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Based on document review and interview, the facility failed to include family in the patient's plan of care in 1 of 10 patient medical records reviewed (Patient 6).

Findings Include:

1. Review of policy titled, "Patient Rights and Responsibilities", PolicyStat ID 15601140, last approved 05/2024, under Procedure: 8. Patients and families, guardian and other resources will be included in the planning of patient care as appropriate.

2. Review of Patient 6's medical record indicated patient was court ordered to be admitted to facility due to having been deemed incompetent to stand trial. Patient's initial psychiatric evaluation indicated patient 6 parents were his/her primary support. MR lacked documentation of communication with patient's family regarding the patient's plan of care and indicated Family Member #1 was patient's contact and support person.

3. Interview with A2 (Chief Operating Officer) on 06/24/2024 at approximately 2:45 p.m. confirmed that patient 6's chart lacked documentation of communication with family regarding patient's plan of care.

4. Interview with S1 (Licensed Mental Health Counselor) on 06/24/2024 at approximately 3:40 p.m. confirmed patient 6 was a participant in a jail based program to restore competency of jailed patients with serious mental health issues. S1 confirmed that patient had a mental health diagnosis of Schizophrenia, had previously been a patient at this facility, had the same rights as all patients, and had the right to have family participate in the treatment plan. S1 confirmed that they had not spoken to any family member regarding the patient's treatment plan.