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Based on facility policies and procedures, medical record review, credential file reviews, and staff interviews, it was determined the facility failed to develop and implement consistent policies to ensure compliance related to notice of patient rights and ensuring a copy of the patient rights was provided to the person's representative, healthcare surrogate or proxy (refer to A0117). The facility failed to implement policies to ensure patients receive an individualized treatment plan that allowed the patient to participate (refer to A0130). The facility failed to develop and implement consistent policies to ensure compliance with patient rights for general consent for treatment and specific authorization for psychotropic medications (refer to A0131). The facility failed to ensure the facility licensed impendent physicians (LIP's) in the Emergency Department and Behavioral Health Units (BHU's) received mandatory Baker Act training/education (refer to A0022) and training in use of restraints/seclusion (refer to A0176 ). The facility failed to implement policies to ensure patient compliance with patient rights and inventory of personal effects (refer to A0129). The facility failed to ensure a representative of either the patient's choice or one designated by the patient was notified of the patient's involuntary admission (refer to A0133).

Based on medical record review, policy review, and staff interview it was determined the facility failed to provide patient rights or ensure a copy of the patient rights was provided to the person's representative, healthcare surrogate or proxy for 8 (#1, #6, #7, # 8, # 9, #10, #11, #12) of 12 patient medical records sampled.

Finding Included:

On 05/10/19 at 9:20 AM the facility policy for Patient Rights was requested and three different documents entitled patient rights were provided.

A review of the policy entitled, "Patient Rights," # RI.001, reviewed 03/14/18, showed it is the policy of the service to ensure that all patients receive a copy of the Patient Rights, as well as an oral explanation of those rights as part of the admission process nursing will orient patient to their rights and responsibilities regarding access to treatment, emergency procedures, confidentiality, and grievance process through a review of the patient handbook. Included in these rights are:
- Prior to or at time of admission, each individual shall be provided with a copy of the Patient Rights and the managing conservator, Durable Power for Healthcare (DPOA) or legal guardian will be given the patient's Rights and Responsibilities.
- The individual and/or the DPOA, conservator, or guardian shall be requested to sing and date a copy of the Patient Rights form prior to at admission to acknowledge receiving written and verbal explanation of those rights and signing attestation to an understanding of the Patient Rights. The singed copy shall be witnessed by a family member and place in the patient's medical record.
- A copy of the Patient Rights also shall be provided to the patient and to the individual's family member, DPOA or friend prior to admission.

A review of the policy entitled, "Patient Rights and Responsibilities Policy," no #, revised 01/04/19, showed;
- A hospital must inform each patient, or when appropriate, the patient's representative of the patient's rights in advance of furnishing or discontinuing patient care.
- The hospital must inform each patient, or when appropriate, the patient's representative of the patient's rights.
- All patients should receive the hospital's Notice of Patient Rights and Responsibilities form (ADM-19801) at the time of Admission/Registration.
- A refusal by the hospital of an individual request to be treated at the patient's representative must be documented in the patient's medical record, along with the specific basis for refusal.

A review of a document entitled, "Patient Handbook Golden Care Unit," showed a list of patient rights, but failed to list the right that a copy of the rights statement, signed by the person evidencing receipt of the copy, and shall also be provided to the person's guardian, guardian advocate, representative, and health care surrogate or proxy.

A review of the clinical record, Notice of Patient Rights and Responsibilities, for Patient's #1, #6, #7, # 8, # 9, #10, #11, #12 revealed there was no documentation that the patient or the patient's representative received patient rights information. There was no documentation the patient rights information was mailed to the patient's representative.

On 05/10/19 at 12:30 PM, an interview with the Director of the Behavioral Health Unit (BHU) confirmed there was no documentation in the above patient medical records showing the patient or the patient's representative received patient rights information.

Based on policy review, medical record review, and staff interview, it was determined the facility failed to implement policies to ensure compliance with patient rights and inventory of personal effects for four (#1, #3, # 4, # 5) of 12 medical records sampled.

