HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure that parents and legally authorized representatives of minor patients were notified of each meeting in a manner that allowed them to participate actively in the treatment planning for 4 of 4 minor patients (Patients #5-7 and #9). In addition, the justification for a lack of participation in treatment planning by parents for each of the patients was either non-existent or was not supported by facility policy.

Findings were:

Facility policy #1800.5 entitled "Right of Family / Guardian to Participate in Treatment," last reviewed 5/18, included the following:
" ...The involvement of the family / guardian throughout the course of the patient's treatment begins at admission and continues throughout treatment ...
3. Therapy staff are responsible for:
3.1 Arrangements for the family's involvement with the treatment.
3.2 Maintaining regular communication with the family in regard to the patient ..."

Facility policy #1000.77 entitled "Treatment Planning," last revised 4/2018, included the following:
" ...An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be initiated, reviewed and updated by the interdisciplinary Treatment Team with patient and parent/guardian/family member participation (as appropriate) on a regular basis during the course of treatment ...
8. The involvement of the family/guardian throughout the course of the patient's treatment begins at admission, continues throughout treatment and discharge. Patients and parents/guardians/ family members are strongly encouraged to participate in treatment team meetings, as patient and parent/guardian/family member input into treatment objectives and goals are valuable in planning the patient's course of treatment and aftercare. The clinical service staff member will schedule for treatment team meetings. Parent/guardian/family members may participate in the MTP (master treatment plan) or TPR (treatment plan review) meeting via conference telephone call if unable to attend in person."

Facility policy #1800.4 entitled "Patient Participation in Care Decisions," last reviewed 6/18, included the following:
" ...3. Each program will hold interdisciplinary treatment plan review meetings to review patient progress and determine future goals: ...
3.3 The patient and parent / guardian are invited to be present and participate with the treatment team in the review and evaluation of his/her plan, as appropriate.
3.4 The attending Physician/Clinician or Program staff will review the treatment plan with the patient and/or family after, or during each treatment review meeting or when unanticipated changes in treatment conditions occur.
3.4.1 Staff will document patient and parent/guardian involvement/review and agreement or disagreement with the treatment plan on the treatment plan form and/or in the medical record.
3.4.2 Staff will document additional patient involvement/discussion in the treatment notes section of the patient's chart.
3.5 Dependent minor patients and their parents/guardians are expected to be involved in the treatment planning process as noted above ..."

Facility policy #1800.1 entitled "Patient Bill of Rights and Responsibilities," last revised 11/16, included the following:
" ...4. Treatment team will plan each patient's care based on individual needs, strengths, and assets.
4.4. Patients and families, guardians, and other resources will be included in the patient care planning, as appropriate ..."

The treatment team of Patient #6 completed her Interdisciplinary Master Treatment Plan on 1/4/19. At the meeting on 1/4/19, the mother of Patient #6 was documented to be " ...unable to participate (reason): distance to hospital ..." It was noted that the social worker reviewed the plan with the mother by telephone 15 minutes later that same day. On 1/10/19, a special problem added to the plan read as follows: " ...[Patient #6] is being placed on SAOP (sexually acting out precautions) due to inappropriate sexual contact with a peer ..." For this update, Patient #6's mother was documented to be " ...unable to participate (reason): distance to hospital ..." It was again noted the social worker reviewed the plan with the mother 15 minutes after the meeting had occurred.

The treatment team of Patient #7 initiated an Interdisciplinary Master Treatment Plan on 1/8/19. The team updated her treatment plan on 1/10/19 and again on 1/14/19. The only documented notice made to a family member of a treatment plan meeting was for the meeting on 1/8/19. The record of Patient #7 included no documented evidence of other notifications having been made to family members regarding treatment team meetings. Also, for the updates above, there was no documented evidence of parent or guardian participation at all. There was no reason documented as to why they were unable to participate.

A review of the record of Patient #5 revealed a Master Treatment Plan was initiated on 1/11/19. A note on the plan read simply " ...Legal representative is unable to review in person ..." Updates to her treatment plan were made on 1/18/19 and on 1/25/19. The updated plans included no documented evidence of parent/guardian involvement. The record of Patient #5 also included no page noting parental notifications for treatment plan meetings.

The multidisciplinary treatment plan of Patient #9 included a note regarding parental involvement as follows: "Unable to participate (reason): distance to hospital ...Legal representative is unable to review in person ...[names of parents] message left, neither parent available to discuss treatment plan ..." The record of Patient #9 included updates to the treatment plan on 1/28/19 and 1/31/19. On 1/31/19, the updated plan included the following reason for a lack of parent involvement as "distance to hospital ..." An update to the plan on 2/8/19 again included no parental participation with the following reason: "distance to hospital ..." The record of Patient #9 also included no page noting parental notifications for treatment plan meetings.

The above reasons noted as "distance to hospital" did not address the facility policy that parents or legally authorized representatives of patients may participate by telephone.

In an interview with Staff #16, clinical case manager and therapist, in the administration meeting room on the afternoon of 4/2/19, she stated, " ... We reach out to the parents and let them know there will be a meeting. If they can't be here in person, we'll do the meeting over the phone. Parents or family are always notified of treatment goals ..."

Based on interview and record review, the facility failed to ensure a discharge summary was completed in a timely manner.

Findings included:

Review of Patient #2's medical chart on 4/2/19 revealed he was admitted on 1/23/19 and discharged on 1/31/19, but was missing a discharge summary.

In an interview on 4/2/19 at 10:54 am, Staff #2, Director of Risk Management stated the discharge summary for Patient #2 was still in Staff #15's (physician) inbox and not yet completed. He stated Medical Records Department are supposed to keep track for delinquent reports on a monthly basis.

Review of facility provided police titled Incomplete Record Notification and Suspension (Policy Number: 1400.27) with reviewed date of 05/18 reflected "Medical Records are to be completed within 30 days of discharge ... a complete record is one in which the attending physician/clinician has competed and authenticated the psychiatric evaluation, history and physical exam, and discharge summary."