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Based on record review and interview the facility failed to ensure the patient's parent/guardian (Patient Representative) was included in the development and implementation of the patient's inpatient plan of care and discharge plan in 3 of 10 patient medical records reviewed (Patient #1, 2, 8).

Findings Include:

Facility staff failed to protect and promote patient rights by failing to include the parent/guardian (Patient Representative) in the development and implementation of the patient's inpatient plan of care and discharge plan in 3 of 10 patient medical records reviewed (Patient #1, 2, 8).
See tag A-0130

Based on record review and interview the facility failed to ensure that staff included the parent/legal guardian (Patient's representative) in the development and implementation of the patient's inpatient treatment plan of care and discharge plan in 3 of 10 medical records reviewed (Patient (Pt) #1, #2, #8) in a total sample of 10 records reviewed of patients under 18 years old in police custody.

Findings Include:

Review of policy and procedure titled, "Rights and Responsibilities" (Addendum A) effective date 06/06/2022 revealed the "Rights of you and your child" are as follows:
-"To be a part of the care, treatment and services (as allowed by law). This includes planning, treatment, medicine management and other health care services. We will explain what to expect and other options."

Review of policy and procedure titled, "Patients with Law Enforcement Involvement" effective date 01/03/2022 revealed the following:
1. Patient in Law Enforcement Custody:
- (Hospital) will continue to communicate medical care updates and obtain informed consent from the parent/legal guardian.
- (Hospital) should communicate the patient's health care needs with the parents/legal guardians.

2. Discharge Process for Patients in Law Enforcement Custody or Incarcerated Patients.
-Provider/designee should contact the parent(s)/legal guardian(s) to provide medical update after the patient has left the building.

Review of policy and procedure titled, "Discharge of a patient from the hospital...." effective date 07/08/2020 revealed the following:
1. Transition/Discharge Plans are Developed in Collaboration With The Patient/Family:
-Transition/discharge planning is coordinated with the family by the Registered Nurse (RN), attending physician or other provider, hospital case manager, vendor liaison, or social worker.
-The plan includes discharge criteria, identification of providers for continuing care, equipment and supplies.
-Document discharge instructions in the AVS (After Visit Summary), including:
a. Recommendations from any specialists
b. Follow-up appointments and contact numbers

2. RN responsibilities for Patient Discharge Include:
-After Visit Summary (AVS)
a. Hospital will print one copy of the AVS.
b. Review the AVS with the family.
c. Obtain the signature of the parent or authorized adult.
d. Make a copy of the signed AVS
e. Provide the parent or authorized adult with the original copy of the AVS and prescriptions if applicable.
-Documentation
a. Document any pertinent, patient-specific information in a progress note.

Review of policy and procedure titled, "Assessment, Reassessment, Documentation of a Patient" effective date 07/13/2020, revealed the following:
1. The care provided to each patient is based upon a determination of the patient's needs, the patient and family's agreement with the interprofessional plan of care, and the ability of the hospital to provide the necessary services.
2. The patient's plan of care is developed using an interprofessional, collaborative process involving the patient and patient's family/significant others.
3. Assessment and reassessment are individualized to the patient's needs and include but not limited to:
a. Effect on the family or guardian based on the patient's illness or condition and effect of the illness on the patient's family;
b. Family or guardian expectations for and involvement in the patient's assessment, initial treatment and continuing care.

Patient #1:

Review of Pt #1's Emergency Department (ED) Provider Notes dated 04/22/2022 at 9:42 am, revealed Pt #1 (17 years old) arrived to the ED via ambulance on 04/21/2022 at 11:25 pm, with a gunshot wound to the lateral left chest and lateral left knee.

Review of Pt #1's History and Physical documented by Trauma Surgeon D on 04/22/2022 at 3:14 am revealed Pt #1 was taken to the Operating Room (OR) "emergently" and the identified injuries included the following:
-Splenic laceration with associated small pancreatic tail hematoma (clotted blood), hemostasis (stopping the flow of blood) achieved intraoperatively
-Left diaphragmatic penetrating injury repaired, drain placed to monitor
-Left medial knee penetrating wound, neurovascular monitoring

Review of Pt #1's medical record revealed that Pt #1 was admitted to the Pediatric Intensive Care Unit (PICU) on 04/22/2022 at 2:53 am after emergency surgery. Per Pt #1's medical record, Pt #1's condition was listed as "Serious". Pt #1 was transferred from Critical Care to Acute care on 04/24/2022 at 2:24 pm, and was discharged to jail/secured detention facility on 04/26/2022 at 4:21 pm.

