. Consent is informed when the person giving consent is fully aware of the: specific treatment, reason for treatment or procedure, attendant risks versus benefits, alternatives, right to ref, use, consequences associated with consent or refusal of the program. Informed consent shall include, but not be limited to, the following: An explanation of the recommended treatment or procedure in layman's terms and in a form of communication understood by the patient or the patient's legal representative.

The Personal Representative policy read, it is the facility policy to treat a personal representative of a patient as the patient, if the law requires and if the personal representative has authority under applicable law, to act on behalf of the patient with respect to Protected Health Information (PHI) and in making decisions related to health care. The facility will recognize the following individuals as the personal representative of a patient with respect to disclosure of PHI: A person with legal authority to make healthcare decisions on behalf of a patient who is an adult or an emancipated minor (examples: healthcare power of attorney, court-appointed legal guardian, general power of attorney).

1. The facility failed to involve a patient's legal guardian in the ongoing treatment plan and health care decisions.

A. Record review

a. Review of Patient #1's medical record revealed the patient was admitted to the facility on 4/13/22. The record revealed Patient #1 had an existing legal guardian temporarily granted prior to admission and then permanently granted by the court on 5/17/22. On 6/9/22, a monthly interdisciplinary treatment team meeting was held. The guardian attended the meeting virtually and informed the facility team he had been appointed guardianship. On 7/7/22, another monthly interdisciplinary treatment team meeting regarding Patient's treatment plan was held. There was no evidence that Patient #1's legal guardian was notified of or invited to participate in the meeting or provided an update by the care team before or after the meeting.

On 9/7/22, another interdisciplinary treatment team meeting was held. There was no evidence in the medical record that Patient #1's legal representative was notified of the meeting or invited to participate.

b. A review of email communications between the guardian and Psychiatrist #2 was provided by social worker (SW) #1 and revealed on 9/7/22 Psychiatrist #2 provided an email update on Patient's #1's treatment plan to the guardian. On 9/9/22, the guardian emailed Psychiatrist #1 and wrote he not been notified of or invited to the treatment team meeting held on 9/7/22 and found out about it through a third party who had spoken to Patient #1 on the phone. He wrote he should be included and notified of medical legal or treatment team meetings for Patient #1. On 9/9/22 Psychiatrist #1 replied to the guardian's email and apologized that the team mistakenly neglected to include the guardian during the 9/7/22 treatment team meeting.

B. Interviews

a. An interview with social worker (SW) #1 was conducted on 10/25/22 at 8:51 a.m. SW #1 stated guardians were expected to be notified of treatment team meetings by the patient's social worker. She further explained if a guardian was not able to attend a treatment team meeting, it was expected for a member of the team to update the guardian about the patient's treatment plan either via phone or email. She stated if a guardian was contacted and provided an update via phone or email, the practice was to place a note in the patient's medical record regarding the communication.

In reviewing Patient #1's medical record, SW #1 was unable to find evidence of communication with the guardian regarding treatment updates or the treatment team meeting held on 7/7/22. In further review of the treatment team meeting held on 9/7/22, SW #1 stated she was unable to find any documentation in the medical record that the guardian was notified of or invited to participate in the meeting. She stated she could not find any notes in the medical record that the guardian was provided an update from the facility, but stated she recalled email exchanges between the guardian and the facility after the treatment team meeting.

b. An interview with Psychiatrist #2 was conducted on 10/25/22 at 10:21 a.m. Psychiatrist #2 stated treatment team meetings were held weekly for the first two months after a patient's admission and held on a monthly basis after two months. He stated if a patient's family was involved in the care, they would be invited by the patient's social worker to join the meetings virtually. Psychiatrist #2 stated there were several changeovers of the assigned social workers for Patient #1 over the past summer, resulting in gaps in communication with the guardian. He stated he mistakenly forgot to include the guardian in a treatment team meeting and the guardian emailed him after the meeting was held. Psychiatrist #2 stated he replied to the guardian's email and provided an update on the patient's progress and treatment at that time.

Psychiatrist #2 stated guardians should be consulted for changes in treatment and be asked for their input and discuss the treatment options with the team. He further stated the risk to a legal guardian not being involved in a patient's treatments was that patients could consent or sign up for something they did not understand.