HospitalInspections.org

Based on record review, interview, and observation, the facility failed to ensure the rights of two of seven patients (Patient #5, #4) to participate in the development and implementation of his or her plan of care.

1) Patient #5 had been hospital evaluated for a fractured right foot in addition to his admitting diagnoses of Alcohol Dependence and Major Depressive Disorder. The patient complained of pain. Patient #5 was not involved in his care plan decisions until surveyor inquiry five days into the patient's hospitalization.

2) Patient # 4 had been admitted with psychiatric and medical diagnoses. For at least eight days into his treatment there was no evidence that the patient was involved in his treatment care plan.

Findings included:

1) Patient #5 was surveyor observed on 05/16/17 at 1305. Patient #5 was limping and showed the surveyor his swollen right ankle. Patient #5 stated at that time that he had surgery on his right ankle and "it had not healed right." The patient complained of pain.

Patient #5's Psychiatric Evaluation dated 05/11/17 reflected Patient #5's 05/10/17 admission date. Diagnoses included Alcohol Dependence and Chronic Right Foot Pain Issues.

Patient #5's History and Physical Exam dated 05/11/17 reflected a previously fractured right heel.

Record review of Patient #5's treatment plan on 05/17/17 at 1415 did not reflect a patient signature.

Personnel #5 acknowledged the above findings at that time.

2) On 05/17/17 at 1135, Patient #4 was surveyor observed to have difficulty understanding spoken comments.

Patient #4's Integrated Assessment dated 05/09/17 reflected the patient had a hearing loss and staff was encouraged to "talk loud to patient."

Personnel #16 stated on 05/15/17 at approximately 1137 that Patient #4 was "deaf in his right ear after a car accident."

Record review of Patient #4's treatment plan dated 05/12/17 at 1630 reflected diagnoses including Altered Mood, Hypertension (high blood pressure), and Benign Prostatic Hyperplasia. The line evidencing Patient #4's participation in the treatment plan was left blank.

Personnel #12 acknowledged the finding on 05/17/17 at approximately 1137.

Record review of Hospital Policy POC 139 titled Provision of Care, Treatment, and Services dated 03/2013 reflected that patients "have the right to be involved in all aspects of the patient's care...[and] the right to take part in the development of an individualized treatment plan for his/her hospitalization..."