HospitalInspections.org

Based on observations, interviews and policy reviews the facility failed to include the patient/family or legal representative in participation of the treatment planning process for all 35 Patients (#1 - #35) open records reviewed. Facility census was 69.
Findings included:
Review of policy: Patient and Family Education #H-PC 04-005 dated 01/07 on 10/08/09 stated in part: Policy: The goal of patient and family education is to improve patient health outcomes by promoting healthy behavior and involving the patient and family in care and care decisions. Education promotes health behaviors, supports recovery and a speedy return to function, and enables patients and families to be involved in decisions about their own care. The processes addresses activities including but not limited to : promoting interactive communication between patient and family and providers; improving patient and family understanding of health status, options for treatment and the anticipated risks and benefits of treatment; encouraging patient and family participation in decision-making about care and increasing the likelihood that patient and family will follow therapeutic plans of care.
Review of policy: Interdisciplinary Care Conference #H-ML-10-014 dated 07/09 on 10/08/09 stated in part: Policy Purpose: Increase professional collaboration between disciplines on complex patient care management.; Increase global oversight by the interdisciplinary team in infection control, avoidable days/patient flow barriers, National Patient Safety Goals and other interdisciplinary identified opportunities.; Increase the progression of patient care to target discharge dates as appropriate. Policy Statement: An Interdisciplinary team meets within seven days of a patient admission and at a minimum weekly thereafter.; The team identifies and prioritizes patient's clinical and educational needs, expectations and outcome goals.; The identified patient goals are summarized and prioritized by the team.; Each patient's care conference summary is documented and maintained in the patient's medical record. Team member role: Each team member is responsible to update the Patient Care Plan as appropriate.
Review of policy: Assessment/Reassessment - Interdisciplinary Patient #H-PC 04-009 dated 05/09 on 10/08/09 stated in part: Purpose: To assure care provided to each patient is based on an assessment of the patient's relevant physical, psychological and social needs; to outline a systematic process for gathering pertinent information about each patient; to establish a comprehensive information base for decision making about each patient ' s care; to define initial assessment timeframe; and to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization. Nursing Department 7. A collaborative assessment and individualized Patient Care Treatment Plan is discussed with the interdisciplinary team during the Patient Care Conference. It is recommended that each patient be reviewed within at least seven days of admission and no less than weekly thereafter at the Interdisciplinary Patient Care Conference.
The policies fail to clearly include the patient/family or legal representative at the beginning of the care plan process and to solicit their desired goals and outcomes in the treatment planning process. The inclusion of the patient/family or legal representative is an action after the care plan has been determined and is educationally focussed.
Observation on 10/08/09 at approximately 11:00 - 11:30 A,M. of the Interdisciplinary Care Team Meeting included representation from nursing, dietary, pharmacy, social services, two case managers, respiratory, wound care and laboratory services. Six patients were discussed regarding progression toward discharge and discharge planning.
During an interview on 10/08/09 at 11:30 A.M. the Director of Case Management stated case management services are responsible for discharge planning beginning at admission and is not responsible for the entire plan of care. Nursing staff are responsible for involving the patient and family within the process.
Open record reviews on 10/05/09 - 10/08/09 of 35 (Patients #1 - #35) records reviewed failed to include patient, family or legal representation participation in the development or review of the patient care plan within the electronic or paper medical record documentation. Areas reviewed included nursing notes, nursing care plan, progress notes, social service notes, case management notes and the Interdisciplinary Care Plan, which included an area for patient/family discussion of discharge planning.

Based on policy and record reviews the facility failed to allow the patient to make informed decisions regarding their care by failing to obtain patient's consent for service and complete the required intake admission packet, which includes the patient rights and advance directive information at time of admission for nine patients (Patient #1, #2. #4, #7, #8, #10, #13, #22 and #25) of 35 open records reviewed. The facility provided medication and treatment during the interim without their informed consent. Facility census was 69.

Findings included:

Review of policy: Section 2.0 - Patient Admissions, no date on 10/08/09 stated in part: Patient admissions are based upon documented consent, accurate billing and payment information and completed timely. Purpose: To provide guidelines for obtaining proper admissions documentations and timely admitting procedures for admissions to the hospital according to the hospital ' s established admission criteria. Scope: This applies to all patient admissions. Introduction: The procedures help ensure that a) the appropriate legal representative is identified, b) consent for the admission is obtained, e) ensure data is communicated throughout the organization. The essential elements in the admission process include: Obtain referral status, indentify the appropriate legal representative for the admission, communicate and explain the admission process and provide a complete admission documentation package to the patient and/or legal representative and obtain the necessary signatures.

