HospitalInspections.org

Based on policies and procedures, review of documentation and staff interview, the department determined that the facility did not document any communication with the legal guardian regarding the patient's health conditions. This poses a potential risk that the legal guardian is unable to make informed decisions regarding care for the patient.


Findings include:

Policy titled: "Routine & Critical Labs" (05/2020), revealed: "...personnel will immediately notify the nursing staff regarding critical lab results...The nurse will contact the patient's attending physician or physician on call within 30 minutes of receipt of the critical result...."

Policy titled: "Confidentiality" (May 2020), revealed: "...Specific information about a patient cannot be communicated to anyone without consent of the patient or individual authorized to give consent...."

Policy titled: "CORE: Identification of Appropriate Legal Representative, Including Guardian Involvement" (06/2021), revealed: "...recognized the right of all competent adults to make decisions( such as giving or withholding informed consent). Legally recognized representatives, including court-appointed guardians, conservators or other representatives recognized under state law may also act on the patient's behalf when the patient is unable to make decisions...."

Policy on Legal Guardian Notification was requested but not received.

Policy on COVID-19 Testing was requested but not received.


Patient #1 presented to the facility on 12/18/2020 for evaluation/treatment of delusions and hallucination. This was an involuntary admission. The patient/guardian signed consent for treatment, and receipt of Patient Rights & Responsibilities. The patient received an initial assessment to include a psychiatric evaluation. The patient discharged from the facility on 02/10/2021.

Employee #4 confirmed during an interview conducted on 06/23/2021, that the patient tested positive for COVID-19 on 12/29/2020, 12/31/2020, 01/24/2021 and on 01/27/2021. The results for the 01/30/2021 test is not in the medical record. The patient tested negative for COVID-19 on 02/10/2021. Additionally, Employee #4 revealed there is no legal guardian notifications in the medical record regarding any test results. The expectation is that the guardian be notified of all test results.

Employee #3 confirmed during an interview conducted on 06/24/2021, that the medical record does not have any record of the legal guardian being notified of COVID-19 test results. Additionally, Employee #3 revealed the facility's expectation is the legal guardian be notified of all test results.