HospitalInspections.org

Based on record review and interviews, the facility failed to ensure the patient and his or her representative the right to make informed decisions regarding his or her care in 1 out of 10 sample patients (SP) #1.


The findings:

Review of sampled patient (SP) #1 Discharge Summary showed he brought in by EMS (ambulance), screaming and with agitated behavior. He apparently was not taking his medications for an unknown amount of time. Patient was Baker Act on arrival. Patient admitted for close observation, hydration and psych (psychiatric) eval (evaluation). Psych (Psychiatrist) recommended psychiatric unit.

Record review of the Multidisciplinary Progress Notes electronically signed by MSW ( Master of Social Work) on 11/6/2017 at 2: 31 PM, the SW placed a call to Guardian to inform her of patient admission. Guardian is aware and is in agreement with the plan. The SW requested a copy of the guardianship paperwork for the patient. At 2:44 PM, SW received copy of guardianship paperwork via fax.

Review of the Multidisciplinary Progress Notes of the LCSW (Licensed Certified Social Worker) showed on 11/10/2017 at 11: 21AM, a call was placed to the guardian, voicemail full, unable to leave message. At 12:45 PM, the mother called back asking about consents.

Review of the SP#1 consents showed that the consents has a note showing the patient is "unable to sign".

The notes showed SP#1 was accepted at the receiving facility on 11/10/2017 at 4:32 PM.

Review of the Multidisciplinary Progress Notes on 11/12/2017, of the Case Manager showed that the physician accepted SP #1 at the receiving hospital. At 7:39 PM, the Registered Nurse notes showed SP #1 was a baker act discharge to the receiving hospital.

Review of the Multidisciplinary Progress Notes on 11/13/17 of the Registered Nurse/ Case Manager revealed that she provided the Guardian (mother) with the receiving hospital information after patient was discharged (transferred) on 11/13/2017.


Interview with Supervisor of Patient & Guest Services on 12/19/2017 at 10:00 AM revealed that a call came from the Mother/ Guardian the day after the patient was transferred/ discharged to another hospital. The guardian expressed her concerns. I forwarded her concern to the Supervisor of Case Management/ Social Worker.


Interview with the Registered Nurse/ Case Manager on 12/19/2017 at 10:40 AM revealed that she was called by Patient & Guest Services to call the Guardian. I called and I gave her the information about the receiving hospital. She further stated that we do not have to wait for the Legal Guardian in order for us to proceed with transfer.