HospitalInspections.org

Based on record review and interview, facility staff failed to involve the patient's support person with medical decision making when the patient was unable to, for 1 of 10 inpatients (Patient #1) out of a total universe of 10 medical records reviewed.

Findings include:

Review of the facility policy, titled "Patient Rights and Responsibilities, AW" last reviewed on 3/14/2020, revealed: "Procedure: 4. Participate in the development, implementation, and revision of their plan of care, treatment and services, and the involvement of family, with permission. Make informed decisions and provide consent about their care, treatment and services, unless they are unable to. Except in emergencies, patient consent or the consent of the patient representative shall be obtained before treatment is administered ...9. Identify someone to make decisions for the patient if/when the patient cannot make decisions about their care, treatment or services, as permitted by law. Prepare and/or revise advance directives or instructions about the patient's medical treatment, to appoint a decision maker, and to have staff comply with these directives, as permitted by law."

Review of Patient #1's medical record revealed: Physician progress notes, completed from 12/30/2021 through 1/11/2022 documented that Patient #1 was confused and/or delirious on the following dates: 1/1/2022, 1/2/2022, 1/3/2022, and 1/6/2022 with no documentation of family update or involvement in medical care decisions.

During an interview on 3/1/2022 at 1:30 PM, Hospitalist H stated, "I don't automatically call all my patient's family. Ideally, the nurse will let me know if the family has questions, then I will call."

During an interview on 3/1/2022 at 2:15 PM, Nurse Manger (NM) F stated, "We don't have a specific policy regarding updating patient's family." When asked where do nurses and doctors document updating family, NM F stated, "I would expect to see a narrative note." NM F stated, "We (facility staff) chart by exception, so we only do a narrative note for something not captured in our nursing flow sheets."