Findings included:

A review of the facility policy entitled, "Baker Act Patient; Care of Mental Health Involuntary Hold," no #, effective 03/03, showed a patient's right to the possession of his or her clothing and personal effects shall be respected. The facility may take temporary custody of such effects when required for medical and safety reasons. A patient's clothing and personal effects shall be inventoried upon their removal into temporary custody. Copies of the inventory shall be given to the patient and to the patient's representative and shall be recorded in the patient's clinical record. If the personal effects are not returned to the patient, the reason must be documented in the clinical record along with the disposition of the clothing and personal effects.

A review of Patient #1, #4, #5's medical record failed to reveal the presence of an Inventory of Personal Effects.

A review of Patient #3's Inventory of Personal Effects, no date or time, showed four patient belongings, but failed to show the signature of patient or the patient's healthcare proxy or that a copy was provided to either.

On 04/29/19 at 1:30 PM, an interview with the BHU Director confirmed the above findings in the medical records of Patient #1, #3, #4, and #5,

Based on policy review, medical record review, and staff interview, the facility failed to implement policies to ensure patients receive an individualized treatment plan that allowed the patient to participate for one (#1) of 12 medical records sampled.

Findings included:

A review of the policy entitled, "Patient Rights," # RI.001, reviewed 03/14/18, showed it is the policy of the service to ensure that all patients have the right to participate in decisions about their care and in the development and review of their treatment plan.

A review of Patient #1's Behavioral Health Unit (BHU) Treatment Plan Initial Data, dated 08/20/18, showed the nurse documented the patient's wife was the durable medical power of attorney (POA). The care plan was updated on the following dates; 08/21/18, 08/28/18, 09/04/18, 09/11/18. All care plans failed to show that the patient or patient's representative signed the plan acknowledging the plan had been reviewed or that the opportunity was given to participate in the care planning. The signature box for the patient and/or patient representative was left blank on all the updated care plans. Additionally, each care plan showed the patient was not present during the treatment team review.

On 04/29/19 at 1:30 PM, an interview with the BHU Director confirmed the above findings in the medical record care plan of Patient #1.

Based on policy review, medical record review, and staff interview it was determined the facility failed to develop and implement consistent policies to ensure compliance with patient rights for general consent for treatment and specific authorization for psychotropic medications for five (#1, #2, #3, #4, #5 ) of 12 medical records sampled.

Findings included:

The facility was unable to provide a policy that addressed general consent for treatment and consent for psychotropic medications for patients admitted to the behavioral health unit under involuntary status.

A review of the facility document entitled, "Authorization for Treatment Except for Psychotropic Medications;" showed the document must specify the specific treatments and document the name of the person that authorized consent, whether they are the healthcare surrogate (HCS), or healthcare proxy (HCP), the date, time and signature of the decision maker. The form clearly states that if the patient is incompetent to consent, the consent of his or her HCS or HCP is required.

A review of the facility document entitled, "Specific Authorization for Psychotropic Medications;" showed the document must indicate:
1. The proposed medication and dosage range and frequency;
2. The purpose of the treatment;
3. Common short and long term side effect of proposed medication, including contraindications and clinically significant interactions with
other medication;
4. Approximate length of care.

1. A review of Patient #1's General Authorization for Treatment Except for Psychotropic Medications dated 08/20/18 at 8:15 PM, showed the health care surrogate/proxy box marked requesting authorization for; routine medical care, psychiatric assessment, group therapy, individual therapy, physical therapy, and recreational therapy. The document failed to show the patient's healthcare surrogate/proxy was contacted for authorization. Instead the document showed the signature of two facility RN's authorizing treatment. The document indicated a person was called by telephone, but did not indicate who that person was.

A review of Patient #1's Certification of Person's Competence to Provide Expressed and Informed Consent dated 08/21/18 at 11:15 AM showed the patient was incompetent to provide express and informed consent to voluntary admission and incompetent to provide express and informed consent to treatment

A review of Patient #1's Specific Authorization for Psychotropic Medications showed three separate documents and a signature of the HCS/HCP with a date and time indicating it was a phone authorization. However, the document was signed by facility staff on the line that is for the signature of the HCS/HCP. The signature of the HCP was shown on the signature line and dated 08/22/18 at 6:20 PM and the box was marked indicating the HCP consented via telephone and a note showed "out of town." The signature at the bottom of the document, which certified that the person has met and talked with the person's physician and proposed treatment, matched the signature of the HCP authorization via telephone while "out of town."

