HospitalInspections.org

Based on document review and interview the facility failed to ensure protection of patient rights related to the right of patients and/or family members to participate in their treatment/plan of care in 4 (N5, N6, N9, N10) of 10 closed medical records (MR) reviewed:

Findings include:

1. Policy/procedure, Patient Rights and Responsibilities, 704.02, revised/reviewed 1/18 indicated on page 2: "A patient or his/her representative has the right to make informed decisions regarding his/her care. This includes being informed of health status, being involved in care planning/treatment, and being able to request medically necessary treatment".

2. Policy/procedure, Right of Family/Guardian to Participate in Treatment, 704.06, revised/reviewed 1/18 indicated: "Clinical services staff are responsible for: arrangements for the family's involvement with the treatment. Maintaining a regular communication with the family in regard to the patient. Ensuring family participation, involvement and acknowledgement of treatment plan. Facilitating family therapy and guardian participation in treatment".

3. Review of Interdisciplinary Master Treatment Plan dated 10/8/18 lacked documentation related to F2's involvement and/or acknowledgment of treatment plan. Review of patient N5's MR lacked documentation of F2's participation in family sessions and/or communication with facility staff regarding patient N5's care and treatment.

4. Review of patient N6, N9 and N10's MR lacked documentation of a family session and/or communication regarding the patient's treatment plan with family/support individuals.

5. On 11/14/18 at approximately 1430 hours, staff P4 (Director of Clinical Services) was interviewed and confirmed patient N5's MR lacked documentation of family participation/involvement in the patient's care planning and lacked documentation of communication between facility staff and F2 regarding the patient's care.