HospitalInspections.org

Based on record review and interview, the facility failed to offer education about, or an opportunity to, formulate an advanced directive for 12 (#s 1, 2, 8, 9, 10, 11, 14, 15, 16, 17, 19, and 20) of 21 sampled patients. Findings include:

Review of the medical records for patient numbers 1, 2, 8, 9, 10,11, 14, 15, 16, 17, 19, and 20, showed the patients had not been asked by staff about advance directives for care, and were not offered education regarding the formulation of an advance directive.

During an interview on 4/27/16 at 2:45 p.m., staff member D said the question (regarding advance directives) was normally asked during the admit process during the day. She said the nurses may miss asking the question at night because the process is slightly different.

During an interview on 4/28/16 at 5:55 p.m., staff member D said "the nurses just didn't get it done and they would hold a training on this matter.

Review of the ADVANCED CARE PLANNING policy and procedure, showed that patients over the age of 18 years of age will be offered the opportunity to complete advanced care planning.

Based on record review and interview, the facility failed to obtain a consent for treatment for 1 (#13) of 21 patients sampled. Findings include:

A review of patient #13's medical record reflected the facility had not obtained a consent to treat, when services were rendered on 4/08/16.

During an interview on 4/28/16 at 5:55 p.m., staff member D said they had been unable to find the consent, even after checking with medical records.

Based on interview and record review, the facility failed to assess for discharge planning within 24 hours of admission or at least 48 hours prior to discharge for 1 (#1) out of 21 sampled patients. Findings include:

A medical record review for patient #1 reflected the patient was admitted to the hospital as an inpatient for approximately a three days stay. Review of the medical record reflected the patient did not have a discharge plan assessment initiated upon admission. The medical record reflected a discharge summary dated on the day the patient discharged.

In an interview on 4/28/16 at 2:30 p.m., staff member C reported discharge planning starts upon admission for all patients.

Review of the facility policy titled Discharge Planning reflected, "all patients will be assessed for discharge planning needs beginning within 24 hours after admission, unless admitted to the ICU."