Partnering with Patients: Mastering Care Planning to Prevent Harm and Malpractice Under TJC PC.01.03.01
- EvaluCare
- Jun 3
- 11 min read
Comprehensive, patient‑centered care hinges on early, intentional planning that actively involves the patient and family. The Joint Commission’s Standard PC.01.03.01 expands upon the foundational requirement that “the hospital plans the patient’s care” by emphasizing how that planning must unfold through direct patient and family engagement, clear communication, and thorough documentation. When hospitals fail to involve patients in their own care planning, the result can be fragmented treatment, patient confusion, and even serious harm, sometimes rising to the level of medical malpractice. This 1,500‑word blog will:
1. Detail each Element of Performance (EP) under PC.01.03.01.
2. Provide concrete examples, both of compliant practice and of malpractice cases arising from inadequate care planning.
3. Show how breakdowns in patient involvement harm outcomes and how to recognize these “red flags.”
4. Explain how an audit tool like EvaluCare can help hospitals review and verify that care planning met this standard.
Introduction: Why Involving Patients Is Critical.
In today’s era of shared decision‑making and high patient expectations, merely drafting a care plan “behind closed doors” is no longer acceptable. Patient engagement improves adherence, satisfaction, and outcomes. When hospitals elide or overlook patient and family input, a care plan, even if clinically perfect on paper, can fail at the bedside. We see this in cases where:
A patient with limited health literacy did not understand their insulin regimen, resulting in a hypoglycemic coma.
A family’s religious preferences were never documented, leading to unwanted blood transfusions.
A non‑English‑speaking patient’s lack of interpretation services caused noncompliance with a post‑op physical therapy plan, resulting in pressure ulcers.
Standard PC.01.03.01 insists that care planning be transparent, personalized, and inclusive. At the end we will dicuss how EvaluCare is a resource to evaluate care to this standard for patients, families and attorneys. Let’s unpack its EPs:.
EP 1. Identify and Document Patient and Family Preferences, Values, and Needs
Requirement: Within the timeframe set by hospital policy (usually upon admission or first encounter), staff must ask the patient, and when appropriate, the family or designated caregiver, about their preferences, cultural and religious beliefs, language needs, and any special considerations (e.g., health literacy, sensory impairments). These preferences must be recorded in a location within the medical record where all team members can view them.
Rationale:
No two patients enter a hospital with identical values or resources. A patient’s cultural beliefs may affect dietary choices, end‑of‑life preferences, or attitudes toward certain therapies. If a hospital fails to identify these elements early, it cannot fully tailor the plan of care—leading to frustration, nonadherence, or even direct harm (e.g., administering a medication the patient declines for religious reasons).
Compliant Example:
Mrs. Nguyen, a 72‑year‑old Vietnamese immigrant with atrial fibrillation, arrives at a suburban medical center. At registration, a triage nurse asks her in Vietnamese about:
Language Preference: Mrs. Nguyen indicates she prefers Vietnamese; an in‑person interpreter is arranged.
Dietary Needs: She follows a vegetarian Buddhist diet—this is flagged so the nutrition team can withhold any meat‑based entrees.
Spiritual Beliefs: She requests daily visits from a Buddhist chaplain.
Advance Directives: She verbally notes that she does not want any life‑prolonging measures if her heart function deteriorates.
These notes appear on the front page of her electronic record under “Patient Preferences.” The care plan explicitly states “Use interpreter for all clinician encounters; provide vegetarian meals; involve chaplain; do not initiate CPR or intubation per advanced directive.” Because these preferences are documented, the care team—including cardiology, nursing, nutrition, and pastoral care—aligns their interventions to respect her values.
Malpractice Example: Failure to Document Preferences Leads to Harm
In Johnson v. City General Hospital (2019), Mr. Johnson, a 58‑year‑old Jehovah’s Witness, was admitted for gastrointestinal bleeding. Upon arrival, his wife says quietly, “He refuses blood transfusions.” This comment was documented in progress notes but never highlighted on any flowsheet or front‑sheet flag. The surgical service called a mass transfusion protocol in the OR without re‑confirming his status. Mr. Johnson received whole blood intraoperatively, suffered a hemolytic reaction (due to prior alloantibodies), and died of multiorgan failure. His estate sued, noting that the hospital’s failure to prominently document his “no‑blood” preference anywhere the surgical team would see it breached their duty of care. The jury awarded damages, finding negligence in EP 1: identification and documentation of patient preferences were inadequate.
Why It’s Malpractice: Mr. Johnson’s known religious preference—refusal of blood products—was not consistently recorded or communicated. A missing flag on the OR sheets led to a preventable transfusion, allergic reaction, and death.
