HospitalInspections.org

A. Based on review of one (1) of one (1) medical record, document review and staff interview, it was determined that the facility failed to ensure that an informed consent to treat is obtained.

Findings include:

Reference: Facility policy titled "Informed Consent" states, "Objective: Ensure that each Buttonwood Behavioral Health (BBHH) patient (or health care proxy/power of attorney) is provided with information on [sic] which make decisions about their care and treatment. Procedure: 1) Informed consent for medical treatment shall be obtained as part of the admission process. The patient' [sic] informed consent will be documented in the patient's medical records. 2) In the event that the patient is unable to provide informed consent, informed consent will be obtained from the patient's designated health care proxy or power of attorney. ...4) The consent provides authorization for the physicians/practitioners to order medical treatment."

1. Review of Medical Record #1 revealed the following:

a. Patient #1 was admitted to the facility on 12/2/21.

b. There was no evidence that an informed consent for medical treatment was obtained.

c. This finding was confirmed by Staff #5.

B. Based on review of one (1) of one (1) medical record , staff interview and document review, it was determined that the facility failed to ensure that the Power of Attorney (POA) is involved in the patient's care and treatment.

Findings include:

Reference: Facility policy titled "Comprehensive Care Planning" states, "...A Comprehensive Treatment Plan (CTP) is crucial to successful treatment philosophy. All patients, and when appropriate, patients' families have a right to be informed of, and participate in, decisions regarding treatment. ...13. Treatment plans are updated as needed and/or through weekly meetings with the intention of re-evaluating and revising the plan based on assessment of the patient's clinical condition, problems, and response to treatment. ...Family members are invited and strongly encouraged to attend. ..."

1. Review of Medical Record #1 on 1/4/22 revealed the following:

a. A treatment team meeting was held on 12/13/21, 12/20/21 and 12/27/21. There was no evidence that the POA was invited to the treatment team meetings.

b. The Medical History & Physical, dated 12/3/21 states, "...Plan...need neuro [neurology] f/u [follow up] on disch [discharge]..."

c. A nursing note, dated 12/19/21 at 10:39 PM states, "____[name of caller] called nursing station to ask nursing if ____[first name of patient] will be going to [his/her] appointments. Nursing referred [him/her] to UM [unit manager] voicemail and informed [him/her] someone can get back to [him/her] with the information tomorrow. ..."

(i) There was no evidence that the facility followed up and kept the POA informed of Patient #1's care/treatment.

2. On 1/4/22 at 12:42 PM, Staff #4 confirmed that there was no follow up with the POA regarding the off site neurology appointment.

Based on medical record review, staff interview and document review, it was determined that the facility failed to ensure that its visitation policy is followed and the policy as the facility's practice changes, is updated.

Findings include:

Reference: Facility policy titled, "Visiting Hours" states, "...Procedure: 1) Visiting hours are from 9:00AM to 10:00AM and 7:00PM to 8:00PM daily. ...The "Visitor Orientation Guidelines" is sent to family members when a power of attorney or guardian has been identified or upon family's visit. ..."

1. Upon review of Medical Record #1 on 1/4/22, the following was revealed:

a. Patient #1 was admitted on 12/3/2021 and had a Power of Attorney (POA).

b. There was no evidence that the "Visitor Orientation Guidelines" were provided to the POA.

c. A Social Work Progress note written on 12/28/21 at 1:25 PM states, "Mother left a telephone message regarding virtual visitation for family and patient. Program does not have a system in place to provide virtual visitation, therefore this would need to be discussed with administration. ..."

(i) There was no evidence that there was a follow up with Patient #1's POA regarding the virtual visit request.

d. Upon interview on 1/4/22 at 12:20 PM, Staff #4 stated that in-person visitation has been restricted since March 2020 and has not resumed since that time. Staff #4 also stated that virtual visits were available.

(i) The above referenced policy states "...revised: ... 4/22/20." The policy failed to reflect the facility's practice that visitors were not permitted and also failed to address virtual visitation.

2. These findings were confirmed by Staff #4 and Staff #5.