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UT HEALTH EAST TEXAS SPECIALTY HOSPITAL

1000 S BECKHAM FL 5

TYLER, TX null

PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING

Tag No.: A0130

Based on record review and interview the facility failed to ensure documentation of family involvement in Plan of Care (POC) process. Citing 6 of 20 patient medical records reviewed (Patient record #2, #4, #8, #9, #10, and #13).

Findings include:
Review of patient medical records on 12/4/2013 at 11:00 am revealed the following:
1. Patient medical record #2- no documentation of patient involvement in POC process found.
2. Patient medical record #4- no documentation of patient involvement in POC process found.
3. Patient medical record #8- no documentation of patient involvement in POC process found.
4. Patient medical record #9- no documentation of patient involvement in POC process found.
5. Patient medical record #10- no documentation of patient involvement in POC process found.
6. Patient medial record #13- no documentation of patient involvement in POC process found.

Interview with staff #1 on 12/4/2013 at 2:30 pm in the conference room confirmed the findings.