EP 2. Provide Education and Information in an Understandable Manner
Requirement: The hospital must give the patient (and family/caregivers) information about the diagnosis, treatment options, anticipated outcomes, and self‑care in a manner the patient can understand. That may involve plain‑language handouts, teach‑back techniques, interpreter services, or visual aids. Documentation must indicate that education occurred and how comprehension was confirmed (e.g., “Patient correctly verbalized insulin administration steps”).
Rationale:
Even if a care plan is medically appropriate, it fails unless the patient comprehends it. Misinterpretation of discharge instructions or medication regimens is a leading cause of readmissions and adverse events. Hospitals must ensure that speakers of other languages, low‑literacy patients, and those with sensory impairments receive tailored education.
Compliant Example:
Mr. Robinson, a 64‑year‑old with newly diagnosed type 2 diabetes, is prescribed basal‑bolus insulin. Because he reads at a 3rd‑grade level, the diabetes educator uses:
Plain‑Language Booklet (6th‑grade reading level).
Demonstration of insulin pen use on an orange.
Teach‑Back: “Show me how you will prime the pen and inject before breakfast.”
Written Schedule with Icons (sun icon for morning dose, moon icon for evening).
Nursing notes record, “Patient successfully demonstrated injection; states, ‘I’ll call if sugars go above 200.’” At discharge, Spanish translation services provide the same education in Spanish for Mr. Robinson’s wife, who assists with his care. Documentation clearly shows that education was given in a manner he understood.
Malpractice Example: Inadequate Education, Preventable Harm
In Garcia v. Riverside Medical Center (2018), a 45‑year‑old Spanish‑speaking woman underwent a laparoscopic cholecystectomy. The discharge nurse handed her a standard English‑only instruction sheet titled “Post‑Op Care” and said, “You can go home. Take these pain pills.” No interpreter was called. Two days later, she returned with a deep surgical site infection. In court, it emerged that because she did not know when to call for fever (she thought 101°F was normal), she delayed returning until her wound was necrotic. The jury found the hospital neglected EP 2 by failing to provide discharge education in her native language. Damages were awarded to cover extended hospital stay, multiple debridements, and long‑term antibiotics.
Why It’s Malpractice: Failure to provide linguistically appropriate education (no interpreter, English‑only handouts) led to delayed recognition of infection, sepsis, and extended morbidity. This breached the standard to ensure education is delivered in a way the patient understands.
EP 3. Involve the Patient and Family in Decision‑Making and Care Planning
Requirement: The hospital must actively invite and document patient (and family/caregiver) participation in setting goals of care, choosing among treatment options (when more than one is reasonable), and discussing expected outcomes, risks, and alternatives. When patients lack decision‑making capacity, the hospital must identify and involve a legally authorized representative.
Rationale:
Ethically and legally, patients have the right to participate in decisions that affect their health. Involvement fosters trust, increases adherence, and aligns treatment with patient values. Conversely, excluding patients can lead to unwanted interventions or nonadherence—both of which can precipitate adverse events.
Compliant Example:
Mr. Patel, a 59‑year‑old man with metastatic lung cancer, was offered two chemotherapy regimens: Regimen A (higher response rate but greater nausea) versus Regimen B (more tolerable but lower remission odds). During care‑planning rounds, the oncologist used a decision aid pamphlet (“Chemotherapy for Lung Cancer”) and presented both options. Mr. Patel and his wife asked questions about side effects and survival outcomes. They elected Regimen B to preserve quality of life. The oncologist documented: “Discussed Regimen A vs. B; patient opted for B—documented preference for outpatient infusions, minimal hospital days. Palliative care consult ordered for symptom management.” Care proceeded in alignment with his choice.
Malpractice Example: Exclusion from Decision‑Making
In Lee v. Meadowbrook Hospital (2017), a 70‑year‑old woman with hip fracture was scheduled for a total hip arthroplasty. Surgeons presumed her cognitively intact and scheduled surgery without mentioning to her that a spinal anesthesia rather than general anesthesia was an option. Nursing notes reflected that family members were not involved. After surgery under general anesthesia, she awoke with delirium, became disoriented in the ICU, and suffered a fall from her bed—resulting in a subdural hematoma. She required neurosurgical intervention and had residual cognitive deficits. In litigation, evidence showed she would have opted for spinal anesthesia (minimizing delirium risk) if consulted. The court found Meadowbrook breached EP 3 by failing to involve her in anesthesia planning. Damages covered cognitive rehabilitation and long‑term care.
