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Based on medical record review, facility policy review and interview, the facility failed to ensure the patient had the right to participate in development of the plan of care for four patients (#2, #3, #4, and #5) of five patients reviewed.

The findings included:

Medical record review revealed patient #2 was admitted on March 10, 2010, with diagnoses to include Schizophrenia. Continued medical record review revealed the patient had not initialed the Check Sheet for Patient Orientation initialing acknowledgement of patient room door being locked daily from 7:00 a.m., until 9:00 p.m.

Medical record review revealed patient #3 was admitted on February 3, 2010, with diagnoses to include Paranoid Schizophrenia. Continued medical record review revealed the patient had not initialed the Check Sheet for Patient Orientation initialing acknowledgement of patient room door being locked daily from 7:00 a.m., until 9:00 p.m.

Medical record review revealed patient #4 was admitted on March 18, 2010, with diagnoses to include Bipolar Disorder. Continued medical record review revealed the patient had not initialed the Check Sheet for Patient Orientation initialing acknowledgement of patient room door being locked daily from 7:00 a.m., until 9:00 p.m.

Medical record review revealed patient #5 was admitted on March 21, 2010, with diagnoses to include Manic Depressive Disorder. Continued medical record review revealed the patient had not initialed the Check Sheet for Patient Orientation initialing acknowledgement of patient room door being locked daily from 7:00 a.m., until 9:00 p.m. Interview with patient #5 in the physician's office of G Unit on March 22, 2010, at 12:50 p.m., revealed the patient complained of not being able to go into the bedroom as the doors were "...locked right after we get up until time for bed..." at about 9:00 p.m. Continued interview revealed patient #5 complained of having to nap in the chairs in the day area when tired.

Review of the facility "Information Guide" provided to each patient on admission revealed "...Privileges will be ordered as your physician and treatment team feel your condition warrants. Kinds of privileges which may be ordered are:...Restricted - you must stay on the unit...Your rights as a MTMHI (Middle Tennessee Mental Health Institute)...Access to services in the least restrictive environment appropriate to the patient's needs and requirements..."

Review of the facility policy Management of Patients at Risk revealed "...to provide specific guidelines for clinical staff and define various levels of special observation and care for patients at risk of being a danger to themselves or others...The patient shall be provided with a level of security as dictated by the patient's assessed needs...One-to-One (1:1):...indicates constant visual 24-hour observation by assigning one (1) individual staff member who must be within arm's length of the patient...with no physical barriers...between the staff and the patient...Intensified Observation:...Prescribed for patients at less risk than those on one-to-one status. Employees assigned to monitor these patients will be continually aware of the patient's location and activities. If the patient leaves the visual range of the employee, the employee will immediately take measures to account for the patient's location and activities...Close Observation (CLO):...shall be prescribed for patients at less risk than those on Intensified Observation and requires the patient to have 5 to 15 minute irregular checks...The Unit Charge Nurse or Unit Nurse Manager shall assign the required number of nursing staff to observe the 1:1, Intensified Observation, and Close Observation patients...Patients on any level of special observation for suicide/self harm also require that the patient's room is checked for safety at the beginning of each shift by both the on-coming and off-going psychiatric technicians...When patients are on special precautions for suicide/self-harm, bathroom and closet doors will be locked at all times and access will require supervision by staff..."

Interview with the Chief Executive Officer, Director of Nursing and Director of Quality Assurance/Risk Manager in the conference room on March 22, 2010, at 2:55 p.m., confirmed all patients on G unit are on 1:1 or Intensified Observation status until time prior to discharge. Continued interview confirmed the patient room doors are locked form 7:00 a.m. until about 8:30 p.m. Continued interview confirmed the Cheek Sheet for Patient Orientation to Unit was not initialed by patient #2, #3, #4, or #5 to indicate the patients were informed of and provided acknowledgement of or agreement to participate in the unit practice to lock patient room doors from 7:00 a.m., until 9:00 p.m.
C/O #24920

Based on medical record review, review of facility documents, facility policy review and interview, the facility failed to ensure care was provided in a secure setting for one patient (#1) of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility on January 11, 2010, with diagnoses to include Paranoid Schizophrenia. Medical record review of the Visitation Form, dated January 12, 2010, revealed one person, a friend, listed as an approved visitor by the patient. Medical record review of the documentation in the Patient Progress, dated January 16, 2010, at 4:30 p.m. (late entry for 2:15 p.m.) revealed "...received call from Security to verify visitor...Informed by (unit) staff who is monitoring visitation the (patient's) mom was allowed onto unit by a staff member from outside of entrance door. Security informed that patient's mom was not allowed to visit...was also informed (by security) that (patient's) brother was also here and in route to visit...informed security that only one person was on the list and the only authorized visitor was already visiting...Brother came to unit and was redirected to Security. Patient informed (note writer) that this was not (patient's) brother but was (patient's cousin). Patient upset at the fact the mom who has a restraining order against (patient) came into to visit without (patient's) approval..."

Review of facility documents, dated January 16, 2010, at 1:50 p.m., revealed "...Pt (patient) mom allowed onto unit by (named) tech (technician). Pt mom was told not to visit R/T (related to) the restraining order against (patient) and charges against (patient). Mom came to the unit and allowed in by (named) tech..."

Continued review of facility documents, dated January 19, 2010, at 4:35 p.m., revealed "...(named tech) reported to work on 1/17/10 (January 17, 2010) to accompany patients on an OT (Occupational Therapy) outing...When (named tech) walked past the Security desk, the guard asked (named tech) if (named tech) would show a visitor where Unit G was located. (Named tech) walked the woman to the unit door and instructed her to ring the buzzer on the side of the wall. Appearing unable to locate the buzzer, (named tech) opened the door for her and told the staff member sitting in the hallway that they had a visitor coming on the unit. (Named tech) did not know the visitor or the patient on Unit G..."

Continued review of facility documents, dated January 19, 2010, at 5:32 p.m., revealed "...she (patient's mother) was not on the visitor list but allowed to come onto the unit...Reinforces the visitor policy may need to be highlighted for security, nursing and support staff..."

Review of the facility policy Visitation, revealed "...guidelines for visitation of patients...protect the interest of both patients and visitors...Visitors will...register with the reception desk...will be asked to provide name and name of the patient they wish to visit...Staff will contact the unit to inform the charge nurse of the visit, and to confirm that the patient is able and willing to receive visitors...when the visit has been approved by the unit staff, the staff will issue a numbered clip-on badge designating the person as a "VISITOR" and will provide the visitor with a map...highlighting the route to be taken to the unit. The visitor will be instructed on the use of the intercom at the entrance to the unit..."

Interview with the Chief Executive Officer, Director of Nursing, and Director of Quality Assurance/Risk Management in the conference room on March 22, 2010, at 2:55 p.m. confirmed the patient was not kept safe from unauthorized visitors.
C/O #24920