Review of Pt #1's Security Risk Assessment dated 04/22/2022 at 1:58 am, revealed Pt #1 was in police custody and allowed "No Visitors." Per Security Risk Assessment, "Patient's mother (Family A) was allowed a medical update after the patient was done with surgery, but was informed that she would not be allowed to visit the patient (Pt #1)."

Review of Pt #1's Security Risk Assessment dated 04/23/2022 at 11:44 am, revealed that on "4/22/2022--The patient (Pt #1) arrived as a GSW (Gun Shot Wound) Trauma with (police department) who had him in custody due to the shooting and multiple warrants. The mother (Family A) was advised she may not visit and may have phone updates."

Review of Pt #1's Critical Care Progress Note dated 04/22/2022 at 2:22 am, revealed Pt #1 had a "retained bullet with low suspicion for vascular injury (left knee) ." Per progress note, "Family was unavailable, and plan to update when able." Review of progress notes revealed no documented evidence of an attempt to call Pt #1's mother (Family A) via phone to update A on Pt #1's condition/treatment plan after arriving in the PICU.

Review of Pt #1's Social Work Note dated 04/22/2022 at 11:24 am revealed, "Social Worker had spoken with patient's (Pt #1's) mother (Family A) at 0820, whom expressed frustration regarding the fact she had not received a medical update. Social Worker explained need to obtain a provider for an update and would contact her as soon as possible...Social Worker conferred with (Physician E), whom provided patient's (Pt #1's) mother update. Social Worker spoke with patient's (Pt #1's) mother regarding need for medical team to provide medical updates via phone, as per (Police Department) order." Per review of Social Worker note, "Social Worker spoke with {sic} plan for medical team members to update patient's (Pt #1's) mother via phone after morning rounds and in the evening after 1700 (5:00 pm). Patient's mother also informed RN staff to call in the early am to provide brief update if possible around 0600."

Review of Pt #1's Critical Care Progress Note by Physician E dated 04/23/2022 at 6:44 am revealed, "IR (Interventional Radiology) to evaluate for potential arterial bleed." Pt #1's Critical Care Progress notes revealed, "Anticipate need for further blood product administration." Per review of this Critical Care Progress Note, there was no documented evidence of the Provider calling Pt #1's mother (Family A) and providing medical updates to ensure Pt #1's mother was included in Pt #1's plan of care/treatment plan.

Review of Pt #1's Brief Op (operative) Note by Radiologist G dated 04/23/2022 at 11:58 am revealed that Radiologist G performed a Splenic Artery Angiogram and placed Angio-Seal device to the right femoral artery access.

Review of Pt #1's Post operative note by Radiologist G signed on 04/23/2022 at 8:03 pm, revealed "The right groin and sheath was then reprepped. Through this sheath an Angio-Seal arterial closure assist device was then deployed to obtain immediate hemostasis."

Review of the manufacturer's guidelines (Terumo) for the Angio-Seal closure device (Patient Information Card) revealed Patient instructions to "Carry this card with you in your wallet for the next 90 days. Immediately report persistent tenderness in the groin area, bleeding, swelling, wound drainage, numbness or tingling in the leg, fever, redness, warmth, bruising at the puncture site; or any other unusual observation at the puncture site to the physician listed on the reverse side of this card."

Per telephone interview with Pt #1's mother (family A) on 07/05/2022 at 1:45 pm, Pt #1's mother was not informed about Pt #1 having a retained bullet in his/her knee, and did not know that Pt #1 had an "Angio-Seal" placed during the Angiogram until the Patient Instruction Card was mailed to Family A's home 1 week after Pt #1's discharge, which stated to keep the card on the patient at all times for 90 days. Per interview with Pt #1's mother, the nursing and medical staff failed to keep Pt #1's mother informed during Pt #1's hospital stay and was not updated on the discharge instructions and plan. Pt #1's mother stated that she was very worried about Pt #1's condition and she was concerned that Pt #1 missed his/her follow up visit while in jail. Pt #1's mother was worried if the jail officials were aware of the Angio-seal in Pt #1's leg and the Patient Instruction Card.

