HospitalInspections.org

Based on policy review, document review, medical record review, and interview, the facility failed to allow the patient to make informed decisions regarding their care for 3 of 5 (Patient #1, 2 and 3) sampled patients.

The findings included:

1. The facility's "Patient Rights and Responsibilities Summary" policy revealed, "...Dignity: You have the right to considerate and respectful care...Decision-making: You have the right to make decisions about the plan of care prior to...the course of treatment...Visitation Rights...If visitation is limited because of clinical restrictions or limitations, you must be informed..."

2. The Behavioral Health Unit's (BHU) "Patient Handbook" revealed, "15 Barry-West Adult Visitor's Guide Visitation Times: Tuesday and Thursday, 7:30 - 8:30pm...Saturday and Sunday, 2:00pm-3:00pm..."

The Patient Handbook also included the unit schedule, telephone times, items that could be brought to the unit, items that could not be brought to the unit, the Declaration for Mental Health Treatment, Patient Rights and other general information about the hospital.

3. Review of the 15 Berry-West Schedule revealed activities beginning at 7:30 AM with various groups and activities scheduled throughout the day with Wrap-up group at 7:00 PM.

During an interview on 8/27/18 at 1:45 PM in the conference room the Director of the BHU was asked if the unit schedule was the same on the weekend as it was during the week. The Director stated, "It should be."

4. Medical record for Patient #1 revealed an admission date of 4/21/18 with diagnoses which included Major Depressive Disorder, single episode, Obesity, and Irritable Bowel Syndrome.

Patient #1 signed the "Condition of Service" agreement on 4/21/18 at 2:14 AM verifying that she received the facility-wide "Patient Rights and Responsibilities Summary." There was no documentation she had received the BHU patient Handbook.

During a telephone interview on 8/30/18 at 1:40 PM, Patient #1 revealed that she was not informed that she could not see her children until she got to her room at 4:00 AM on the day of admission. Patient #1 revealed that she asked the Social Worker if she could visit with her children and was told, "No. It's against the rules because it is not safe." Patient #1 further revealed that she did not know what to expect from treatment and some of the staff told her to wait until Monday to find out because the care was different on the weekends.

Patient #1 verified that she did not receive a BHU Patient Handbook upon admission.

5. Medical record review for Patient #2 revealed an admission date of 8/20/18 with a diagnosis of Acute Depression.

During an interview in the multi-purpose room on 8/28/18 at 9:45 AM, Patient #2 verified that she did not receive a BHU Patient Handbook upon admission. Patient #2 further revealed that she had not seen the unit schedule until staff had posted it yesterday.

6. Medical record review for Patient #3 revealed an admission date of 8/22/18 with a diagnosis of Bipolar Disorder with Psychotic features.

During an interview in the multi-purpose room on 8/28/18 at 11:00 AM, Patient #3 verified that she did not receive a BHU Patient Handbook upon admission and the schedule was different on the weekend.

7. During an interview in the Clinical Assessment Center (CAC) on 8 /27/18 at 2:10 PM, the Director of the BHU verified that all patients should be given a Patient Handbook when they are admitted to the BHU. The Director further verified that Patient #1 was not given a handbook when she was admitted.

8. During an interview on 8/28/18 at 11:45 AM in the multi-purpose room, the BHU Nurse Manager verified there is a weekend schedule for 15 Berry-West.

Based on medical record review and interview, the facility failed to ensure medical record entries were complete for 1 of 5 (Patient #1) sampled patients.

The findings included:

1. Medical record for Patient #1 was a 35 year old who presented to the hospital's Clinical Intake center on 4/21/8 at 11:35 PM. Patient #1 was assessed by Assessor #1 beginning at 1:05 AM.

The Unified Clinical Assessment/Clinical Assessment performed by Assessor #1 revealed Patient #1's chief complaint was, " ...suspects chemical imbalance and psychological distress has caused her to experience the desire to harm herself." Assessor #1 documented Patient #1's stated goals for treatment were, " ...head to stop hurting and for her children to not see her [illegible] anymore ..."

Assessor #1 failed to document Patient #1's current risk to self or others in the Initial Evaluation of Risk to Self or Others section of the assessment.

2. During an interview on 8/27/18 at 3:55 PM in the multi-purpose room, Assessor #1 verified that he should have documented Patient #1's risk to self or others in that section of the assessment.