HospitalInspections.org

Based on review of facility documents, record review, and family and staff interview, the Critical Access Hospital (CAH) failed to inform the patient and/or family representative of their health status, the right to be involved in care planning and treatment, and the right to make informed decisions regarding their care, as allowed under state law, for 1 of 20 closed Emergency Department (ED) records reviewed (Patient #11). Failure to inform patient and/or family representatives of their health status limited their ability to exercise their rights.

Findings include:

Review of the "Patient Information" booklet occurred on 05/07/25. The "Patient Information" booklet, page 11, stated, ". . . You have the right to participate in the development and implementation of your plan of care. You or your representative have the right to make informed decisions regarding your care, including being informed of your health status, being involved in care planning and treatment, and being able to request or refuse treatment. . . ."

Review of Patient #11's medical record occurred on 05/07/25. The medical record showed the patient as a minor child and a family member appointed as patient representative. Diagnoses included anxiety, depression, and suicidal ideation. Law enforcement had transported Patient #11 to the ED on 03/27/25 for assessment of suicidal ideation. The medical record showed the patient admitted to the ED after contact with the patient's representative for consent to treat. The facility's plan included a transfer of the patient to an appropriate acute facility. ED facility staff placed the patient on 1:1 supervision.

A nurse's note, dated 03/27/25 at 1:56 p.m., stated, "Patient left AMA [against medical advice] at 1:20pm [sic] and reported [patient] was headed to [patient representative's] house. Law enforcement was contacted and they will attempt to locate . . ." The record lacked documentation facility staff contacted Patient #11's representative when the patient left the facility.

During an interview on 05/07/25 at 11:35 a.m. the patient's representative confirmed the facility requested consent to treat and transfer the patient to an appropriate acute hospital, and the representative's agreement to both. The representative confirmed notification from law enforcement when Patient #11 left the facility, but no notification from the facility.

During an interview on 05/07/25 at 1:00 p.m. an administrative nurse (#1) confirmed the medical record lacked documentation the facility notified the representative when Patient #11 left the facility.

The CAH failed to inform the representative of a change in the patient's status which limited the representative's ability to exercise the right to request or refuse treatment for the patient.