HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure the rights of patients to make informed decisions regarding their care for 3 out of 4 sampled patients.

Findings include:

Record review of clinical record of patient #1 revealed he was a 53 year old male admitted to the facility on 11/25/17 with the diagnoses of Major Depressive Disorder, recurrent, severe, Suicidal Ideations, Sedative, Hypnotic or Anxiolytic dependency, Atherosclerotic Heart disease, Hypertension, Type II Diabetes, and Intervertebral Disc Degeneration and Displacement. Further record review failed to reveal signed consent forms for the psychotropic drugs Librium and Sertraline. In addition, record review of the Medication Administration Records (MAR) revealed Patient #1 had been receiving both these medications while residing as a patient in the facility.

Record review of Patient #2's clinical records revealed he was a 47 year old male admitted to the facility on 12/23/17 with the diagnoses of Schizoaffective Disorder, bipolar type, Gential Herpes, Neuropathy, and Chronic Pain. Further review revealed patient had not signed a consent form for the psychotropic drug Depakote. In addition, further review of the patient's MAR revealed he was administered this drug while residing as a patient in the facility.

Record review of Patient #3's clinical records revealed the was a 54 year old female admitted to the facility on 5/22/18 with the diagnosis of Bipolar Disorder, current episode-depression. Further review revealed the patient had not signed a consent form for the psychotropic drug Trazadone. In addition, the patient's MAR reveal she had been administered this drug while residing at the facility.

In an interview on 7/17/18 during various times of record review with CNO-Staff #55, she stated that these patients should have had signed consent forms in their charts.

Record review on 7/17/18 at time of survey of facility's "Patient's Bill of Rights" policy (no date) stated: "Care and Treatment.....26. You have the right to be told about the care, procedures, and treatment you will be given: the risks, side effects, and benefits of all medications and treatment you will receive...........27. You have the right to receive information about the major types of prescription medications which your doctor orders for you (effective May 1, 1994)".

Based on observation, interview, and record review, the facility failed to ensure that nursing staff developed a nursing care plan for 1 out of 10 patients sampled.

Finding include:

Record review of clinical record of Patient #1 revealed he was a 53 year old male admitted to the facility on 11/25/17 with the diagnoses of Major Depressive Disorder, recurrent, severe, Suicidal Ideations, Sedative, Hypnotic or Anxiolytic dependency, Atherosclerotic Heart disease, Hypertension, Type II Diabetes, and Intervertebral Disc Degeneration and Displacement. Review of Intake Assessment notes, dated 11/25/17 (author unknown) under the heading of "Clinical Summary" ( page 10 of 11) revealed patient wanted to "end his pain he would end his life". In addition, it stated "he (the patient) is experiencing a lot of pain in the back, reported #15 surgeries..."

Further record review failed to reveal that the patient's chronic back pain was addressed in a Nursing Care Plan.

Interview on 7/17/18 during record review of Patient #1's clinical chart with CNO staff #55, revealed she stated that the patient's back pain should have been addressed in a Nursing Care Plan, which was absent from the chart.

Record review of facility's policy called "Patient's Bill of Rights" (not dated) states "....25. You have the right to a treatment plan for your stay in the hospital that is just for you".

Review of regulatory requirements under requirement §482.24, in summary, states that nursing care planning starts upon admission and is a medical records requirement. It includes planning the patient's care while in the hospital. A nursing care plan is based on assessing the patient's nursing care needs. The plan develops appropriate nursing interventions in response to the identified nursing care needs.