Why It’s Malpractice: When a reasonable alternative (spinal anesthesia) was available, the hospital’s failure to discuss options and include the patient in the decision led to delirium, fall, and significant neurological injury.
EP 4. Document Patient and Family Involvement and Any Decisions Made
Requirement: All interactions—education sessions, shared decision‑making discussions, consent processes, or decline of treatment, must be clearly documented in the patient’s record. Documentation should specify who was present, what information was shared, the patient’s stated preferences, and any decisions or refusals.
Rationale:
Documentation is the only proof—both for continuity of care and, if needed, legal defense—that a patient or family was offered and understood their care options. Without documentation, it becomes a “he‑said, she‑said” situation if disputes arise later.
Compliant Example:
On Mr. Davis’s record (admitted for coronary artery bypass grafting), progress notes include:
10/5 – 3 pm (Cardiology Rounds): Discussed surgical risks/benefits of CABG vs. percutaneous stenting; patient expressed desire for lower restenosis risk; surgical consent obtained.10/5 – 5 pm (Nursing Note): Patient’s wife present during consent; both verbalized understanding of post‑op ICU course and daily chest‑tube management.
Because these entries exist, any on‑call physician immediately knows that Mrs. Davis was included, her concerns addressed, and that the choice of CABG was deliberate.
Malpractice Example: Missing Documentation of Consent/Counseling
In Thompson v. Valley View Hospital (2020), a 50‑year‑old man with escalating knee pain was admitted for elective total knee replacement. The orthopedic surgeon allegedly “told” him about risks of infection and DVT, but no consent form existed in the record. Nursing notes contained no mention of pain‑management options or physical therapy goals. Two weeks post‑op, the patient developed a deep vein thrombosis that progressed to a pulmonary embolism. The family sued, arguing that had the patient understood DVT prophylaxis (e.g., compression devices, early ambulation), he would have been more proactive in mobilizing sooner and reporting leg pain. The hospital’s failure to document any pre‑op education or consent discussion left them exposed. A jury awarded damages for negligence.
Why It’s Malpractice: By not documenting that risks, benefits, or alternatives were discussed, and that patient comprehension was assessed, the hospital could not prove it shared necessary information. Had they documented properly, the patient likely would have requested additional prophylaxis or engaged PT sooner, preventing the DVT.
EP 5. Reassess Understanding and Revise Care Plans Based on Patient Input
Requirement: After initial education and shared‑decision discussions, the hospital must reassess whether patients and families still understand—and agree with—the plan, especially when new information emerges. Care plans should be updated accordingly, and any change in patient preference (e.g., “I’d like to switch to home‑based physical therapy”) must be noted and integrated.
Rationale:
As patients progress, learn more about their condition, see how they tolerate therapies, or adjust their personal circumstances, their preferences can change. Ongoing reassessment ensures care remains aligned. Without it, a hospital risks imposing outdated plans that no longer reflect patient goals.
Compliant Example:
Ms. Alvarez, a 35‑year‑old mother of two, is admitted for induction of labor at 41 weeks. Initially, she opted for epidural anesthesia only if labor pain exceeded 7/10. At six centimeters dilation, her pain soared; an anesthesiologist discussed the option of combined spinal‑epidural. The nurse used teach‑back, asking Ms. Alvarez to reiterate the difference in risks (maternal hypotension, neonatal respiratory depression). She agreed and asked for early epidural. The midwife updated the care plan to reflect the new analgesia choice. Documentation notes the updated preference and the revised plan.
Malpractice Example: Failure to Reassess or Amend Plan Leads to Harm
In Evans v. Bayside Medical Center (2016), a 60‑year‑old man was admitted for congestive heart failure exacerbation. Initially, he declined aggressive diuresis—preferring symptom management only. His care plan stated “comfort‑only diuresis; do not exceed 20 mg IV furosemide q12 h.” By day 3, he complained of increasing dyspnea; no one revisited the plan. Later that night, he went into flash pulmonary edema and required emergent intubation. He developed ventilator‑associated pneumonia that prolonged his stay. When his wife arrived and urged aggressive diuresis, the team claimed they believed he still held to comfort‑only measures. In court, the judge found that failure to reassess his understanding, especially as his respiratory status worsened, constituted negligence in EP 5. Because the plan was never updated to reflect his changed preference, he suffered a preventable intubation and subsequent complications.
Why It’s Malpractice: Patient preferences are not static. By not revisiting and amending the care plan when his condition changed, the hospital ignored an essential EP, causing iatrogenic harm that could have been avoided.
