HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 patient (Pt. #1) clinical record reviewed for care planning, the hospital failed to ensure that Pt. #1's representative participated in the development of the care plan.

Findings include:

1. The hospital provided a document titled, "Rights of Individuals Receiving Mental Health and Developmental Disabilities Services" (undated) was reviewed and included, "Medical/Dental Services: Except in emergencies, no medical or dental services will be provided to you without informed consent."

2. On 07/17/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 due to increasing aggression. The clinical record included the following:

-Medicine Progress Notes (MD #2) dated 07/07/24, included, "I was called to evaluate (Pt. #1) complaining of toothache. Patient is pointing to right upper molar tooth. Problem/Assessment: Toothache" The clinical record did not include documentation that (MD #2) or nursing staff contacted (Pt. #1's) mother regarding tooth infection and treatment with oral antibiotics.

-Physicians' orders, dated 07/07/24, "Acetaminophen (pain medication) 500 mg (milligrams) by mouth every 6 hours as needed for pain. Amoxicillin (antibiotic) 500 mg oral every 8 hours by mouth for tooth infection for 7 days."

3. An interview was conducted with the Attending Physician (MD #2) on 07/18/24 at 9:20 AM. MD #2 stated that MD #2 was called to evaluate (Pt. #1) several times for different reasons including a toothache. MD #2 stated that it is protocol to contact the parent or guardian to inform of any change in condition and treatment plan including tooth infection with plan to treat with antibiotics. MD #2 stated that MD #2 did not call the parent, and assumed that the nursing staff would call to update (Pt. #1's) mother.