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Based on interview and record review, the facility failed to ensure a patient's representative was included in the patient's plan of care for 1 of 10 patient clinical records reviewed, Patient #1, as evidenced by failing to notify the patient's representative for Patient #1 when there was a change in condition necessitating the treatment and plan of care to be altered.

The findings include:

Review of the facility's policy titled, Plan for Provision of Care states in part, 'The facility has a process in place to assess, refer, transfer or discharge the patient to meet their health care needs as they make the transition from one level of care to the next. This process identifies the patient needs and the type and amount of service to be rendered. Communication for the coordination of care is facilitated through family, physician and nursing care and case management.

On 06/08/16 at approximately 3:00 p.m. a side by side electronic clinical record review was conducted with the facility Director of Infomatics.

Review of the clinical record for Patient #1 revealed an admission date of 04/26/16 to the medical/surgical telemetry unit with a diagnosis of urinary tract infection. Further review of the clinical record revealed the patient's status was stable until there was a change in her condition on 04/28/16 at 10:15 p.m. when the Registered Nurse (RN) documented in the clinical record the patient's blood pressure was low. The RN contacted the physician and on 04/28/16 at 11:44 p.m. orders were received to hold all blood pressure medications. Review of the clinical record revealed no evidence of documentation this change was communicated to the patient's family representative.

Further review of the clinical record revealed the RN reassessed the patient again on 04/29/16 at 1:12 a.m. and the blood pressure remained significantly lower than her baseline blood pressure for the past 2 days. The physician was again notified and an order received on 04/29/16 at 1:20 a.m. to transfer the patient to the cardiovascular intensive care unit (CVICU). Patient #1 was transferred to the CVICU on 04/29/16 at 2:15 a.m. to a higher level of care. Review of the clinical record revealed no evidence of documentation this continued change of health status requiring a higher level of care in the CVICU was communicated to the patient's family representative by the medical/surgical telemetry RN.

Further review of the clinical record revealed documentation the patient's condition rapidly declined in the CVICU and on 04/29/16 at 2:30 a.m. required the initiation of cardiac and respiratory life support. Review of the clinical record revealed no evidence of documentation the patient's decline in health status was communicated to the patient's family representative by the CVICU RN.

On 06/08/16 at approximately 3:30 p.m. a request was made to the Director of Infomatics to provide evidence of documentation Patient #1's family representative was informed of the patient's change in condition to which she replied 'It looks like the nurses did not document any communication with the family.'

On 06/09/16 at approximately 10:30 a.m. the Risk Manager stated they have checked the patient's record and could not find any documentation Patient #1's family representative was notified of the changes in condition and transfer to a higher level of care.

On 06/09/16 at 11:35 a.m., in the presence of the Assistant Chief Nursing Officer (ACNO) an interview was conducted with a RN on the medical/surgical telemetry unit and an inquiry was made if there was a change in patient condition or the patient required the transfer to a higher level of care when would she notify the patient's family representative to which she replied once the situation was stabilized she would notify the family of any changes right away at any time of the day or night.

On 06/09/16 at approximately 11:40 a.m. a side by side electronic clinical record review was conducted with the Nurse Manager of the medical/surgical telemetry unit in the presence of the ACNO. After accessing three different electronic documentation data bases for clinical records, she was unable to provide any evidence of documentation Patient #1's family representative was notified of the changes in condition by any staff member of the medical/surgical telemetry unit or the CVICU. While scrolling through scanned documents in one electronic data system the Nurse Manager came across the Cardiopulmonary Flow Sheet dated 04/28/16 at 2:30 a.m. which documented on the bottom of the page with an X the 'Family Notified' however there is no time, date or name of person notified of the change in the patient's condition. The ACNO acknowledged at this time that information was missing.

On 06/09/16 at 12:05 p.m. an interview was conducted with a RN on the medical/surgical telemetry unit and an inquiry was made if there was a change in patient condition or the patient required the transfer to a higher level of care when would he notify the patient's family representative to which he replied he would notify the family representative of any general changes in patient status and when the patient was stabilized or transferred. He further stated 'I would want to know if something was happening with my family.'

On 06/09/16 at 12:10 p.m. an interview was conducted with the CVICU Manager who stated the family would be notified of any changes in patient status once the condition was stabilized and the notification would be documented in the patient's record.

On 06/09/16 at 12:13 p.m. an interview was conducted with a RN in the CVICU who stated they would notify a patient's family of any changes in condition such as vital signs or mental status, any cardiac arrests or transfers to a lower level of care. He stated they would document the communication in the clinical record.

On 06/09/16 at approximately 2:00 p.m. an exit conference was conducted with the Risk Manager, Chief Medical Officer, Assistant Chief Nursing Officer, Emergency Room Director and Interim Chief Nursing Officer. The Interim Chief Nursing Officer acknowledged and confirmed Patient #1's family representative was not notified of the changes in the patient's condition in a timely manner and review of the clinical record revealed a physician progress note dated 04/29/16 at 10:00 a.m. documenting a discussion was held with Patient #1's family representative. In review of the clinical record it could not be determined how the family representative came to learn of the patient's sudden decline in health status with one possibility the family came to visit the patient on the medical/surgical telemetry unit and was informed the patient was transferred to the CVICU overnight.

Further review of the facility policy titled Plan for Provision of Care states in part under Patient Assessment, 'The patient's significant other or caregiver is included as appropriate during the initial assessments/reassessments.'

