HospitalInspections.org

Based on interviews and record reviews the hospital failed to ensure that a patient's designated representative was notified after an IDT (Interdisciplinary Team) meeting of the patient's updated care plan and treatment modality and the hospital failed to notify a patient's designated representative following a radiological health status result. This failed practice was evidenced by no documentation in 1 (Patient #3) of 4 patient's medical record reviewed for documentation for designated patient representative's notifications of patient's care planning and treatment.

Findings:
A review of Patient #3's medical record revealed that the patient was admitted to the hospital from a NH (Nursing Home) on 07/29/15 with an admitting psychiatric diagnosis of recurrent Major Depressive Disorder and Anxiety. The medical record revealed that Patient #3 was discharged back to the NH on 08/10/15. A further review of Patient #3's medical record revealed that the patient's medical diagnoses upon admit included in part: Hypertension, Diabetes, Esophageal Reflux and mild Dementia. The patient's medical record further revealed that Patient #3 had 2 (two) designated family representatives with POA (Power of Attorney).

A review of Patient #3's Treatment Plan of Care revealed that the IDT would communicate and involve the patient's designated representatives in Patient #3's care planning and treatment. A review of Patient #3's medical record and the IDT treatment plan and progress notes revealed that Patient #3 had 2 (two) IDT treatment plan conferences dated 7/31/15 and 8/05/15 during her admission at the hospital and prior to the patient's discharge on 8/10/15. A further review of the IDT treatment plan progress notes from S7SW revealed no documented evidence that S7SW had communicated with Patient #3's designated representative regarding the treatment plan modality update from the IDT conference on 8/05/15.

In an interview on 10/16/15 at 12:15 p.m. with S7SW she indicated that she was a member of the IDT for Patient #3 and was the social worker on the patient's team who was responsible for communicating with and involving the patient's designated representatives on Patient #3's care planning and treatment. S7SW's IDT progress notes were reviewed with S7SW. S7SW indicated that she thought she communicated with the patient's designated representative regarding the patient's ITD conference on 8/05/15, but she indicated that she did not document the communication and follow up. S7SW indicated that she probably did not communicate with the patient's designated representative since she did not document it on her progress notes.

A review of Patient #3's medical record revealed that Patient #3 had a fall on 8/03/15 and was evaluated in an Emergency Room at the local hospital. The patient had negative findings and was returned to the psych hospital within 24 hours. Patient #3 had complained of continued pain to the left thigh on 8/07/15 and was examined by S16NP who indicated that the left thigh bruise was attributed to her fall 3 days ago. S16NP ordered mobile x-rays of the left thigh to rule out fracture. Patient #3's x-ray report on 8/08/15 revealed negative findings.

A review of the nurse's notes after 8/08/15 revealed no documented evidence that Patient #3's designated representative were notified of the x-ray findings from 8/07/15.

In an interview on 10/16/15 at 4:30 p.m. with S1Adm and S2RN/RM they indicated that they remembered discussing the results with the patient's designated family member, but could not remember if they had called the family or if the family had called the psych hospital regarding the x-ray findings. S2RN/RM reviewed Patient #3's medical record and indicated that there was no documented evidence of any communication with anyone at the psych hospital and Patient #3's designated family regarding the results of the x-ray report on 8/07/15. S1Adm indicated that staff probably forgot to document the conversation with Patient #3's family in the patient's medical record.