HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 2 (Pt#5) patient converting from an Involuntary admission status to a Voluntary admission status, the Hospital failed to ensure the patient was aware and understood their rights and agreed. This has the potential to affect all patients converting from Involuntary to Voluntary Admission status.

Findings include:

1. The policy titled "Admission Documentation" (revised date 12/29/16) was reviewed on 6/14/17 at 10:00 AM. The policy indicated, "Accurate and timely completion of all documents, with informed consent and patient signature, at the time of admission. The Intake Specialist facilitating the admission has the responsibility to provide the following documents to the patient and/or their legal guardian. All documents will be explained to the patient and/or guardian, and their family where applicable, in a language or mode that they can understand. The patients signature on the document is requested in order to document that they have received the information, understand it, and agree."

2. The clinical record of Pt#5 was reviewed on 6/12/17 at 11:00 AM. Pt #5 was admitted to the Adult Unit on 5/31/2017 with the diagnosis of Unspecific Psychosis not due to substance abuse. On 6/5/17 Pt#5 signed the Application for Voluntary Admission.
The Hospital failed to have the Patient Bill of Rights, Receipt of Notice of Privacy Practices and Advance Directive/Healthcare Proxy Acknowledgement signed by Pt#5 and witnessed by staff as required by Hospital policy.

3. An interview was conducted on 6/12/17 at 2:50 PM with the Quality Assurance/Performance Improvement Manager (E#2). E#2 stated that when a patient transitions from involuntary admission to voluntary admission the social worker is to have all forms sign by the patient and witnessed by staff at the time of admission.


B. Based on document review and interview, it was determined in 1 of 5 (Pt#10) Adolescent patient charts reviewed, the hospital failed to ensure the guardian was aware and understood the patient's rights and agreed. This has the potential to affect all inpatients and outpatients serviced by the hospital with a current census of 60 and 25 respectfully.

Findings include:

1. The policy titled "Admission Documentation" (revised date 12/29/16) was reviewed on 6/14/17 at 10:00 AM. The policy indicated under, "Child/Adolescent Psychiatric Treatment-additional information, the Intake Specialist admitting the minor will be responsible to obtain consent for admission from the legal guardian. If the parent or guardian is not able to travel to the hospital at the time of admission, a verbal consent for admission is to be documented including the name of the person giving verbal consent, their relationship to the patient, the date and time the consent was obtained, and will be documented with the signature of the Intake Specialist who heard the consent."

2. The clinical record of Pt#10 was reviewed on 6/13/17 at 11:00 AM. Pt#10 was admitted to the Adolescent Unit on 3/15/17 with the diagnosis of Post Traumatic Stress Disorder. The Patient Registration form dated 3/14/17 indicated the mother gave verbal consent for admission. The following required documents lacked:

Consent for Treatment Services-Signature of Witness including date and time

Patient Bill of Right - Guardian Oral consent given box not marked or date consent given
Staff signature including date and time

Receipt of Notice of Privacy Practices- Patients Signature including date and time
Patient's Authorized Representative Signature including date and time
Witness Signature including date and time

Verbal Authorization for Release of Protected Health Information-Parent/Guardian Verbal Consent box not marked
Parent/Guardian Printed Name
Signature of staff with date Verbal Consent Received
Print Staff Name with Time Verbal Consent Received
Signature of 2nd Staff with Date Verbal Consent Received
Print 2nd Staff name with Time Verbal Consent Received
Reasoning written consent was not obtained


3. An interview was conducted on 6/15/17 at 11:30 AM with the Case Manager (E#11). E#11 stated the admission documents should have all been completed upon admission with the appropriate signatures, dates and verbal authorization.

A. Based on document review and staff interview, it was determined for 1 of 1 Adult Inpatient Psychiatric Unit Controlled Substance Log dated 6/12/17, the Hospital failed to ensure the accuracy of the controlled medication inventory. This has the potential to affect all 12 patients (census) on the Adult Inpatient Psychiatric Unit.

Findings include:

1. Hospital Policy "Controlled Substances", (reviewed January 2017) was reviewed on 6/14/17 at 3:00 PM. Under, "Page 3. 7. Nursing policy will include the shift change counting of all controlled substances with any discrepancy brought to the Director of Nursing and pharmacist. The controlled substance log will be verified daily against physician orders by the pharmacist and any discrepancy found in the perpetual nursing controlled substance inventory will be brought to the immediate attention of the nurse administrator."

2. During a tour of the Adult Inpatient Psychiatric Unit on 6/12/17 at 11:00 AM a physical count of Ativan 1 mg (medication for anxiety), oral was completed with a total count of 6 tablets. The Controlled Substance Log inventory count record indicated 7 Ativan 1 mg tablets. The Controlled Substance Record Sheet at shift change at 0730 AM on 6/12/17 was verified by 2 registered nurses incorrectly indicating 7 tablets.

3. An interview was conducted with the Charge Nurse of the Adult Unit (E#5) on 6/12/17 at 11:15 AM. E#5 confirmed the Ativan 1 mg was incorrectly recorded as having 7 tablets and confirmed the correct Ativan 1 mg count should have been 6 tablet.

B. Based on document review and staff interview, it was determined for 1 of 1 Adult Inpatient Psychiatric Unit Controlled Substance Log dated 6/12/17, the Hospital failed to ensure proper documentation of waste of a controlled substance medication. This has the potential to affect all 12 patients (census) on the Adult Inpatient Psychiatric Unit

1. The Hospital Policy "Controlled Substances", (reviewed January 2017) was reviewed on 6/14/17 at 3:00 PM. Under, "Page 3. #7. The nurse must sign out each dose in the controlled substance log and note on that log the waste of any drug or part of a drug. Any wastage must include the signature of a witness".

2. During a tour of the Adult Inpatient Psychiatric Unit on 6/12/17 at 11:00 AM the Controlled Substance Record Sheet was reviewed. On 6/12/17 at 9:35 AM documentation indicated Ativan 2 mg/ml was signed out and indicated 1/2 (1 mg) was wasted. There was no signature of a witness noted.

3. An interview was conducted with Charge Nurse of the Adult Psychiatric Unit (E#5) on 6/12/17 at approximately 11:25 AM. E#5 stated there should be a second signature of a witness confirming the 1 mg waste of Ativan.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on June 12 & 13, 2017, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Sample Validation conducted on June 12 & 13, 2017, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated June 13, 2017.