Based on interview and record review, the facility failed to ensure a patient's representative was included in the patient's plan of care for 1 of 10 patient clinical records reviewed, Patient #1, as evidenced by failing to notify the patient's representative for Patient #1 when there was a change in condition necessitating the treatment and plan of care to be altered.

The findings include:

Review of the facility's policy titled, Plan for Provision of Care states in part, 'The facility has a process in place to assess, refer, transfer or discharge the patient to meet their health care needs as they make the transition from one level of care to the next. This process identifies the patient needs and the type and amount of service to be rendered. Communication for the coordination of care is facilitated through family, physician and nursing care and case management.

On 06/08/16 at approximately 3:00 p.m. a side by side electronic clinical record review was conducted with the facility Director of Infomatics.

Review of the clinical record for Patient #1 revealed an admission date of 04/26/16 to the medical/surgical telemetry unit with a diagnosis of urinary tract infection. Further review of the clinical record revealed the patient's status was stable until there was a change in her condition on 04/28/16 at 10:15 p.m. when the Registered Nurse (RN) documented in the clinical record the patient's blood pressure was low. The RN contacted the physician and on 04/28/16 at 11:44 p.m. orders were received to hold all blood pressure medications. Review of the clinical record revealed no evidence of documentation this change was communicated to the patient's family representative.

Further review of the clinical record revealed the RN reassessed the patient again on 04/29/16 at 1:12 a.m. and the blood pressure remained significantly lower than her baseline blood pressure for the past 2 days. The physician was again notified and an order received on 04/29/16 at 1:20 a.m. to transfer the patient to the cardiovascular intensive care unit (CVICU). Patient #1 was transferred to the CVICU on 04/29/16 at 2:15 a.m. to a higher level of care. Review of the clinical record revealed no evidence of documentation this continued change of health status requiring a higher level of care in the CVICU was communicated to the patient's family representative by the medical/surgical telemetry RN.

Further review of the clinical record revealed documentation the patient's condition rapidly declined in the CVICU and on 04/29/16 at 2:30 a.m. required the initiation of cardiac and respiratory life support. Review of the clinical record revealed no evidence of documentation the patient's decline in health status was communicated to the patient's family representative by the CVICU RN.

On 06/08/16 at approximately 3:30 p.m. a request was made to the Director of Infomatics to provide evidence of documentation Patient #1's family representative was informed of the patient's change in condition to which she replied 'It looks like the nurses did not document any communication with the family.'

On 06/09/16 at approximately 10:30 a.m. the Risk Manager stated they have checked the patient's record and could not find any documentation Patient #1's family representative was notified of the changes in condition and transfer to a higher level of care.

On 06/09/16 at 11:35 a.m., in the presence of the Assistant Chief Nursing Officer (ACNO) an interview was conducted with a RN on the medical/surgical telemetry unit and an inquiry was made if there was a change in patient condition or the patient required the transfer to a higher level of care when would she notify the patient's family representative to which she replied once the situation was stabilized she would notify the family of any changes right away at any time of the day or night.

On 06/09/16 at approximately 11:40 a.m. a side by side electronic clinical record review was conducted with the Nurse Manager of the medical/surgical telemetry unit in the presence of the ACNO. After accessing three different electronic documentation data bases for clinical records, she was unable to provide any evidence of documentation Patient #1's family representative was notified of the changes in condition by any staff member of the medical/surgical telemetry unit or the CVICU. While scrolling through scanned documents in one electronic data system the Nurse Manager came across the Cardiopulmonary Flow Sheet dated 04/28/16 at 2:30 a.m. which documented on the bottom of the page with an X the 'Family Notified' however there is no time, date or name of person notified of the change in the patient's condition. The ACNO acknowledged at this time that information was missing.

On 06/09/16 at 12:05 p.m. an interview was conducted with a RN on the medical/surgical telemetry unit and an inquiry was made if there was a change in patient condition or the patient required the transfer to a higher level of care when would he notify the patient's family representative to which he replied he would notify the family representative of any general changes in patient status and when the patient was stabilized or transferred. He further stated 'I would want to know if something was happening with my family.'

On 06/09/16 at 12:10 p.m. an interview was conducted with the CVICU Manager who stated the family would be notified of any changes in patient status once the condition was stabilized and the notification would be documented in the patient's record.

On 06/09/16 at 12:13 p.m. an interview was conducted with a RN in the CVICU who stated they would notify a patient's family of any changes in condition such as vital signs or mental status, any cardiac arrests or transfers to a lower level of care. He stated they would document the communication in the clinical record.

On 06/09/16 at approximately 2:00 p.m. an exit conference was conducted with the Risk Manager, Chief Medical Officer, Assistant Chief Nursing Officer, Emergency Room Director and Interim Chief Nursing Officer. The Interim Chief Nursing Officer acknowledged and confirmed Patient #1's family representative was not notified of the changes in the patient's condition in a timely manner and review of the clinical record revealed a physician progress note dated 04/29/16 at 10:00 a.m. documenting a discussion was held with Patient #1's family representative. In review of the clinical record it could not be determined how the family representative came to learn of the patient's sudden decline in health status with one possibility the family came to visit the patient on the medical/surgical telemetry unit and was informed the patient was transferred to the CVICU overnight.

Further review of the facility policy titled Plan for Provision of Care states in part under Patient Assessment, 'The patient's significant other or caregiver is included as appropriate during the initial assessments/reassessments.'