HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure of the MD to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 1 (#2) of 3 (#1-#3 ) patient medical records reviewed for care plan development and implementation.
Findings:

Review of the hospital's policy titled, "Patient Rights Louisiana", revised date 09/01/2023, revealed in part: PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's rights if deemed necessary. PROCEDURE: 4. If the patient is cognitively and/or physically unable to sign and comprehend this information about their rights, the patient's guardian or a family member will be so informed and will sign for them legally appropriate; or if the patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services. Treatment: You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient's behalf will be respected in accordance law and regulations.

Review of Patient #2's medical record reveals documentation that Patient #2 remains confused, lethargic with poor insight and judgement with significant impairments and concentration throughout hospitalization. Furthermore social service staff documents working with Patient #2's grandson to facilitate safe discharge. Patient #2 was living independent prior to hospitalization, but is no longer capable of doing so because Patient #2 requires supervision and assistance. Social service staff documents three times that Patient #2's grandson request the MD caring for Patient #2 to communicate Patient #2's treatment plan, but no documentation that MD contacted Patient #2's grandson.

On 10/08/2024 at 2:30 p.m. S1QD verified the above mentioned documentation in Patient #2's medical record.

On 10/08/2024 at 2:30 a.m. S5CD verified the above mentioned documentation in Patient #2's medical record.

On 10/09/2024 at 10:00 a.m. an interview with S8MD verified that he did not communicate with Patient #2's grandson.