HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) clinical records reviewed for restriction of privileges, the Hospital failed to ensure a physician order was obtained.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 22 year old female admitted on 6/19/17 with a diagnosis of autism. The clinical record of Pt. #1 indicated that visitation privilege was restricted on 6/28/17. However, the record lacked a physician's order for the restriction of privileges.

2. On 7/12/17 at approximately 1:30 PM, the Hospital's policy titled, "Restriction of Privileges" (revised 2/17) was reviewed and required, "The following privileges/activities may be temporarily restricted by staff when there is a genuine concern for a patient and/or unit safety and welfare: visitors...C. Physician... orders obtained regarding duration of restriction."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that, "There should have been an order for the restriction for visitation."

B. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) clinical record reviewed for restriction of privileges, the Hospital failed to ensure guardian was notified as required.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 22 year old female admitted on 6/19/17 with a diagnosis of autism. The clinical record of Pt. #1 indicated that visitation privilege was restricted on 6/28/17. The clinical record lacked documentation that Pt. #1's guardian (mother) was notified.

2. On 7/12/17 at approximately 1:30 PM, the Hospital's policy titled, "Restriction of Privileges" (revised 2/17) was reviewed and required, "...E. Patient, family members, (in case of... guardian...) will be notified of restriction."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 who stated that there was no documentation that guardian was notified.

Based on document review and interview, it was determined for 1 of 3 psychotropic drug record reviewed (Pt #3), the Hospital failed to ensure that consent to psychotropic medication was completed as required.

Findings include:

1. On 7/11/17 at approximately 10:40 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 53 year old male admitted on 7/7/17 with a diagnosis of depression. Pt. #3 had a physician's order of Wellbutrin (antidepressant) on 7/8/17. Pt. #3 received Wellbutrin on 7/8/17; 7/9/17; and 7/10/17. However, Pt. #3's clinical record did not include the Psychotropic Counseling Medication form to indicate informed consent was provided.

2. On 7/12/17 at approximately 3:00 PM, the Hospital's policy titled, "Psychotropic Medications" (revise 2/17) was reviewed and indicated, "...Purpose: To facilitate the patient's informed consent and cooperation... Procedure:... B. The patient and psychiatrist or other Behavioral Health Member giving the explanation will sign the Psychotropic Counseling Medication form..."

3. On 7/11/17 at approximately 10:45 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that there was no consent form for the Wellbutrin.

Based on document review and interview, it was determined for 1 of 3 (Pt. #4) clinical records reviewed for suicide assessment, the Hospital failed to ensure a suicide assessment was completed for each shift, as required.

Findings include:

1. On 7/11/17 at approximately 10:30 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 15 year old male admitted on 7/9/17 with a diagnosis of suicidal ideation. The clinical record lacked documentation of a suicide assessment for the 3-11 shift on 7/10/17.

2. On 7/12/17 at approximately 2:00 PM, the Hospital's document titled, "Suicide Assessment: Proper documentation for suicide assessments" (undated) was reviewed and required, "...The suicide assessment is a crucial part of assessing the patient for safety... This assessment is completed... every shift..."

3. On 7/11/17 at approximately 10:35 AM, findings were discussed with E #2 (Behavioral Health Services Manager) who stated that documentation of a suicide assessment for the 3-11 shift on 7/10/17 should have been completed.

Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed for violent restraints, the Hospital failed to ensure a physician order was obtained.

Findings include:

1. On 7/12/17 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 22 year old female admitted on 6/19/17 with a diagnosis of autism. The clinical record indicated that Pt. #1 was in restraints on 6/26/17 from 1:30PM to 5:30 PM. However, the clinical record lacked a physician's order for the restraints.

2. The Hospital's policy titled "Utilization of Restraints & Seclusion" (revised 6/13) was reviewed and indicated, "... Procedure... 2. Orders for all restraint use should be as follows:a. Each episode of restraint or seclusion must be initiated in accordance with the order of a physician..."

3. On 7/13/17 at approximately 9:00 AM, findings were discussed with E #2 who agreed that there was no order for Pt. #1's restraint.