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Based on interviews, record review, and review of facility policies, it was determined that the State Guardian was not allowed to make an informed discussion regarding care for one (1) of three (3) patients (patient #1).

The findings include:

A review of the medical record for patient #1 was conducted on October 26, 2010. Patient #1 was admitted to the facility on January 21, 2010, as a direct admission to the fourth floor medical surgical unit. The medical record revealed no evidence that consent was obtained from the State Guardian for patient #1's treatment/admission to this facility. Further review of the medical record revealed patient #1 received intravenous antibiotics and wound care treatment for an ulcer to the patient's right foot. Patient #1 was discharged from the facility on January 24, 2010, and transported by ambulance back to a local nursing facility where the resident resided. There was no evidence found that the State Guardian was notified of the patient's admission, treatment, or discharge.

A telephone interview was conducted on October 26, 2010, at 5:15 p.m., with the Admission Nurse, who did not remember patient #1 but did know that consent should have been obtained from the State Guardian for patient #1's admission. The Admission Nurse stated, "I assumed the clinic staff had notified the State Guardian to get permission to admit the patient."

A telephone interview was conducted on October 26, 2010, at 1:45 p.m., with the Discharge Nurse, who did not remember patient #1 but stated consent should have been obtained for patient #1's admission. The Discharge Nurse stated the State Guardian was normally called when a patient was discharged but the nurse did not always document the call. The Discharge Nurse added that the State Guardian was hard to reach at times.

The DON stated in interview on October 26, 2010, at 10:15 a.m., that admission/treatment consents were to be obtained on every patient admitted. The DON stated that if a patient had a State Guardian then the Admitting staff was required to call the State Guardian and get permission to treat/admit the patient. The DON gave no explanation why the State Guardian was not contacted regarding patient #1's admission on January 21, 2010.

An interview was conducted with the Performance Improvement (PI) Coordinator on October 26, 2010, at 3:30 p.m. The PI Coordinator stated the facility had a monitor in place to track State Guardian notification and the tracking was at 100 percent for the past six months so the monitor was dropped by the PI committee. The PI Coordinator stated patient #1 "fell out" most likely because the patient was a direct admission from the clinic.

On October 26, 2010, during a review of the facility policies, the policy for consent for treatment was also reviewed. No problems were identified.

Refer to: 902 KAR 20:016, Section 3.(11)(d)1.