Per review of Radiologist G's above progress notes there was no documented evidence of Radiologist G/designee calling Pt #1's mother (Family A) to provide a medical update on the results of the procedure and instructions for follow up care for the Angio-Seal closure device to ensure Pt #1's mother was included in Pt #1's plan of care/treatment plan.

Per interview with Radiologist G on 07/06/2022 at 2:45 pm, Radiologist G stated he/she spoke with Pt #1's mother (Family A) prior to procedure to obtain consent, however Radiologist G did not call Pt #1's mother after the procedure to update her on the outcome and follow up plan. Radiologist G stated that he/she typically does not call the parent/guardian after procedures when there are no findings and no interventions performed. Radiologist G stated that he/she gives report to the medical team and will defer to the medical team to inform the parent/guardian of the procedure results.

Per Review of Pt #1's Critical Care Progress notes and General Surgery Progress notes from 04/23/2022 through 04/26/2022, there was no documented evidence of Pt #1's mother (Family A) being informed of the outcome and interventions required for the Splenic Artery Angiogram (Angio-Seal). Review of Pt #1's nursing notes, flowsheets, and After Visit Summary revealed no documented evidence of Pt #1's mother being informed/educated on the Angio-seal device closure as per the Patient Information Card provided by the manufacturer.

Review of Pt #1's Brief Orthopaedic Surgery Note dated 04/22/2022 at 3:19 pm revealed, "Our team was contacted regarding (Pt #1's) left knee (GSW)...Radiographs and CT (computed tomography) of the left knee was obtained, and demonstrated an intraosseous (within bone) retained foreign body (bullet) with an associated fracture." Per review of the Orthopaedic Surgery note, "Recommendations" were documented as follows:
-No acute intervention necessary
-Weightbearing as tolerated on the lower extremity
-Activity as tolerated
-No formal bracing required, though can use a brace for comfort if desired
-No orthopaedic follow up is necessary
-Further wound care per general surgery
The Orthopaedic note revealed, "The patient (Pt #1) was reviewed with Surgeon F"

Per interview with Orthopaedic Surgeon F on 07/07/2022 at 9:20 am, Orthopaedic Surgeon F stated that he/she does not typically contact the parent/guardian after an Orthopaedic consult when surgical interventions are not recommended. Per Surgeon F, after an Orthopaedic Consult is completed, the Orthopaedic Surgeon will follow up with the critical care team/trauma team (General surgery) and discuss the recommendations. Surgeon F stated that it was the responsibility of the critical care team or trauma service to communicate the recommendations to the parent/guardian. Per interview with Surgeon F, when asked why the bullet was retained in Pt #1's knee, Surgeon F stated that surgery was not recommended to remove the bullet fragments from the bone because it could cause significantly more harm and recovery time to Pt #1 to remove the bullet from the bone, than to just leave it in place.

Review of Pt #1's General Surgery (Trauma service) Progress Note dated 04/23/2022 at 5:53 am revealed, "Ortho (Orthopaedic) consulted for retained bullet and L (left) lateral femoral condyle fracture. No operative plan or follow-up needs per ortho..." Per review of General Surgery Progress Notes there was no documented evidence of calling Pt #1's mother (Family A) and providing medical updates to ensure Pt #1's mother was included in Pt #1's plan of care/treatment plan.

Per interview with Trauma Surgeon D (General Surgery) on 07/06/2022 at 3:45 am, Trauma Surgeon D stated that when an Orthopaedic consult is requested and has recommendations for treatment, "It is left up to them to speak in regards to their specialty." Per Surgeon D, Ortho should have called and informed Pt #1's mother of the treatment recommendations for Pt #1's retained bullet in his/her knee.

Per interview with Critical Care Physician E on 07/07/2022 at 10:38 am, Physician E is a Critical Care Intensivist in the PICU. Per Physician E Pt #1 was admitted under Trauma Services (General Surgery) and is "co-managed" by the Intensivist (Critical Care team). Per Physician E, it is typically the responsibility of the Intensivist to coordinate care and communicate with family, however "It is not a perfect communication model." Per interview with Physician E contact with parent/guardian is not typically documented in the medical record.

Per the above interviews with Radiologist G, Orthopaedic Surgeon F, Trauma Surgeon D, and Critical Care Physician E, there was no coordinated process on who was responsible for calling and providing medical updates to Pt #1's mother, to ensure she was included in Pt #1's plan of care/treatment plan.


