HospitalInspections.org

The hospaital failed 1 of 1 Patient, Patient #1 by failing to allow patient #1 to Participate, in the development and implementation of her Treatment Plan of care.

Findings Include:

Through interview with Staff #3, Patient #1 did not participate in the Treatment Plan. Records indicate the hospital completed an Initial Treatment Plan, at admission which Patient #1 signed all initial consents. Patient #1's Master Treatment Plan was also generatated, and it was not presented and signed by Patient #1 prior to discharge. Patient #1 was an inpateint in the hospital for 96 hours. By Policy the Patient has 72 hours to sign the Treatment Plan.

Through Record Review Patient #1 Treatment Plan was found in the medical record. The record revealed patient participation was not present or guardian participation was not present. The record also revealed that the documentation was not signed.

Policy
The hospital Patient Rights Policy dated 02/1/17 reflected, "This facility fully supports, endorses and enforces the rights of patients. This facility informs each patient, patient's guardian /or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements."

The hospital Treatment Plan Policy dated 12/2020 reflected, "It is the policy of the Wellbridge Healthcare to provide an organized and systematic process to plan and patient care ...PATIENT/GUARDIAN/CARETAKER INVOLVEMENT:
i: Following the initial meeting ...The patient is given an opportunity to report his/her reason for admission, goals of treatment, and interventions felt to be supportive to recovery. The patient then signs the ITP following this discussion.
b. When a patient has a legal guardian, the social worker shall attempt to coordinate communication with 72 hours with the guardian to discuss the ITP and elicit the guardians signature.