HospitalInspections.org

Based on record review, facility document review and interview, the facility failed to allow adolescent patient's parents or legal guardians participate actively in the development and review of an individualized treatment plan.

Findings included:

Facility Based Policy titled "Treatment Team Planning" date revised 7/14 stated in part, "The Master Treatment Plan involves input from all disciplines and the patient and/or family. All patients will be encouraged to participate in their treatment planning ...
Procedure:
...3. The case manager will consult the patient and/or family for input and involvement in the treatment team plan. When a patient is unable to make decisions about his or her care, treatment and services, the hospital involves a surrogate decision-maker in making these decisions in accordance with law and regulations ...
5. The treatment team along with the patient will complete the Master Treatment Plan within seventy-two hours of admission. When clinically appropriate, the family and/or guardian will be invited to attend staffing.
6. The case manager will document during Treatment Team meetings on the Master Treatment Plan and/or the Treatment Plan review update the discussion.
7. All disciplines, the patient, and/or family will sign completed Master Treatment Plan and on the Treatment Team Update Form, indicating their agreement and involvement. "

Review of patient #5's clinical record revealed a treatment plan without parent/guardian approval. Patient, an adolescent, and staff signed on 9/4/15. Interdisciplinary note stated in part, "Called mom during treatment team - no answer." Discharge flow sheet revealed several conversations in which guardian was called regarding discharge planning, but no notes existed related to treatment planning.

During an interview on the afternoon of 4/5/16, the above was confirmed with the Risk Manager.