Traditions Health

Based on review of facility policy and procedure, review of medical records and interview, the Department has determined the Administrator failed to ensure that informed consent for the administration of psychotropic medications was provided for 7 out of 20 patients reviewed, Patients #1, 6, 7, 10, 12, 16 & 18.  Failure to provide informed consent for medication administration can result in unforeseen medication interactions and patients not understanding possible medication side effects and adverse reactions, leading to poor patient outcomes.

Based on review of patient medical records, review of facility policy and procedures and interview, the Department has determined the Administrator failed to ensure that a copy of the health care power of attorney (HCPOA) or mental health power of attorney (MPOA) is in the medical record if a patient or a patient's representative indicates one has been executed for 6 out of 20 patients reviewed, Patients #5, 9, 10, 13, 17, &19..  Failure to ensure an executed HCPOA/MPOA is in the medical record can result in medical decisions being made improperly for patients leading to poor patient outcomes.   Findings include:

Based on review of patient medical records, review of facility policy and procedures and interview, the Department has determined the Administrator failed to ensure that patient medical records contained a copy of the patient's living will or health care directive or DNR for 10 out of 20 patients reviewed, Patient #1, 2, 5, 6, 8, 10, 13, 16, 17 & 20.  Failure to ensure that the patient's DNR is in the medical record can result in health care providers and family members being unaware of the patient's wishes when end-of-life decisions must be made.   Findings include: