HospitalInspections.org

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Based on Medical Record review, document review and interview, in two (2) of two (2) Medical Records, the Nursing Staff did not ensure that Consents were obtained for patients who lacked capacity to make decisions regarding their care.

Findings include:

Patient F's Medical Record identified that on 06/08/15 the patient was brought in by ambulance to the Emergency Department with a chief complaint of Seizures. The patient was diagnosed with Bipolar Disorder with Disorganized Behavior. On 06/10/15 a Psychiatric Consultation documented that the patient "lacks capacity to refuse acute medical care. Please refer to next of kin and if family is not available please obtain Administrative Consent." Although the patient's mother and daughter visited the patient, the "Consent to Admission and Treatment" was not obtained.

The same lack of Consent for a confused patient was found in the Medical Record for Patient A.

During interview of Staff #4 (Director of Nursing Medical Surgical) on 06/25/15 at 9:50AM, she stated we should have followed the Policy, we didn't. We'll get the Consent from the daughter.

The facility Policy and Procedure titled "Informed Consent" last revised 06/25/14, described the following: If a patient is judged to lack capacity to make decisions regarding their care by a Psychiatrist, then the Legal Surrogate can make the decision. Consent of the Patient's Surrogate should be obtained first from the adult children and then the parents.
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Based on Medical Record review, document review and interview in one (1) of one (1) Medical Records, the Emergency Room Physicians failed to complete the "Workplace Violence Incident Report" form, as required by the facility's Policy resulting in a four (4) day delay of starting the investigation of an alleged assault.

Findings include:

Patient D's Medical Record identified the patient was brought in by Police ambulance at 5:22PM on 06/04/15, after an altercation at a car wash, was drinking, and had erratic, agitated behavior, with threats to harm himself. The Triage Nurse documented that the patient was suspected of Alcohol Intoxication and that the patient was confused, agitated, taking off his gown, climbing off the stretcher and bothering other patients. The patient was put in two (2) point restraints and placed on a cardiac monitor with pulse oximetry then medicated for agitation at 7:30PM. The Nurse's Note at 10:10PM documented that patient was now "alert and oriented, restraints removed and ambulating with a steady gait".

The Psychiatry Resident documented at 2:26AM on 06/05/15 that the patient allegedly was hit by one (1) of the Doctors and the Attending Psychiatrist documented that the patient reported that he was hit by some Doctor. The Physician documented that the ER (Emergency Room) Doctor on shift was spoken to and stated that he was given no such sign out. There is no additional documentation regarding the allegation contained in the Record.

The facility Policy and Procedure tilted "Workplace Violence Policy and Prevention Program" last revised on 01/29/15 directs "Any employee who becomes aware of a display of violent, abusive or threatening behavior must report such behavior"; "following an exposure to a hostile act, the employee must immediately notify their Supervisor. The Supervisor and employee will complete a "Workplace Violence Incident Report" and an "Incident Report" electronically" and "all Incidents, including potential Incidents, should be reported within 24 (twenty-four) hours or as soon as possible". However, there was no evidence that the Psychiatric Resident, Attending Psychiatrist or Emergency Physician completed the required Reports.

During an interview with Staff #3 (Vice President of Quality Management) on 06/26/15 at 11:00AM, the staff member stated that the allegation was self-disclosed to the President / CEO and the investigation was ongoing. But the Emergency Room Physicians should have completed a "Workplace Violence Incident Report" when they became aware of the allegation, regardless of which Department the Physician was employed under, which would have started the investigation early.