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Based on record review and interviews, this hospital did not demonstrate that the patient and/or family were involved in the care planning process in 5 of 10 (Patients #3, #8, #9, #10, #11) medical record reviews in a total universe of 12 and 1 of 2 patient interviews (Patient #10). This deficiency has the potential to affect all patients receiving care at this hospital during the time of survey (patient census on 5/23/2017 of 22).

Findings include:

Review of Lakeview Specialty Hospital and Rehab Hospital Patient and Family Handbook effective date April 14, 2003 revealed under "What to Expect after you arrive at Lakeview Specialty Hospital", Within 72 hours of admission: "Case Managers will meet with patients within 72 hours of admission to develop a plan of care."

During review of Patient #3's medical record on 5/24/2017 at 2:42 PM, record revealed Patient #3 was admitted to the facility on 7/29/16 and discharged on 8/29/16. There were no case management notes or completed "Interdisciplinary Team Meeting" notes in this record dated prior to 8/03/2016.

An interview was conducted with Quality Director B on 5/24/2017 at 3:05 PM; B reviewed Patient #3's medical record and confirmed there were no case management notes or interdisciplinary team notes until 8/03/2016, five days after patient #3's admission. B stated "I'm not surprised".

During review of Inpatient #8's medical record on 5/24/2017 at 4:15 PM with Quality Director (QD) B and Chief Nursing Officer (CNO) D, record revealed Patient #8 was admitted on 5/17/2017, no case management notes or completed "Interdisciplinary Team Meeting" notes were in this record.

During review of Inpatient #9's medical record on 5/24/2017 at 4:25 PM with QD B and CNO D, record revealed Patient #9 was admitted on 4/10/2017, no case management notes or completed "Interdisciplinary Team Meeting" notes were in this record.

During review of Inpatient #10's medical record on 5/24/2017 at 4:35 PM with QD B and CNO D, record revealed Patient #10 was admitted on 3/27/2017, completed "Interdisciplinary Team Meeting" notes were in this record.

During review of Inpatient #11's medical record on 5/24/2017 at 4:50 PM with QD B and CNO D, record revealed Patient #11 was admitted on 5/08/2017, no case management notes or completed "Interdisciplinary Team Meeting" notes were in this record.

An interview was conducted with Patient #10 on 5/24/2017 at 4:56 PM, Patient #10 stated that he/she was not involved in their plan of care, that he/she did not feel as though they had included him/her in the decision making process, and that he/she was not ready to go home yet, and stated "I don't know the plan".

Based on record review and interview, the hospital failed to ensure that all patient/patient representatives were informed about the right to formulate an advanced directive in 2 of 10 (Patient #3 and #8) patient record reviews in a total universe of 12. This deficiency has the potential to affect all patients receiving care at this hospital during this survey (patient census on 5-23-17 of 22).

Findings include:

1) Patient #3's medical record was reviewed on 5/24/2017 at 2:42 PM with B and revealed no documented evidence that Patient #3 had an Advanced Directive on their chart or that Patient/patient representative #3 had been informed about the right to formulate an advanced directive. "Is Advanced Directive on chart" was marked no, "Was further information given to patient/family?" was left blank.

2) Patient #8's medical record was reviewed on 5/24/2017 at 4:15 PM with B and revealed no documented evidence that Patient #8 had an Advanced Directive on their chart or that Patient/patient representative #8 had been informed about the right to formulate an advanced directive. "Is Advanced Directive on chart" box was marked no, "Was further information given to patient/family?" was left blank.

On 5/24/2017 at 4:15PM, Quality Director B agreed, advance directive information was not documented in the medical records of patient's #3 and #8.