HospitalInspections.org

Based on review of Pt #3's medical record, policy/procedure for the multidisciplinary treatment plan, and staff interview, it was determined the hospital failed to provide an opportunity for Pt #3's Mental Health Power of Attorney (MHPOA) to be included in the development of the multidisciplinary treatment plan.

Findings include:

Pt #3 was admitted on 02/25/12 with dementia and increasing agitation.

Consent for Admission was signed by the daughter / MHPOA and documents were in the medical record confirming the daughter had MHPOA. The Mental Health Power of Attorney Statutory Form was signed, dated, witnessed and notarized on 07/14/05. According to the Clinical Evaluator's Intake Assessment dated 02/25/12 at 1420, the MHPOA was to sign for admission documentation/consents for treatment. According to the Quality Director the intake professional determines if the patient needs to have someone else sign for admission.

The Interdisciplinary Treatment Plan was developed on 02/26/12. The signature line on the form for the patient/family involvement was not signed by the MHPOA. A social worker's note dated 03/03/12, indicated the daughter (MHPOA) would like to stay informed of the changes to the patient's care.

The hospital's policy titled Treatment Plan dated 06/30/09 and revised 11/2011, required: "...The treatment team shall establish a plan for involvement of the family and/or significant others when appropriate...The patient and/or family, if indicated, signs the Treatment Plan after review with a member of the treatment team...The Treatment Plan shall be reviewed and updated as frequently as clinically indicated...but a minimum, the treatment plan is to be reviewed weekly...."

On 08/17/12 at 1630 the Director of Quality confirmed the treatment plan did not have an update according to the requirements of the policy, nor did the treatment plan document involvement with the family (MHPOA).

According to the patient's multidisciplinary treatment plan the patient's MHPOA/family did not sign the treatment plan to indicate their involvement with the development of the plan.

On 08/21/12, the DON confirmed the MHPOA/family were not apprised of the treatment plan and included in the development of the plan.