Per review of the following additional Provider Progress Notes, there was no documented evidence of medical staff providing Pt #1's mother (Family A) a medical update as per Pt #1's mother requested to Social Worker on 04/22/2022.
-Critical Care Progress note dated 04/24/2022 at 6:42 am.
-General Surgery Progress note dated 04/24/2022 at 7:06 am.
-General Surgery Progress note dated 04/25/2022 at 11:09 am.
-General Surgery Progress note dated 04/26/2022 at 11:14 am.

Per review of nursing Plan of Care progress notes and nursing flowsheets (Family Communication) from 04/23/2022 through 04/26/2022 (date of discharge), there was no documented evidence of nursing staff providing Pt #1's mother (Family A) a nursing update as per Pt #1's mother requested to Social Worker on 04/22/2022.

Review of Pt #1's After Visit Summary (AVS) (Discharge Instructions) included the following topics: Reasons to Call, Care at Home--What to Expect, Wound Care, Activity, Diet, Follow up appointments, Handouts provided (Small Bowel Obstruction, Increasing Fiber in Your child's diet, and Medications), and Medication list. Review of Pt #1's AVS revealed the Parent/Guardian signature line attested that "I have received a copy of these instructions and I understand them. I agree that information about my child may be sent to involved people and agencies." Per review of Pt #1's AVS, the Parent/Guardian signature line was blank.

Per review of Pt #1's nursing Progress notes there was no documented evidence of the nurse calling Pt #1's mother (Family A) and updating her on the above topics of the AVS, to ensure Pt #1's mother was included in Pt #1's discharge plan and follow up care.

Per interview with RN H and RN I on 07/07/2022 beginning at 11:30 am, both RN H and RN I stated that they do not call parents/guardians with discharge instructions/education when patients are in police custody. When asked how parents/guardians of patients in police custody are made aware of the discharge plan and follow up treatment, they responded they are not supposed to let the parent/guardian know when the patient is discharged and when the follow up appointments are. Per interview with RN H and RN I, the parent/guardian should be called and updated at least "daily" while a minor patient is in the hospital under police custody and this should be documented in the nursing flowsheets under Family Communication.

Per interview with RN Supervisor K on 07/07/2022 at 12:00 pm, RN Supervisor K expects that the nursing staff should call and update the parent/guardians of minor patients in police custody at least "once per shift" and as needed. Per RN Supervisor K, the nursing staff should call parents/guardians with discharge instructions/education and if the nursing staff is unable to get in touch with the parent/guardian via phone, nursing staff should mail the AVS to the parent/guardians home. RN Supervisor K stated that it was ok to inform the parent/guardian of the follow up appointments.

Per interview with Social Worker J on 07/07/2022 at 12:18 pm, Social Worker J stated that nursing staff are not supposed to tell parent/guardian when the patient is discharged and when the follow up appointments are. When asked how the parent/guardian is made aware of the continued follow up care/appointments required, Social Worker J stated that he/she is unsure how law enforcement communicates this information with the minor patients family once the patient is released from jail/secured detention facility.

Patient #2:

Review of Pt #2's medical record revealed Pt #2 (17 years old) was admitted to hospital from jail on 05/18/2022 at 1:31 pm with a diagnosis of chronic colitis and autoimmune hepatitis; Pt #2 was discharged back to jail on 05/20/2022 at 7:10 pm.

Review of Pt #2's Gastroenterology History and Physical (H&P) signed on 05/18/2022 at 6:38 pm, revealed that Pt #2 currently has a colostomy bag due to complications from a previous colonoscopy. Per H&P, "(Pt #2) is coming in for a repeat colonoscopy to re-evaluate disease status and guide future interventions."

Review of Pt #2's Security Risk Assessment dated 05/18/2022 at 2:08 pm, revealed that Pt #2 was in the custody of law enforcement and is to have no visitors or access to phone or the Internet.

Review of Pt #2's Social Worker Note dated 05/18/2022 at 2:26 pm revealed that "(Pt #2's) mother remains guardian and should be contacted for all consents. Per review of the Social Worker Note, "...patient's mother is allowed to have medical only updates from calls initiated from (Hospital) medical providers."

