HospitalInspections.org

Based on a review of clinical records and facility documentation, the facility failed to protect the patient's right to participate in the development and implementation of his or her plan of care.

Findings were:

During a review of the clinical record for patient #1, the multidisciplinary treatment plan did not contain the patient's signature and gave no indication as to why she was not involved in the development of her treatment plan.

Facility policy titled "Multidisciplinary Treatment Planning Process" states, in part:
"Policy Statement
...The treatment plan is explained to, understood by, and responded to by the patient and/or legal guardian and so documented. In the event that a patient refuses or does not have the capacity to understand or be involved in the treatment planning process, documentation in the medical record reflects this as well ..."

The above was confirmed in an interview with the Medical Director and other administrative staff on the afternoon of 11-16-17.

Based on a review of the clinical record and facility documentation, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

Findings were:

During a review of the clinical record for patient #1, the observation sheets lacked the co-signature of the registered nurse on duty for 19 of the 21 days of the patient's stay.

Facility policy titled "Precaution Levels - Assessment" states, in part:
"Key Points
...
7. The Charge RN [registered nurse] is responsible for assuring that all patient observations are completed and documented by a member of the nursing staff. The Charge nurse will cosign the 'precautions sheet.'..."

During a review of the clinical record for patient #1 (whose stay spanned 9-5-17 through 9-25-17), it was noted that the patient's treatment plan was not reviewed during her stay. The record contained a multidisciplinary plan formulated 9-5-17 and no reviews thereafter.

Facility policy titled "Multidisciplinary Treatment Planning Process" states, in part:
"Procedure
...
Treatment plans are completed during the daily team rounding meetings. During treatment plan reviews, each member of the treatment team comments on patient progress/lack of progress toward goals and make suggestions as to the need for goal/intervention changes. Treatment plan reviews are completed weekly (7 days) during the remainder of the patient's hospitalization."

The above was confirmed in an interview with the Medical Director and other administrative staff on the afternoon of 11-16-17.