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Based on interview and record review, the facility failed to ensure the rights of a patient's guardian to participate in the plan of care, as evidenced by the facility not involving or notifying the guardian for change of condition for 1 of 1 patient (Patient #1).

Findings included:

Record review of Patient #1's nursing progress notes dated 11/16/22 at 7:00 am showed that he got into a physical altercation with a peer on 11/15/22 and hit his hand on a wall. He later complained to nursing that his right thumb hurt. X-rays were ordered by Internal Medicine Dr.-Staff #5 on 11/15/22 at 3:00 pm and were performed in the facility that day by the contracted company Trident Mobile X-ray. Critical Results of X-ray findings showing right thumb fracture was reported to the facility. Dr-Staff #5 was notified and subsequently ordered the patient to be transferred to the emergency room.

Additional review of Patient #1's clinical records failed to show that the patient's guardian, his mother, was informed of the patient's injury or was notified that the patient was ordered to be transferred to the emergency room. There was no indication the mother was allowed to participate in the patient's plan of care for his thumb injury. Per complaint, the mother found out about the patient's injury when she appeared at the facility on 11/16/22 to pick up the patient for routine discharge. There was no indication in the record to the contrary. An ambulance which was to transfer the patient to the emergency room appeared in the facility lobby at the same time the mother did, but the mother refused to allow the patient to be transferred, informing the facility she would be bringing the patient elsewhere.

In an interview on 12/30/22 at 11:00 am, Staff #3 stated the patient's mother was never informed of the injury and about the plans to transfer the patient to the emergency room.