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Based on document review, record review and staff interview it was determined the hospital failed to ensure the patient/decision maker was provided the right to participate in the post-op care of the patient in one (1) of ten (10) records reviewed (patient #1). This failure has the potential to negatively impact patient care.

Findings include:

1. Review of a 1/17/17 security report revealed the charge nurse directed security to remove the caregiver/decision maker for patient #1 from the unit.

2. Interview with the Charge Nurse on 3/20/17 at 1:36 p.m. revealed she indicated the caregiver/decision maker for patient #1 had been loud and uncooperative due to a concern over the handling of one (1) of the patient's home medications. She confirmed the caregiver/decision maker was removed from the unit by security after giving the medication to the Attending Physician. The caregiver/decision maker was banned from the patient's unit until 7:00 a.m. the next day.

3. Interview with the Attending Physician on 3/21/17 at 9:30 a.m. revealed the caregiver/decision maker was concerned about the security of a home medication. He stated she gave him the medication in question and he was unaware she was removed from the unit afterwards. The Physician stated he considered the issue resolved after he received the medication. He also stated he did not observe behavior from the caregiver/decision maker that required her removal from the unit.

4. Review of the clinical record for patient #1 revealed no nursing documentation related to discussion of home medication concerns with the caregiver/decision maker or any steps taken to address the issue. The nursing staff failed to document anything relative to the medication issue or the removal of the patient's caregiver/decision maker from the nursing unit.

5. The above record was reviewed with the Nurse Manager at 2:00 p.m. on 3/21/17. She acknowledged the clinical record lacked any nursing documentation related to the removal of the caregiver/decision maker or what lead up to the removal. She confirmed the expectation is that no caregiver/decision maker would be removed from the patient care unit without documentation of just cause for removal.

Based on document review, record review and staff interview it was determined the registered nurse failed to supervise and document nursing interventions and patient/care giver/decision maker's response to issues regarding home medication in one (1) of ten (10) records reviewed (patient #1). This failure has the potential to negatively impact patient care.

Findings include:

1. Review of a 1/17/17 security report revealed the charge nurse directed security to remove the caregiver/decision maker for patient #1 from the unit.

2. Interview with the Charge Nurse on 3/20/17 at 1:36 p.m. revealed she indicated the caregiver/decision maker for patient #1 had been loud and uncooperative due to a concern over the handling of one (1) of the patient's home medications. She confirmed the caregiver/decision maker was removed from the unit by security after giving the medication to the Attending Physician. The caregiver/decision maker was banned from the patient's unit until 7:00 a.m. the next day.

3. Interview with the Attending Physician on 3/21/17 at 9:30 a.m. revealed the caregiver/decision maker gave him the medication in question and he was unaware she was removed from the unit afterwards. He stated he considered the issue resolved after he received the medication. He also stated he did not observe behavior from the caregiver/decision maker that required her removal from the unit.

4. Review of the clinical record for patient #1 revealed no nursing documentation related to discussion of home medication concerns with the caregiver/decision maker or any steps taken to address the issue. The nursing staff failed to document anything relative to the medication issue or the nursing interventions attempted relative to the issue or removal of the patient's caregiver/decision maker.

5. The above record was reviewed with the Nurse Manager at 2:00 p.m. on 3/21/17. She acknowledged the clinical record lacked any nursing documentation related to the removal of the caregiver/decision maker or what lead up to the removal. She confirmed the expectation is that nursing staff would document all patient/decision maker concerns and all nursing interventions taken to address and resolve issues, prior to a decision for removal of a decision maker.