The policy does not include a timeline for completion of admission consent for service or a plan for admissions arriving after 5:00 P.M.

Review of form titled Verbal Consent for Services, no date on 10/09/09 provides for verbal consent for treatments and care at Kindred Hospital Kansas City, with two areas for witness signatures and date.

During an interview on 10/06/09 at approximately 1:30 P.M. the Director of Quality Assurance stated the Admission Office is responsible for obtaining admission signatures, verifying guardian, providing admission packets and explaining the contents during business hours.

Review of Patient's #1open medical record on 10/06/09 showed admission to the facility on 09/28/09 for right ischial (lower posterior portion of the hip) wound repair. The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The patient consent for service was not signed until 09/30/09, two days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #2 open medical record on 10/06/09 showed admission to the facility on 10/01/09 for pneumonia with respiratory failure and sepsis. The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The consent for service was obtained by the patient's parent on 10/05/09, four days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #4 open medical record on 10/06/09 showed admission to the facility on 08/19/09 for bilateral planter foot ulcers, right foot ulcer, infection and congestive obstructive pulmonary disease (COPD). The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The patient consent for service was not signed until 08/22/09, three days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #7 open medical record on 10/06/09 showed admission to the facility on 09/26/09 for abdominal cellulitis and infection. The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The patient consent for service was not signed until 09/29/09, three days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #8 open medical record on 10/06/09 showed admission to the facility on 09/18/09 for wound care and decubitus ulcers. The patient had a durable power of attorney (DPOA) with appropriate paperwork in the medical record. The patient consent for service was received 09/20/09 by the DPOA, two days after admission. The medical record did not contain documentation of attempts to reach the DPOA or a verbal consent for services.

Review of Patient's #10 open medical record on 10/06/09 showed admission to the facility on 09/30/09 for chronic renal insuffiency, diabetes and wound care. The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The patient consent for service was not signed until 10/02/09, two days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #13 open medical record on 10/06/09 showed admission to the facility on 09/22/09 for pancreatitis and abdominal treatment. The patient was his/her own guardian and documented during the nursing admission assessment as alert and oriented. The patient consent for service was not signed until 09/25/09, three days after admission. No documentation or form for verbal consent of services was noted within the medical record.

Review of Patient's #22 open medical record on 10/07/09 showed admission to the facility on 09/03/09 for stage three and four pressure ulcers. The patient had a DPOA noted within the medical record. Documentation stated the patient's DPOA was contacted on 09/05/09 regarding admission consent for services and admission packet information, the packet was mailed to the DPOA. The packet and consent for services was returned to the facility with dated forms and consent of 09/30/09, 27 days after admission. Documentation did not include receiving verbal consent to treat the patient.

Review of Patient's #25 open medical record on 10/07/09 showed admission to the facility on 09/02/09 for ventilator weaning and acute respiratory failure. The patient had a DPOA noted within the medical record. The patient consent for service was not received by the DPOA until 09/11/09, nine days after admission. Documentation did not include verbal consent for services.

Based on record review the facility failed to ensure the physician staff date, time and/or sign the orders on three of ten open medical records Patients # 6, #12 and #27. Facility census was 69.

Open record review of Patient #6 on 10/06/09 at approximately 10:00 A.M. showed missing physician signature, date and time on 09/18/09 and 09/30/09 Hemodialyses Orders and missing physician signature, time and date on the Acute Hemodialysis Treatment Flow Record for physician visit signature, date and time.

Open record review of Patient #12 on 10/06/09 at approximately 11:30 A.M. showed missing physician signature, date and time on 09/23/09 and 09/30/09 Hemodialysis Orders and missing physician signature, time and date on the Acute Hemodialysis Treatment Flow Record for physician visit, signature, date and time.


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Review of the medical record on 10/06/09 revealed the Patient # 27's was admitted to the hospital on 09/29/09 for wound care and continued IV antibiotics for multiple lower extremity wounds.

Past medical history reveals Hypertension (high blood pressure) for several years, end stage renal disease (kidneys failing) and peritoneal dialysis (using the peritoneum [the membrane that lines the abdominal and pelvic cavities] in the abdomen to cleanse the blood).

Review of the Hemodialysis Orders revealed the following information:
? The order dated 10/05 (no year) was not timed by the physician.
? The order written on 09/30/09 at 1000 was not signed, dated, or timed by the physician.