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HARSHA BEHAVIORAL CENTER INC
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on document review and interview, the facility failed to communicate medication changes and discharge information to parent/guardian in 1 of 10 MRs reviewed (patient #6).
Findings include:
1. Policy #CS1055, Communication Protocol, last reviewed 01/2019, indicated: It is the policy to communicate with families, guardians and treatment providers regarding the care of patients. Procedure: Care Coordinators will give updates to families regarding progress in treatment, discharge and placement. Nursing staff will communicate with the physician on call, the chief nursing officer and guardians regarding the following: (including) g. Psychotropic medication changes in youth. Attempt to communicate should be made within 24 hours of the incident (change) occurring.
2. Policy #CS190, Discharge of Patients, Communication Protocol, last reviewed 8/16/2018, indicated: Procedure: The family/guardian will be notified of the discharge order. Care Coordinators will notify the parent/guardian as to why the patient is being discharged/transferred.
3. Policy #AP210, Child and Adolescent Rights, (no review date listed), indicated:
A. Consent: The child or adolescent has the right to have his/her mother, father or guardian give informed consent for any treatment to be performed as manifested by the following rights:
(1.) including to having his/her mother, father or guardian involved in decisions involving his/her health care.
B. Transfer and Continuity of Care; to have mother, father or guardian informed by the practitioner for any continuing health care requirements.
4. MR of patient #6 lacked documentation that an increase in a psychotropic medication, was communicated to family member #1.
5. MR of patient #6 lacked documentation that the discharge was communicated to family member #1 or that he/she was involved in decision to discharge patient back to PRTF.
6. Although staff member #2, Chief Nursing Officer, indicated in interview that if a psychotropic medication dosage is changed, we don't need to get consent.