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ABILENE BEHAVIORAL HEALTH LLC
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on review of documentation, staff interviews, and review of policies the facility failed to document the notification of the patients family to participate in the development of an individualized treatment plan, the patient discharge plan, and changes to the patients medication regimen.
Findings were:
Review of the patient's medical record and facility policies on 05/24/16 revealed the
that the patient's individual treatment plan was developed on 01/27/2016. There was no documentation that the parents were contacted to participate in the treatment plan.
The patient was started on antibiotic Ceftin for sinusitis and the mother was not notified in advance of the physician's order.
Review of seven (7) patient medical records on the morning of 05/25/2016 revealed that
Five (5) of the medical records showed no evidence that the parent/guardian were contacted to participate in the patients treatment plan.
Patient # 3, #4, #6, #7, and #8 parent/guardian were not contacted to participate in the patient treatment plan.
.
Review of facility document entitled, "Patient Rights - Description and Procedure", stated in part, "#16. The patient and family, when appropriate, have the right to be involved in all aspects of the patient's care. The right to take part in the development of an individualized treatment plan for his/her hospitalization and discharge. The right extends to the parent or conservator of a minor or the legal guardian, when applicable. The patient has the right to request that the parent, legal guardian, conservator, or other person of his/her choice participate in the development of the treatment plan. The patient has the right to be informed of the reasons for denial of such a request. Staff must document, in the medical record that the parent, guardian, conservator, or other person of his/her choice was contacted to participate."
The above findings were confirmed by the facility Case Manager and the Director of Risk Management in the afternoon of 05/24/2016 in a conference office.