HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure 11 (#6-#9, #11, #12, #14, #6, and #18-#20) of 20 (#1-#20) patients were given the opportunity to participate in the planning of their care. The failed practice did not allow the patient to express their needs or desires for the care provided. The failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. In an interview with the Director of Nursing/Risk Manager on 03/26/12 at 1400, when asked how the patient indicated their participation in the plan of care, she stated the patient would sign the "Master Treatment Plan". She stated if the patient was unable to sign or participate in their plan of care the interdisciplinary team would document the reason on the Master Treatment Plan.
B. Review of the Master Treatment Plans for Patient #6-#9, #11, #12, #14, #6 and #18-#20 revealed the patient signature lines were blank. There was no evidence of the reason why the lines were blank.
C. The findings were confirmed in an interview with the Director of Nursing/Risk Manager on 03/26/12 at 1400.