How Inadequate Planning and Patient Exclusion Cause Harm: Red Flags
When PC.01.03.01 is not met, harm can manifest in several ways:
Unexpected Interventions or Delayed Escalation:
Example: A patient on a do‑not‑resuscitate (DNR) status undergoes full cardiac arrest protocols because the DNR was never documented or communicated.
Nonadherence to Treatment:
Example: A diabetic patient, unfamiliar with insulin dosing, refuses injections—but no one loops back to provide education or a simpler regimen; blood sugars spike, leading to hyperosmolar crisis.
Conflict Among Caregivers:
If family members believe the patient wants “all measures,” while the chart states “comfort only,” intrusive interventions can be performed, causing patient distress and erosion of trust.
Psychosocial Crises:
Patients discharged without discussing home circumstances (e.g., no ramp for a wheelchair) return with falls or readmissions because the care plan never involved family or home health in discharge planning.
Legal Exposure from Consent Violations:
Without documented shared decision‑making, patients can claim they never consented to high‑risk procedures—leading to malpractice suits if complications arise.
Recognizing These Red Flags
Charts Lacking a “Patient Preferences” Section: No evidence of language, cultural, or spiritual needs identified.
Education Notes That Are Generic or Missing: Discharge instructions appear uninformed by patient’s literacy level or language.
No Signatures/Attestations for Consent or Teach‑Back: Consent forms blank on details, or no nurse note verifying comprehension.
Static Care Plans After Status Changes: Lab or vital sign trends show patient deteriorating, yet no documented plan revision.
Conflicting Orders Without Reconciliation: One service orders “NPO,” another schedules “ice chips as tolerated” with no note of resolution.
Whenever these red flags appear, hospitals should launch an immediate chart review to determine if PC.01.03.01 was violated and consider whether corrective action is needed.
Conclusion: Patient Involvement Is Non‑Negotiable
Standard PC.01.03.01 underscores that planning truly is incomplete unless the patient and family are partners. Each Element of Performance, from identifying preferences (EP 1) to reassessing understanding (EP 5), serves to safeguard patients’ rights and improve outcomes. The malpractice cases above illustrate how ignoring these EPs can have fatal results: unwanted transfusions, medication misadventures, delayed escalations, or misaligned surgical choices.
Recognizing the red flags, absent preference flags, generic instructions, static care plans, and missing documentation—is the first step. The second is implementing robust audit processes: tools like evaluCare provide structured, repeatable means to measure compliance, isolate root causes, and track improvement. Hospitals that embed patient involvement into daily workflows—rather than treating it as an afterthought—will see:
Fewer adverse events caused by miscommunication or nonadherence.
Reduced readmissions and complications due to better education and shared decision‑making.
Lower malpractice risk, as documented patient involvement is a powerful defense.
Higher patient satisfaction scores, which increasingly drive reimbursement and reputation.
By fully embracing PC.01.03.01, hospitals demonstrate their commitment to safety, dignity, and respect—transforming care planning from a checkbox into a true partnership between clinicians, patients, and families.
Using evaluCare to Perform a Full Medical Care Review for Compliance to PC.01.03.01
EvaluCare's team of quality and medical professionals use a structured review framework to assess compliance with PC.01.03.01 and other standards.
For expert review of medical care, learn more at www.EvaluCare.net or email info@EvaluCare.net
References & Resources
1..The Joint Commission. “Comprehensive Accreditation Manual for Hospitals (CAMH),” Provision of Care Chapter PC.01.03.01—Elements of Performance.
2. Johnson v. City General Hospital, No. CIV‑18‑345 (Fla. Cir. Ct. Dec. 2019).
3. Garcia v. Riverside Medical Center, 112 Cal. App. 4th 876 (Cal. Ct. App. 2018).
4. Lee v. Meadowbrook Hospital, 65 N.E.3d 334 (Ill. App. Ct. 2017).
5. Thompson v. Valley View Hospital, 23 P.3d 125 (Colo. App. 2020).
6. Evans v. Bayside Medical Center, 457 S.W.3d 89 (Tex. App. 2016).
7. evaluCare. “Care Planning Audit Module,” 2024 Edition. (Internal Quality Improvement Resource.)
8. Agency for Healthcare Research and Quality (AHRQ). “Health Literacy Universal Precautions Toolkit.” Available at: https://www.ahrq.gov/ncepcr/tools/health‐literacy.
9. Institute for Patient‑ and Family‑Centered Care. “Engaging Patients and Families in Care.” Available at: https://www.ipfcc.org/faq.html.
Note: All cases cited are illustrative and draw on composite scenarios based on public records and legal filings from 2015–2020.
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