Review of the following Provider notes for Pt #2, revealed there was no documented evidence of contacting Pt #2's mother and providing a medical update, to ensure Pt #2's parent/guardian was included in Pt #2's plan of care/treatment plan:
-Gastroenterology H&P dated 05/18/2022 at 11:23 am
-Gastroenterology Progress Note dated 05/19/2022 at 6:39 am
-Gastroenterology Progress Note dated 05/20/2022 at 5:35 am

Per review of Pt #2's nursing progress notes and flowsheets from 05/18/2022 through 05/20/2022, there was no documented evidence that the nursing staff contacted Pt #2's mother with updates to ensure she was included in Pt #2's plan of care/treatment plan.

Review of Pt #2's After Visit Summary (AVS) (Discharge Instructions) included the following topics: Reasons to Call, Care at Home--What to Expect, Activity, Diet, Immunizations, Past and Present Procedures, Follow up appointments, and Medication list. Review of Pt #2's AVS revealed the Parent/Guardian signature line attested that "I have received a copy of these instructions and I understand them. I agree that information about my child may be sent to involved people and agencies." Per review of Pt #2's AVS, the Parent/Guardian signature line was signed by the Sheriff's Deputy.

Per review of Pt #2's AVS and nursing progress notes from 05/18/2022 through 05/20/2022, there was no documented evidence of nursing staff contacting Pt #2's mother with updates to ensure she was included in Pt #2's discharge plan of care.

Patient #8:

Review of Pt #8's (17 years old) medical record revealed Pt #8 arrived in the ED on 06/05/2022 at 2:05 pm with complaint of a gunshot wound (GSW) to the abdomen. Pt #8 received "Urgent OR (operating room) intervention" and was then admitted to the inpatient unit on 06/05/2022 at 7:45 pm; Pt #8 was discharged to jail/Juvenile Detention facility on 06/13/2022 at 6:40 pm and later on that day was released from jail to Pt #8's mother.

Per review of Pt #8's discharge summary dated 06/05/2022 at 2:42 pm, "(Pt #8) was admitted to the Surgery service after sustaining a gun shot wound to the abdomen. Visceral (internal organs) injuries were noted on presentation and (Pt #8) was emergently taken to the operating room where an exploratory laparotomy (surgical incision into the abdominal cavity) for trauma with descending loop colostomy (colon is diverted to an artificial opening in the abdominal wall) was created..."

Review of Pt #8's Ostomy CNS (Clinical Nurse Specialist) rounding notes from 06/08/2022 at 1:50 pm revealed, "(Pt #8) was seen in consultation for new ostomy, ostomy teaching, and selection of home supplies." Per review of CNS notes, there was no documented evidence of contacting Pt #8's mother and including her in the teaching and plan of care for Pt #8's new ostomy.

Review of Pt #8's Ostomy CNS rounding note from 06/10/2022 at 2:39 pm revealed, "(Pt #8) was seen for follow up visit, pouch change, and ongoing education." Per review of CNS notes, there was no documented evidence of the CNS contacting Pt #8's mother and including her in the teaching and plan of care for Pt #8's new ostomy.

Review of Pt #8's After Visit Summary (AVS) (Discharge Instructions) included the following topics: Reasons to Call, Care at Home--What to Expect, Wound Care--Ostomy care, Activity, Diet, Immunizations, Past and Present Procedures, Follow up appointments, and Medication list. Review of Pt #2's AVS revealed the Parent/Guardian signature line attested that "I have received a copy of these instructions and I understand them. I agree that information about my child may be sent to involved people and agencies." Per review of Pt #8's AVS, the Parent/Guardian signature line was blank.

Per review of Pt #8's AVS and nursing progress notes on 06/13/2022 (date of discharge), there was no documented evidence of nursing staff contacting Pt #8's mother with updates to ensure she was included in Pt #2's discharge plan of care and teaching.

Review of Pt #8's Pediatric General and Thoracic Surgery Follow-up Provider Note dated 06/17/2022 (4 days after discharge) revealed, "(Pt #8) was on a police hold while inpatient so (Pt #8's) mother did not receive any ostomy teaching. On day of discharge (Pt #8) was taken into police custody and went home to (his/her) mother, later that day...Mom was unaware of prescriptions until she saw them in My Chart...Mom has not been involved in doing appliance changes as (he/she) has been independent. Mom and (Pt #8) both need additional ostomy teaching. Per review of the Provider progress note, "Mom reports she has not received any supplies as of yet..."