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Based on record review and interview, the facility failed to ensure that each patient or his/her designee were allowed to actively participate in the patient's plan of care or treatment plan for 1 of 2 patients (Patient #1) reviewed.

As a result of this deficient practice, Patient #1's right to participate in the care plan process were violated.

Findings include:

Record review of the medical record for patient#1 revealed that he was a 91-year-old- male, admitted to the facility on 01/28/2022 with diagnosis of: Advanced Alzheimer's Dementia, Afib, Hypotension, Right Ventricular Regurgitation (RVR), Pacemaker, Degenerative Joint Disease, Hypertension, Metabolic Encephalopathy, Coronary Artery Disease (CAD), Avascular necrosis of the left hip (AVN), and Frequent falls.

Record review of the Physician's progress notes, dated 01/28/2022 to 02/10/2022 revealed the following information:
-1/30/2022 @ 08:26: He (pt. #1) is confused and very impulsive and at times agitated and is repeatedly trying to get up at the station (nurses' station), therefore, begin pelvic restrains and monitor clinically.
Rehab Plan Recommendation:
-Rehab Nursing to provide patient and family education regarding current medications as they relate to medical illness, monitor pain, monitor for altered mental status.
- Continue Aricept (Alzheimer's medication) and due to some intermittent agitation, sundowning, continue also with Seroquel and we will seek psychiatry to follow.

-1/31/2022 @ 08:43: Patient seen this morning sitting in a chair in the hallway. He is confused and yelling out inappropriately. He is on room air and hemodynamically stable.

- 2/07/2022 @ 10:17: Ativan offered PRN (as needed) for agitation; however, patient's son has expressed a wish that his father not be "overmedicated" This is unfortunate given how distraught the patient gets during episodes of agitation (discharge planning note).

-Plan:
-Ativan PRN agitation (Alzheimer's dementia)
-Haldol 2 mg once for severe agitation.
-physiatrist consulted for management.

Record review of the Medication Administration Records (MARS) for patient #1, dated 01/28/2022 to 02/10/2022 revealed the following:
- Ativan 0.5 mg was administered on the following days and times by nursing staff: 01/28/2022 @ 17:59, 01/29/2022 @ 12:16, 01/29/2022 @ 12:46, 01/29/2022 @ 23:32, 01/30/2022 @ 00:02, 02/07/2022 @ 23:06, and 02/08/2022 @18:08.

Record review of the interdisciplinary notes for patient #1, dated 01/28/2022 to 02/10/2022 revealed no evidence that facility nursing staff, and/or the facility case manager notified/ educated patient #1's family (son) of the addition of Haldol and Ativan to the patient's medication regimen.

Record review of the facility policy entitled: Patient and Family Education, effective date: 08/19/2019, revealed the following:
Patient/ Family/ Caregiver education is a key interdisciplinary activity in the rehabilitation program ... Based on the patient's condition and assessed needs, the education and training provided may include any of the following:
-An explanation of the plan of care, treatment, and services.
-Information on the safe and effective use of medications.

In an interview conducted on 07/20/2022 at 14:32 the Director of Risk Management confirmed the above findings.