HospitalInspections.org

Based on review of documents and interview it was determined for 1 of 10 (Pt. #3) medical records reviewed, the hospital failed to ensure documentation of written or verbal notification of Patient Rights in the medical record.


Findings include:

1. On 12/18/14 the hospital's Policy titled, "Patient Legal Rights and Responsibilities Achieving Adult Status (9/12)" was reviewed and required, "1. assessment and referral explains rights of individuals receiving mental health and developmental disabilities services...and patient responsibilities..to each patient during the admission process...8. if patient is unable to understand his/her rights and responsibilities at the time of admission, this will be documented on the ...forms at the time by assessment and referrals...17...the program therapist asks the patient to sign a voluntary and if he/she refuses to sign, contact the physician regarding discharge or admitting the patient as an involuntary..."

2. On 12/18/14 at approximately 10:15 am the medical record of Pt. #3 was reviewed. Pt. #3 was a 19 year old mate voluntarily admitted to the adult mental health unit (2S) with a primary diagnosis of Autism. Additional diagnosis include severe mental health disabilities. The medical record also documented Pt. #3 was non-verbal.

3. A review of the consent section of the medical record included the following forms: application for voluntary admission, rights of individuals receiving mental health and developmental disabilities services,consent for treatment, admission notification, philosophy and practice for seclusion and restraint use, patient rights and responsibilities as well as several forms authorization to use or disclose protected health information. The forms lacked documentation that Pt. #3 was unable to sign. The forms also lacked a signature of Pt. #3, or a representative who was informed of Pt. #3's patient rights.

4. On 12/18/14 at approximately 1:30 PM during an interview with the Director of Assessment and Referral (E #4) stated the mental health staff apparently forgot to document Pt. #3's refusal to sign the documents, and that all the documents should have been signed by a staff member.

Based on document review and staff interview, it was determined for 1 of 10 (Pt #1) clinical records reviewed, the hospital failed to successfully implement 1:1 observation/assault precautions and keep pt. #1 safe.

Findings include:

1. The hospital policy entitled "Patient Legal Rights and Responsibilities-Achieving Adult Status" (reviewed 06/2013) required, "...Patients have the right to receive care in a safe setting..."

2. The clinical record for Pt #1 was reviewed on 12/28/14 at approximately 10:00am, and included Pt #1 was a 26 year old female admitted to the adult 2 south behavioral health unit (a unit for adults with intellectual disabilities) under the care of the psychiatrist (MD #1) on 11/6/14 with a diagnosis of episodic mood disorder. MD #1 ' s discharge summary dated 11/25/14 included, " ...She was incidentally struck in the side of the head by a peer in the day room, unprovoked. She was examined, visible upset, crying, but no injury apparent ...She had a bad phone call, was yelling, and crying. One of her peers was triggered and he ran into her room and attacked her. Staff assisted the peer. We evaluated the patient. She was given an ice pack..."

3. Two Healthcare Peer Review Reports (incident reports) regarding Pt #1 were reviewed on 12/28/14 at approximately 10:30 am and included the following:
-11/7/14 at 10:15am: Pt #1 was attacked by another patient (Pt #2 - 29 year old male) in the day room with no apparent injury. MD #1 and the nursing supervisor were notified at 10:30am. The incident report was reviewed and signed by the nursing supervisor and risk management on 11/10/14.
-11/8/14 at 10:00 am: Pt #1 was attacked by Pt #2 in Pt #1 ' s room resulting in "bruise and/or reddened area". MD #1 was notified at 10:15am, and an ice pack was ordered. The incident report was reviewed and signed by the nursing supervisor on 11/8/14 and risk management on 11/9/14.

4. The clinical record for Pt #2 was reviewed and included Pt #2 was a 29 year old male admitted to the hospital on 11/5/14 with a diagnosis of intermittent explosive disorder. Pt #2 was placed on 1:1 observation 11/7/14 at 10:45 am (following the first incident with Pt #1) and remained on 1:1 observation through discharge on 11/17/14. However, Pt #2 was still able to attack Pt #1 again on 11/8/14 while on 1:1 precautions.

5. The hospital ' s policy entitled " Precautions and Observations " (revised 09/2013) required, " ...A dedicated staff will be assigned to the patient while on 1:1 precautions. The dedicated staff will maintain close proximity to the patient all times which afford heightened awareness of patient ' s behavior and status ... "

6. On 12/18/14 at approximately 3:00 pm, an interview was conducted with the Chief Compliance/Nursing Officer (E #1). E #1 stated that Pt #2 was placed on 1:1 observation following the incident on 11/7/14. E #1 could not provide the surveyor with documentation of any follow up actions or investigation of the second attack by Pt #1 while on 1:1 observation. E #1 could not identify any actions the hospital took to ensure the safety of Pt #1 and to have prevented the attacks by Pt #2.