HospitalInspections.org

Based on document review and interview, the facility failed to communicate patient's plan of care and failed to have authorization for treatment completed on 1 out of 10 (P7) medical records reviewed.

Findings Include:

1. Facility policy titled, "Patient Rights and Responsibilities" PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient's care and to participate in the development and implementation of your plan of care.

2. Review of P7's medical record lacked documentation of notification to patient's family of the plan of care as follows:
a. P7 initial treatment care plan/treatment plan, no contact was made to POA through out P7 stay with progress updates.

3. Interview with A5 (Licensed Clinical Social Worker, Director of Clinical Services) on 06/11/2024 at approximately 1455 hours confirmed P7 medical record lacked documentation of notification to patient's family of initial care plan/treatment plan.

Based on document review and interview, the facility failed to have authorization for treatment completed on 1 out of 10 (P7) medical records reviewed.

Findings Include:

1. Facility policy titled, "Admission of Patients (IN)", PolicyStat ID 12508272, Patients or their designees (POA/Guardian) must sign a voluntary consent and authorization for treatment during the admission process. This policy was last revised in 12/2021.

2. Review of P7's MR indicated that the authorization for treatment had not been completed by P7 or the POA.

3. Interview with A3 (Director of Nursing) on 06/11/2024 at 1500 hours confirmed that the authorization for treatment had not been completed by P7 or the POA for this hospital stat at F1.