The first dated 08/20/18 at 8:15 PM showed the individuals authorizing treatment with psychotropic medications as the patient (a competent adult) and the healthcare surrogate. The patient had already been assessed to be incompetent to consent to treatment. The following medications were being requested for treatment; Clonazepam and Temazepam. The document failed to contain authorization from the patient's healthcare surrogate and once again two RN's signed on the document as the patients substitute decision maker.
The second Authorization for Psychotropic Medications dated 08/21/18 at 5:35 PM showed the HCS was asked to consent to the following medications; Aripiprazole, Haloperidol, Lorazepam, Mirtazapine, Olanzapine. The document indicated the HCS authorized consent by phone but failed to contain the HCS's required signature.
The third Authorization for Psychotropic Medications dated 08/22/18 at 6:20 PM showed the HCS was asked to consent to Quetiapine. The document showed the consent was obtained by phone from the HCS indicating the HCS was "out of town". The HCS's name authorizing treatment by phone was also the same signature placed on the line, which required the actual signature of the HCS and not the facility staff signature.
All three documents failed to show a dosage range, frequency, purpose, or alternatives for the medications being requested.
None of the documents contained the signature of the patient's HCS authorizing any of these medications.

A review of Patient #1's Behavioral Health Unit (BHU) medication administration record (MAR), dated 08/20/18 through 09/13/18, showed the following psychotropics were administered without consent from the patient's HCS. Additionally, there were no physician emergency treatment orders (ETO) documented during the patients BHU admission.
1. Abilify 2 mg daily at bedtime
2. Remeron 15 mg daily titrate to 45 mg daily at bedtime
· 08/21/18 15 mg dose administered
· 08/22/18 through 08/27/18 - 30 mg dose administered
· 08/29/18 - 09/12/18 - 45 mg dose administered
3. Seroquel 25 mg twice daily administered 08/22/18 - 09/13/18
4. Seroquel 50 mg daily at 6:00 PM administered 08/23/18 - 09/13/18

2. A review of Patient #2's General Authorization for Treatment Except Psychotropic Medications dated 0423/19 at 6:00 PM, failed to show the patient or the patient's HCP signature certifying they had met and talked with the person and person's physician in person, if at all possible, and by telephone, about the proposed treatment prior to signing this form. Additionally, there was no documentation, as required, indicating why the person could not be present in person.

A review of Patient #2's Specific Authorization for Psychotropic Medications dated 04/23/19 at 6:00 PM, showed the following psychotropic medications: Depakote, Seroquel, Trazadone, Mentamine, Haldol, Ativan, and Geodon. The psychotropics medications did not show a dosage range, frequency, purpose of treatment, short term and long term side-effects, contraindications, alternative medication or approximate length of care. Additionally, there was no documentation, as required, indicating why the person could not be present in person.

A review of Patient #2's MAR, showed the following active medications, dosages, and frequency;
· Depakote 125 mg every 12 hours
· Seroquel 25 mg every 12 hours
· Trazadone 75 mg at bedtime
· Memantine 5 mg at bedtime

3. A review of Patient #3's Specific Authorization for Psychotropic Medications dated 04/27/19 at 7:30 AM, showed the following psychotropic medications: Trazadone, Haldol, Ativan, Escitalopram and Geodon. The psychotropic medications did not show a dosage range, frequency, purpose of treatment, short term and long term side-effects, contraindications, alternative medication or approximate length of care. The document failed to show, as required, why the person was not present in person.

A review of Patient #3's second Specific Authorization for Psychotropic Medications dated 04/29/19 at 11:06 AM, for the psychotropic medication valproic acid showed the patient's signature. The psychotropics medication did not show a dosage range, frequency, purpose of treatment, short term and long term side-effects, contraindications, alternative medication or approximate length of care.

