HospitalInspections.org

Based on interviews and record review, the hospital failed to inform Legally Appointed Representative (LAR) of one of three patients reviewed (patient # 1) the rights in advance before furnishing care in that:

The facility failed to provide a written summary to patient # 1 LAR on risks, benefits, side effects etc. for a psychoactive medication after a verbal consent.

This failure placed the patient's LAR no offer to ask or answer questions concerning the patient's treatment.
Findings included:

Admission record review on 12/19/18 at 10:30 AM indicated patient #1 was a 17-year-old female admitted to the hospital on 06/26/18 with diagnosis including major depressive disorder.

Physician order reviewed on 12/19/18 at 10:35 AM indicated an order written on 06/27/18 for the following psychotropic medication: Zoloft 25mg (milligram) po (by mouth) AM (every morning) for depression.

On 06/27/18 at 6:00 PM, a telephone Verbal consent to treat with psychoactive medication (Zoloft) was obtained from Patient # 1's father. It was signed by two nurses, one acting as a witness to the telephone consent. The physician signed it on 06/29/18.

Interview with Assistant Director of Nursing on 12/19/18 at 02:38 PM reported the hospital did not mail a written summary information on the medication, along with an offer to answer any questions concerning the treatment of depression to LAR after verbal consent.

Review of Sundance Hospital Policy and Procedure, Title: Informed Consent for Psychoactive Medications, Date Issued: 08/11/2014 found that it contained the requirement, "The patient and his or her LAR must also be provided a summary of this information in writing, along with an offer to answer any questions concerning treatment. If the LAR is not present, the information must be mailed to the representative (via certified letter) within 24 hours, except on weekdays and legal holidays when the information will be mailed the next business day."

Based on record and interview reviews, the hospital failed to ensure nursing staff developed and kept current nursing care plan for one of three patients (Patient #1) reviewed after a significant change in condition in that:

The hospital failed to ensure patient#1 Treatment Plan was updated and /or addressed the patient's falls.

This failure placed the patient at a risk of not receiving appropriate therapeutic treatment and interventions.

Findings included:

Admission record review on 12/19/18 at 10:30 AM indicated patient #1 was a 17-year-old female admitted to the hospital on 06/26/18 with diagnosis including major depressive disorder.

Review of Nurses assessment and progress notes dated 06/28/18 reviewed Patient #1 fell twice resulting in the patient transfer to Emergency Department.

A review of patient #1's Master Treatment Plan revealed the plan was not updated and/or the falls addressed after the significant change clinical condition.

Interview with Assistant Director of Nursing on 12/19/18 at 02:38 PM confirmed the Master Treatment Plan was not updated/and or the falls addressed. The ADON said "I don't know why it was not updated or the falls addressed." The ADON reported patient # 1 was a high fall risk.

Interview with the hospital Risk Manager on 12/19/18 at 02:45 PM revealed the master care plan was supposed to have been updated. The goals and interventions were supposed to have been indicated. She said she did not know why it was not done.

Review of the hospital Fall Prevention policy dated 08/11/14 and revised on 09/26/16 revealed the hospital would "institute high fall risk measures as warranted ...implementation and analysis performed on falls.