HospitalInspections.org

Based on record review, policy review, and staff interview it was determined that the facility failed to involve the patient's legal guardian in the revisions of the patient's plan of care for one (#3) of three patients sampled. This practice does not ensure the patient's legal guardian full participation in their treatment.


Findings include:

Review of patient #3's medical record revealed the patient was admitted to the facility on 7/12/10 with the diagnosis of schizoaffective disorder in acute exacerbation. Review of the documentation in the medical record revealed the patient had a plenary guardian appointed by the court. The facility's policy "The Multidisciplinary Treatment Plans", dated 2/09, states the Treatment Plan is a dynamic tool which will reflect any significant changes in the patient's status. Evaluation is a continuous process of appraising clinical interventions and treatment on the mental health status and expected outcomes. The policy further states if the patient has a guardian they will be asked to sign, date, and time the treatment plans and be given a copy. If they are unavailable, the coordinator will be notified to mail a copy of them to the appropriate representative. Review of the initial Treatment Plan revealed the plan was completed and presented to the guardian on 7/14/10 as evidenced by the guardian's signature dated 7/14/10 and timed 6:40p.m. Subsequent Treatment Plans II dated 7/15/10, 7/21/10, 7/27/10, 7/29/10, 8/05/10, and 8/12/10 were not signed by the guardian. Review of the physician, nursing, therapist and social workers notes revealed no documentation the Treatment Plans were discussed with the guardian and no documentation copies of the Treatment Plans were mailed to the guardian. Interview with the assistant clinical director on 8/13/10 at 1:55 p.m. confirmed the patient's treatment plans should be signed by the guardian following each update plan.