A review of Patient #3's Certification of Person's Incompetence dated 04/26/19 at 1:21 PM showed the patient was incompetent to consent to treatment and that status had not been changed at the time the patient signed the consent.

4. A review of Patient #4's General Authorization for Treatment Except Psychotropic Medications dated 05/06/19 at 1:50 PM, listed the following psychotropics on the non-psychotropic consent form. Patient #4 did not have a Specific Authorization for Psychotropic Medications consent in the medical record. The psychotropics medication did not show a dosage range, frequency, purpose of treatment, short term and long term side-effects, contraindications, alternative medication or approximate length of care. Additionally, there was no documentation, as required, indicating why the person could not be present in person.
· Depakote 125-250 mg three time daily.
· Risperdal 0.25 mg twice daily
· Cogentin 2mg twice daily as needed for extrapyramidal symptoms (EPS). (Side effects include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements).

A review of Patient #4' s Certification of Person's Incompetence dated 05/06/19 at 1:30 PM showed the patient was incompetent to consent to treatment and that status had not been changed at the time the patient signed the consent.

A review of Patient #4's MAR dated 05/07/19 through 05/10/19 showed the following psychotropics had been administered;
· Depakote 125-250 mg three time daily.
· Risperdal 0.25 mg twice daily
· Escitalopram 10 mg daily
· Donepezil 5 mg daily
· Trazodone 50 mg at bedtime
· Haloperidol 5 mg every 6 hours as needed - ordered, but not administered.
· Cogentin 2mg twice daily as needed for extrapyramidal symptoms (EPS). (Side effects include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). - ordered but not administered.

A complete review of Patient #4's medical record consents, failed to reveal the presence of a consent for Escitalopram 10 mg daily, Donepezil 5 mg daily, Trazodone 50 mg at bedtime, Haloperidol 5 mg every 6 hours as needed.

5. A review of Patient #5's General Authorization for Treatment Except Psychotropic Medications dated 05/04/19 at 3:40 PM, failed to show the patient or the patient's HCP signature certifying they had met and talked with the person and person's physician in person, if at all possible, and by telephone, about the proposed treatment prior to signing this form. Additionally, there was no documentation, as required, indicating why the person could not be present in person.

A review of Patient #5' s Certification of Person's Incompetence dated 05/04/19 at 10:00 AM showed the patient was incompetent to consent to treatment and that status had not been changed at the time the patient signed the consent.

A review of Patient #5's MAR dated 05/04/19 through 05/10/19 showed the following listed psychotropic medications;
1. Namenda 5 mg daily
2. Lorazepam injection 2 mg every 4 hours as needed for; agitation
3. Risperdal Consta 25 mg injection every 2 weeks
4. Valproic Acid 250 mg 3 times daily
5. Risperdal 1 mg every 12 hours
6. Haloperidol 5 mg injection every 6 hours as need for; agitation
7. Haloperidol 5 mg tabs every 6 hours as needed for; agitation
8. Trazodone 50 mg at bed time as needed for; insomnia
9. Cogentin 2 mg twice daily injection as needed for; EPS

A complete review of Patient #5's medical record failed to reveal the presence of a consent for any of the above psychotropics.

On 04/29/19 at 1:30 PM, an interview with the BHU Director confirmed the findings in the medical records of Patients #1, #2, #3, #4, #5.

Based on policy review, medical record review, and staff interviews it was determined the facility failed to ensure a representative of either the patient's choice or one designated by the patient was notified of the involuntary patient's admission for five (#1, #2, #3, #4, #5) of 12 medical records sampled.

