HospitalInspections.org

Based on interview and record review the hospital failed 1 of 1 patient (Patient #1) to inform Patient #1 or the Patient #1's representative of the treatment plan transcribed for Patient #1 (as allowed under State law), of the patient's righs in advance of furnishing or discontinuing patient care whenever possible.

Findings Inlcude:

In review of the hospital medical record "Treatment Plan" the family was not notified or informed of the decisions of treatment being made for Patient #1. The family was not invited to the Treatment Plan team meeting or notified on the telephone to participate through conference call. During record review the hospital incident report did not reflect that the family was notified of Patient #1's falls. The hospital nursing notes reported a follow up call to the hospital to find out the status of Patient #1. At this point the nurse was informed that this patient would not be returning to the hospital.

During an Interivew with hospital Staff #5 reported that the family was not notified of the family Treatment Plan.
During an Interview with Staff #3, she was asked what is the hospital Policy to about incident reports and notifying the family. Staff #3 reported that anytime an incident report has to be wriitten following an incident the staff documenting the report should notifiy the family.

Policy

The hospital Policy on Patient Rights dated 06/2016 reflected, "It is the policy are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statutes and rules and only if the exercise of those rights would constitute harm to the patient or others."

Based on interview and record review the hospital failed 1 of 1 patient (patient #1), the right to receive care in a safe setting.

Findings include:

Based on interview Patient #1 was assessed upon admission and was considered a High Risk for falls. Patient #1 was not placed on 1:1 status at that time. Patient #1 had two falls prior to being placed on 1:1 status. The hospital staff failed to remain within arms length after the patient had a physician's order for 1:1 staff.

Based on record review Patient #1 had physician orders to placed on 1:1 status. The hospital incident report stated that Patient #1 fell to the floor and the patient was observed at the doorway. The staff failed to remain in arms length.

Policy:

The hospital Policy on Patient Rights dated 06/2016 reflected, "It is the policy are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statutes and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Policy on Falls Prevention and Monitoring, dated 10/2018 reflected, "Upon admission to the hospital, all patients will be assessed using the Morse Falls Scale and Medication Fall Risk Score scale as part of the Nursing Assessment. This assessment is used to identify the patient specific risk factors and to plan care and interventions based on those risk factors. Nurses will look at both scales and identify specific areas of risk and ensure measures and interventions are in place to prevent a future fall."

The hospital Policy on Neglect dated 12/2018 reflected, "Neglectful Supervision Placing in, or failing to remove, the patient from a situation that a reasonable individual would realize required judgement or actions beyond the physical condition or mental abilities and the results in bodily injury or substantial risk of immediate harm to the person ...The failure to provide for one's self the goods or services necessary to avoid physical harm, mental anguish or mental illness or the failure of a caretaker to provide such goods or services."

Based on record review the hospital failed 1 of 1 patient (Patient #1), by assigning the nursing care of Patient #1 to another nursing personnel in accordance the Patient's needs.

Findings Include:

Based on record review the hospital investigation reflected that Patient #1 arrived at Frisco Medical Center without wearing underwear or or briefs, and it unclear as to why the patient would not have been wearng underwear or briefs. The recieving hospital reported upon Patient #1's arrival his pants and shirt were soaked of urine. Patient #1 was not wearing underwear or briefs.

Policy

The hospital Policy on Nursing Services dated 06/2016 reflected, "All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems with in the interdisciplinary treatment plan.

The hospital Policy on Abuse/Neglect dated 12/2018 reflected, "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ...this hospital to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. The hospital mandate ...under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person in the state of abuse, exploitation and/or neglect shall report the information to the appropriate regulatory agency. All allegations, observation or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital."

The hospital Policy on Patient Rights dated 06/2016 reflected, "It is the policy are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statutes and rules and only if the exercise of those rights would constitute harm to the patient or others."