HospitalInspections.org

Based on record review and interview, the facility failed to inform 1 (P (patient) P9) of 10 (P1-P10) patients of their patient rights on admission. This deficient practice is likely to result in patients being uninformed/unable to exercise their rights.

The findings are:

A. Record review of policy "Patient Rights and Responsibilities, last revised 12/2016, ADM POL (Administrative Policy) 2-1". "The patient ...shall be given information about rights and responsibilities upon admission."

B. Record review of P9 medical record, revealed no signed notice of receipt of a copy of the "Patient Rights," that would have been found on the "Consent for Services and Financial Responsibility ...16. Patient Rights: I have received a copy of the Patient Rights," to have been signed by P1 upon admission to the facility.

C. On 08/29/2023 at 1:43 pm, during interview with Staff (S) 18 Quality Coordinator and review of P9 medical record S18 confirmed "there are no consents here."

Based on record review and interview, the facility failed to provide 1 (P (patient) P9) of 10 (P1-P10) patients, the opportunity to be involved in his or her own medical care or to be able to request or refuse treatment. This deficient practice is likely to cause patients to be unable to participate in their own care or be able to request or refuse treatment.

The findings are:

A. Record review of policy "Element V-Admission/Discharge," last revised 01/2021. "A. Admission Policies, 6. Consent, a. Patients presenting to the Emergency Department for examination and/or treatment ...sign a consent for treatment."

B. Record review of P9 medical record, revealed no signed notice of receipt of a copy of the "Patient Rights," no signed "Consent for Services and Financial Responsibility," and no "Emergency Department Consent for Treatment," that would have been signed upon admission to the Emergency Department.

C. Record review medical provider's note for P9, dated 06/13/2023 at 10:58 am revealed "Patient was evaluated by Dr. [physician name] of psychiatry this tele psych [refers to the delivery of psychiatric assessment and treatment via telecommunications technology, usually video conferencing] and recommended inpatient admission for acute psychosis [a common psychiatric emergency that involves hallucinations, delusions, disorganized thoughts or behaviors]."

D. Record review of P9 medical record, revealed no signed "General Informed Consent for Telemedicine Services."

E. On 08/29/2023 at 1:43 pm, during interview with Staff (S) 18 Quality Coordinator and review of P9 medical record S18 confirmed "there are no consents here."

Based on record review and interview, the facility failed to provide 1 (P (patient) 9) of 10 (P1-P10) patients, the opportunity to formulate an advance directive (legal documents that provide instructions for medical care and only go into effect if you cannot make your healthcare decisions yourself). This deficient practice could lead to patients being unable to prepare an advance directive.

The findings are:

A. Record review of policy Patient Rights and Responsibilities, last revised 12/2016. " ADM POL (Administrative Policy) 2-1". "8. The patient has the right to have an advance directive, such as a living will or durable power of attorney for health care ..."

B. Record review of P9 medical record, revealed no signed notice of receipt of the "Advance Directive Acknowledgment," to verify that the patient was provided the opportunity to formulate an advance directive.

C. Record review of P9 medical record revealed no signed "Consent for Services and Financial Responsibility" which includes section "18. Advance Directive Acknowledgement" with the following statements with checkmark boxes:
1. "I have executed an Advance Directive"
2. "I have not executed and Advance Directive"
3. "I would like to formulate an Advance Directive and receive additional information"

D. On 08/29/2023 at 1:43 pm, during interview with Staff (S) 18 Quality Coordinator and review of P9 medical record S18 confirmed "there are no consents here."

Based on observation, record review and interview, the facility failed to provide care in a safe environment by having the curtains in the patient rooms in the Behavioral Health Unit that represent a ligature risk (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation; ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges, and closures). This deficient practice is likely to lead to serious injury or death to all patients in the Behavioral Health Unit.

The findings are:

A. During observation of Behavioral Health Unit on 08/28/2023 at 1:36 pm, found the curtains in the patient rooms are securely attached to the window frames and do not pull away when tugged with force.

B. Record review of CMS (Centers for Medicare and Medicaid Services) Center for Clinical Standards and Quality/Survey & Certification Group, S&C (Survey and Certification) Memo: 18-06-Hospitals, Date: December 08, 2017, defines a Ligature Risk as: "anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include ...window and door frames ...."

C. During interview on 08/28/2023 at 1:36 pm with Staff (S)2 Chief Nursing Officer confirmed the curtains in the unit do not pull away from the window frames.

D. During interview on 08/28/2023 at 1:36 pm with Staff (S)16 Director of Nursing Behavioral Health. When asked if the curtains may pose a ligature risk. S16 stated "Yes, the curtains do not pull off and they are planning on replacing the curtains with pull away versions."

Based on record review and interview the facility failed to perform an evaluation after restraints (restrictive measure used to alter how a patient interacts with their environment) for 1 (P [patient] 1) of 10 (P1 - P10) patients reviewed for proper use of restraints. This failed practice can lead to restraints being improperly ordered and patients not evaluated in a timely manner.

The findings are:

A. Record review of facility policy titled, "Restraint/Seclusion in Patient Management" dated 08/2022 on page 4 under "Guidelines for Restraint Use" it stated, "Face-to-Face: Evaluation will be performed by a qualified practitioner within 1 hour [from the time the restraint was applied]."

B. Record review of "Nurse's Notes" for P1's emergency department visit from 05/14/2023 - 05/24/2023 revealed restraint documentation starting on page 13. Patient was restrained on 05/14/2023 at 9:30 AM, 05/17/2023 at 5:00 PM, 05/20/2023 at 9:54 PM, and 05/23/2023 at 3:14 AM.

C. Record review of Physician Documentation for P1's emergency department visit from 05/14/2023 - 05/24/2023 revealed under "Procedures" on page 3 there is a note dated 05/17/2023 at 5:03 PM that stated, "Restraint/Seclusion [isolated to allow patient to calm down and/or keep them safe]: "My in-person evaluation, was conducted within one hour of the initiation of restraints or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others." The evaluation included the patient's immediate situation. "The patient is active and exhibiting inappropriate behavior at this time. The patient remains violent at this time." No evidence was found that a face to face was done on 05/14/2023, 05/20/2023, or 05/23/2023.

D. During an interview on 08/29/2023 at 11:00 AM with S (Staff)18, Quality Coordinator when asked about the face-to-face evaluation for all of P1's restraint events, it was confirmed that a face-to-face was not documented for each event.