Findings included:

A review of the policy entitled, "Patient Rights," # RI.001, reviewed 03/14/18, showed it is the policy of the service to ensure that all patients receive a copy of the Patient Rights, as well as an oral explanation of those rights as part of the admission process nursing will orient patient to their rights and responsibilities regarding access to treatment, emergency procedures, confidentiality, and grievance process through a review of the patient handbook. Included in these rights are:
- Prior to or at time of admission, each individual shall be provided with a copy of the Patient Rights and the managing conservator, Durable Power for Healthcare (DPOA) or legal guardian will be given the patient's Rights and Responsibilities
- The individual and/or the DPOA, conservator, or guardian shall be requested to sign and date a copy of the Patient Rights form prior to or at admission to acknowledge receiving written and verbal explanation of those rights and signing attestation to an understanding of the Patient Rights. The signed copy shall be witnessed by a family member and place in the patient's medical record.
- A copy of the Patient Rights also shall be provided to the patient and to the individual's family member, DPOA or friend prior to admission.

A review of the policy entitled, "Patient Rights and Responsibilities Policy," no #, revised 01/04/19, showed;
- A hospital must inform each patient, or when appropriate, the patient's representative of the patient's rights in advance of furnishing or discontinuing patient care.
- The hospital must inform each patient, or when appropriate, the patient's representative of the patient's rights.
- All patients should receive the hospital's Notice of Patient Rights and Responsibilities form (ADM-19801) at the time of Admission/Registration.
- A refusal by the hospital of an individual request to be treated at the patient's representative must be documented in the patient's medical record, along with the specific basis for refusal.

1. A review of Patient #1's medical record documentation for the Petition for Involuntary Placement dated 08/23/18 at 12:59 PM, failed to show required notification and that a copy was provided to the representative, healthcare surrogate or proxy. The document showed the patient's wife was the guardian/representative.

2. A review of Patient #2's medical record showed the patient was admitted to the BHU on 04/23/19 under involuntary status, but failed to show required notification and that a copy was provided to the patient's representative. The physician documentation dated 04/23/19 showed the patient's wife provided the physician with information about the patient.

3. A review of Patient #3's medical record documentation for the Petition for Involuntary Placement dated 04/26/19 at 1:37 PM, failed to show a copy was provided to the patient or the patient's representative, healthcare surrogate or proxy. The Certification of Persons Consent and Notification of healthcare proxy (HCP) dated 04/26/19 at 1:21 PM, showed the patient's daughter as the HCP.

4. A review of Patient #4's medical record documentation for the Petition for Involuntary Placement dated 05/06/19 at 2:52 PM, failed to show a copy was provided to the patient or the patient's healthcare surrogate or proxy. The Notification to the Healthcare Surrogate or Proxy dated 05/06/19 showed the patient had designated a healthcare proxy at the time of admission.

5. A review of Patient #5's medical record documentation for the Petition for Involuntary Placement dated 05/06/19 at 3:29 PM, showed the patient's daughter was listed on the form with a telephone number, but no address. There was no documentation a copy was provided to the patient or the patient's healthcare representative, surrogate or proxy.


On 05/10/19 at 12:30 PM, an interview with the Director of the Behavioral Health Unit (BHU) confirmed there was no documentation in the above patient medical records showing the patient or the patient's representative received patient rights information.

Based on policy review, personnel file review, and staff interview it was determined the facility failed to develop and implement policies to ensure compliance with staff training related to the use of patient restraints and seclusion.

Findings included:

A review of the policy entitled, "Restraint and Seclusion," no #, reviewed 04/2018, showed staff that have direct patient care responsibilities receive training and are competent to minimize the use of restraint and seclusion, and to use them safety where their use is indicated. The physician or licensed independent practitioner (LIP) responsible for care of the patient is authorized to order a restraint. LIP's authorized to order restraint and seclusion must have working knowledge of hospital policy regarding restraint and seclusion. The following categories are allowed to order restraints and seclusion;
1. Physicians
2. Nurse Practitioners
3. Physician's Assistants

A review of a Behavioral Health Unit (BHU) Psychiatrist Physician A's credentialing file and Emergency Department (ED) Physician B's credentialing file, failed to show evidence of mandatory Baker Act Training.

In response to a request to provide evidence of restraint/seclusion education for the facility LIP's in the ED and BHU, the facility was unable to provide curriculum, learning objectives, or a tool for assessing the employee's knowledge and competence related to their position and responsibilities.

On 05/10/19 at 2:50 PM an interview with Medical Staff Coordinator confirmed the above findings.