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Based on observation, interview and record review, the facility failed to notify patients of the Important Message from Medicare about Your Rights; failed to provide the state toll free hotline number and log complaints; and failed to provide informed consent for the use of psychotropic medications. The systemic effect of these practices resulted in the facility's inability to ensure the patient rights requirement is met for patients admitted to the facility. The facility had a census of 41 patients.

See A116, A118 and A131.

Based on record review and interview, the facility failed to ensure patients received the Important Message from Medicare About Your Rights. This affected three ( Patients #1, #2 and #4) of ten medical records reviewed. The active census was 41.

Findings include:

1. Record review for Patient #1 revealed the patient was admitted to the geriatric psychiatric unit on 01/30/18. The patient was referred from a long term care nursing facility after the patient was reportedly found playing in feces and had called 911 from her room six times in a 24 hour period. Due to the behavioral disturbances and past history of depression and anxiety the patient was transferred to the inpatient psychiatric facility for further evaluation and stabilization. The medical record lacked evidence the patient received a copy of An Important Message from Medicare about Your Rights and/or signed acknowledgement of the rights.

During interview on 03/27/18 at 3:45 P.M., Staff B confirmed this finding.

2. Record review for Patient #2 revealed the patient was admitted to this hospital from a nursing home on 03/01/18. The patient's primary diagnosis was dementia with behaviors. The psychiatric evaluation dated 03/01/18 revealed the patient's presenting problem was agitation and combative behavior. The medical record lacked evidence the patient received a copy of An Important Message from Medicare about Your Rights and a signed acknowledgement of the rights.

During interview on 03/28/18 at 5:00 P.M., the Director of Nursing confirmed this finding.

3. Review of the medical record for Patient #4 revealed he/she was admitted on 01/18/18. The diagnoses was including manic and hypersexual. The medical record lacked evidence the patient received a copy of An Important Message from Medicare about Your Rights and a signed acknowledgement of the rights.

During interview on 03/28/18 at 5:00 P.M., the Director of Nursing confirmed this finding.

Review of the facility policy titled "Discharge Planning Policy No: PC16", revised 07/2017, stated Medicare Beneficiaries have an appeal process defined by the Centers for Medicare and Medicaid Services (CMS) if he/she disagrees with a decision for discharge. Upon admission, medicare beneficiaries are given a copy of An Important Message from Medicare about Your Rights which outlines the payment responsibilities and defines the Medicare appeal process. The patient will sign an acknowledgement of the Message to Medicare during their hospitalization.

Based on observation, record review and interview, the facility failed to ensure patients were provided the toll free hotline number to file a complaint with the state agency. The facility also failed to ensure incidents were documented and logged as per policy. This affected two (Patients #1 and #2) of ten patients reviewed. The facility census was 41.

Findings include:

1. Review of the handbook each patient received upon admission failed to include the toll free state hotline number to file a complaint. The number listed in the patient handbook was for the hospital patient advocate.

During interview on 03/27/18 at 1:32 P.M., Staff B confirmed this finding.

2. A tour was conducted on the inpatient psychiatric adult and geriatric patient units on 03/28/18 at 11:55 A.M. Observation of the Patient Rights and Responsibilities signage on each unit listed several different entities to file a complaint/grievance. The signage on both units failed to include the toll free state hotline number to file a complaint with the state agency.

An interview was conducted with the Medical Director following the tours whom reported he/she was unaware the patients were not provided the state toll free number to file a complaint.

Interviews were conducted with with three patients during the tour on the geriatric on the unit. All three patients reported they were unaware the state hotline number was available to to file a complaint.

3. Review of an incident report revealed a complaint/grievance was reported to the facility on 03/20/18 and an incident report was not documented until 03/22/18. The incident form lacked all pertinent information received during the phone call received by Staff E.

Druing interview on 03/28/18, Staff E and Staff D both stated in separate interviews that neither documented the information but gave a verbal report to supervisors.

4. Review of the incident report for Patient #1 was found to be a complaint and/or grievances to the facility. Review of the complaint/grievance log failed to include the information provided upon request.

4. Review of the medical record for Patient #2 revealed the patient was admitted on 03/01/18. The patient's primary diagnosis was dementia with behaviors. The psychiatric evaluation dated 03/01/18 revealed the patient's presenting problem was agitation and combative behavior.

