HospitalInspections.org

Based on document review and interviews, the facility failed to actively include the patient's representative in the development and implementation of the plan of care in one of two medical records reviewed of patients who had been deemed incapacitated and provided a court-appointed guardian (Patient #1).

Findings include:

Facility policy:

According to the facility policy Informed Consent for Medications, it is the responsibility of the physician to inform, educate and obtain consent either verbally or in writing from the patient or guardian. Information provided to the patient will include expected actions, risks, and benefits of the medication. The nurse gives the same information to the guardian as is given to the patient. When the guardian is not available and telephone consent is obtained the following shall occur: Notation shall be made on the education sheet, "telephone consent for the following medications obtained from (guardian name) on (date)." A second licensed staff member will witness the phone approval of the guardian. The nurse or physician will follow the process when medications are changed or added to those medications for which the patient or as appropriate conservator/guardian had given consent. Licensed nursing staff member, physician, or pharmacist will supply the patient or conservator/guardian with benefit/risk information about the new education.

1. The facility failed to notify the court-appointed guardian of medication changes for a patient who had been deemed unable to make medical decisions.

a. A review of Patient #1's medical record was conducted on 10/18/22. The review revealed a Letter of Guardianship from the Denver Probate Court dated 1/26/22 designating Patient #1 as an incapacitated person whose needs could not have been met by less restrictive means than a court-appointed guardian (guardian). Patient #1 had been diagnosed with schizoaffective disorder, bipolar type (a medical condition in which a patient experienced delusions, hallucinations, depression, and manic periods of high energy). The Letter of Guardianship read she was unable to evaluate or communicate any decisions related to her care. The document designated a guardian through the Colorado Office of Public Guardianship (OPG).

The Letter of Guardianship granted the guardian the authority to consent to medical/surgical care and treatment. It also contained a personalized letter to the facility that identified a list of when the guardian should have been contacted for consent. This list included contacting the guardian to consent for medications to be administered.

i. The medical record indicated Patient #1 had been hospitalized at the facility for 17 days beginning on 9/20/2022. It included a document titled Social Services Note, signed by Therapist #1, which indicated he had communicated with Patient #1's guardian six days after the date of her admission regarding discharge plans, items the guardian wanted to provide to the patient, and social history. The facility provided emails between Therapist #1 and the OPG that indicated he had communicated with the OPG office twice more. The first email was sent 10 days after Patient #1's admission; the second was sent 13 days after her admission. The emails did not include a discussion on Patient #1's medications.

ii. The medical record also contained a Medication Education and Consent Form with a list of Patient #1's medications. The Form was dated 10/4/22, which was fourteen days after Patient #1 was admitted. Under item 10, "written information on the medications list was given to:", a handwritten notation indicated verbal information had been given. On the line labeled patient/guardian signature was the word "verbal." The form did not include notations the guardian had been contacted. The form had been signed by Nurse Practitioner (NP) #2. NP #2 also signed on the line that was indicated for a witness signature.

There was no evidence in the medical record that Patient #1's guardian was notified to provide consent for medications to be administered throughout the patient's stay at the facility.

b. On 10/19/2022 at 2:02 p.m., an interview was conducted with NP #2. NP #2 was shown the Medication Education and Consent Form from Patient #1's medical record. She verified she had signed the form and that the written notations indicated she had given verbal information to the patient regarding the medications.

NP #2 stated guardians were the ultimate decision makers regarding treatment and medication changes, and that medication changes needed to be approved by the guardian. She stated she remembered Patient #1 was a difficult case, with the need for many different kinds of medications. She stated she had not communicated with Patient #1's guardian.

This was in contrast to the facility policy Informed Consent for Medications, which gave the provider (nurse practitioner or physician) responsibility for informing, educating, and obtaining consent from the patient or guardian. The policy required the provider to educate the patient or guardian on the expected actions, risks, and benefits of the medication. In the instance a guardian was not physically present in the facility, telephone consent should have occurred. Notation should have been made on the education sheet of the guardian's name and the date of contact. A second licensed staff member should have witnessed the phone approval of the guardian.

c. On 10/19/22 at 1:16 p.m., an interview was conducted with Case Manager (CM) #3. CM #3 stated she had been assigned to work on outpatient care for Patient #1. CM #3 stated facility staff communicated with guardians so the guardian understood what the patient needed after discharge and could ensure patients took medications safely. She said facility staff should have communicated with the guardian for a change in the patient's condition or anything that happened after the last update. She further said if the patient had been deemed to need a guardian the facility should have been in full communication. CM #3 stated she believed communication with guardians was done by therapists and clinical staff. She stated she had not personally communicated with Patient #1's guardian.

d. On 10/19/2022 10:45 a.m., an interview was conducted with Therapist #1. Therapist #1 stated guardians should have been updated daily from either a therapist, case manager, doctor, or registered nurse. He explained daily communication was important so the guardian knew if patients were improving or not, and so guardians could provide information to the facility as they knew patients better than facility staff. He further explained communication from the facility helped guardians follow up with appointments and provide other support for patients. Therapist #1 said communication with guardians was documented on Social Services Notes and via email. He stated communication regarding medications was done by the provider.