Review of a private psychiatric notification of an incident that occurred on 03/13/18 in regard to Patient #2 revealed on 03/13/18 there was an incident in regard to physical abuse. The notification of incident revealed on 03/13/18 around 8:10 A.M., Patient #2 told the dietician that the staff had covered her mouth, squeezed her face and then slapped both sides of her face.

Review of the complaint log on 03/27/18 at 11:15 AM for the dates ranging from 01/01/18 to 03/27/18 lacked documented evidence of patient abuse.

This finding was confirmed with the director of nursing on 03/28/18 at 5:00 PM prior to the exit conference.

Review of the Compliments, Concerns, and Grievances Policy Number: RE.11 ( Effective 06/15/16) states patient and families shall be notified of the right to present their concerns or grievances in advance of the hospital furnishing or discontinuing patient care whenever possible. Notification will occur, at a minimum, by signs posted in all patient care areas and individually in the patient handbook.


Review of the Risk Management / Incident Reporting Policy PI.7 ( Effective 06/06/16) states all staff are required to document and report incidents on the designated web based incident reporting system and/or form during system downtime as soon as the incident becomes comes to the attention of the staff member.

Based on record review and interview, the facility failed to ensure patients were given informed consent for psychotropic medications. This affected four (Patients #1, #2, #5 and # 6) of ten medical records reviewed. The active census was 41.

Findings include:

1. Record review for Patient #1 revealed the patient was admitted to the geriatric psychiatric unit on 01/30/18. The patient was referred from a long term care nursing facility after the patient was reportedly found playing in feces and had called 911 from her room six times in a 24 hour period. Due to the behavioral disturbances and past history of depression and anxiety the patient was transferred to the inpatient psychiatric facility for further evaluation and stabilization.

Review of the medication administration record revealed the patient was receiving fourteen different prescribed medications including Paxil, Zoloft and Clonazepam. The medical record lacked evidence informed consent for medications was given. The blank form was found in the medical record.

During interview on 03/28/18 at 3:37 P.M., Staff D confirmed this finding.

2. Record review for Patient #2 revealed the patient was admitted on 03/01/18 with diagnoses including dementia with behaviors. The psychiatric evaluation dated 03/01/18 revealed the patient's presenting problem was agitation and combative behavior.

The medical record revealed physician orders dated 03/14/18 in which the patient was started on Risperidone, an anti-psychotic medication, 0.125 milligrams two times a day for mood. On 03/16/18, the Risperidone was increased up to an additional 0.25 milligrams two times a day for mood. The medical record lacked documented evidence of an informed consent for psychotropic medications.

During interview on 03/28/18 at 5:00 P.M., the Director of Nursing confirmed this finding.

3. Record review for Patient #5 revealed the patient was admitted to the facility on 01/10/18 with a diagnoses including schizoaffective disorder, bipolar type. Symptoms included manic-like, very loud voice, hyper-anxious, very preoccupied and somewhat tangential. The psychiatric evaluation noted the patient was extremely agitated, was having intermittent refusal to cooperate with staff, especially around giving her pills.

Review of the medication administration record revealed the patient was was receiving multiple medications for medical reasons however included Seroquel for psychosis, Latuda for insomnia, Lorazepam for agitation and Olanzepine as needed by mouth or intramuscularly for agitation. The medical record lacked evidence informed consent for medications was given.

During interview on 03/28/18 at 3:52 P.M., Staff D confirmed this finding.

4. Record review for Patient #6 revealed the patient was admitted on 03/08/18. Diagnoses included bipolar disorder, anxiety and suicidal ideations. The resident was receiving psychotropic medications. The medical record lacked documented evidence of an informed consent for psychotropic medications.

During interview on 03/28/18 at 5:00 P.M., the Director of Nursing confirmed this finding.

Review of the facility policy titled "Informed Consent for Medications Policy No: NU 63", revised July 2017, stated all patients will be upheld in regards to consenting requirements for psychotropic medications. The patient will consent at admission includes to treatment that includes the administration of drugs, whether psychotropic in nature of not. Patients shall be treated with psychotropic medication only after being informed of his or her rights to accept or refuse such medications and having consented to the administration of such medication.