HospitalInspections.org

A. Based on observational tour, document review, and interview, it was determined for 4 of 8 adolescent psychiatric patients (Pts. 11, 13, 15, & 16), the Hospital failed to ensure psychiatric patients admission forms were not presigned and were completed in a timely manner.

Findings include:

1. On 10/22/13 at 3:00 PM, policy number 13.10, titled, "Behavioral Health: Admission of Minors", effective 9/19/11, was reviewed. The policy required, "It is the policy of Provena Health to follow the procedures for admission of minors as described in the Illinois Mental Health and Developmental Disabilities Code ('Mental Health Code')..."

2. The Illinois Mental Health and Developmental Disabilities Code was reviewed on 10/22/13 at 3:05 PM and required, "Sec. 3-504 (f) Within 24 hours after admission under this Section, a psychiatrist or clinical psychologist who has personally examined the minor shall certify in writing that the minor meets the standard for admission. If no certificate is furnished, the minor shall be discharged immediately. "

3. On 10/22/13 at 1:20 PM, and observational tour was conducted on the adolescent psychiatric unit. There were 8 patients (Pts. #4, 11 - 17) on the unit.

4. The 8 patient's clinical records were reviewed during the tour. Four adolescent psychiatric patient's (Pts. 11, 13, 15, & 16) "Examination of Minor for Admission or Continued Hospitalization" forms had not been completed - nothing was written, even though all 4 patients had been admitted 4 or more days before the tour, including,

- Pt. #11 was a 16 year old female, admitted on 10/17/13, with a diagnosis of major depression.

- Pt. #13 was a 16 year old male, admitted on 10/17/13, with a diagnosis of major depression disorder, severe.

- Pt. #15 was a 14 year old female, admitted on 10/15/13, with a diagnosis of major depression disorder, recurrent, severe.

- Pt. #16 was a 15 year old male, admitted on 10/16/13, with diagnoses of major depression disorder, recurrent, severe and borderline personality.

5. Two of the same incomplete "Examination of Minor for Admission or Continued Hospitalization" forms (Pts. 13 & 15) had been presigned by a Psychiatrist, even though the forms had nothing written on them.

6. The Manager (E #9) and Director (E #10) of the Behavioral Health Units were made aware of the findings on 10/22/13 at 3:30 PM, during an interview. The records were again reviewed with the Director of the Behavioral Units on 10/24/13 at 1:15 PM, now pointing out the psychiatrist's signature on blank forms. The Director agreed that the forms had not been completed on time and that 2 of those forms had been presigned by the Psychiatrist, which should not occur.


B. Based on document review and interview, it was determined, for 1 of 1 (Pt. #1)clinical record reviewed of a patient refusing to shower, the Hospital failed to ensure the patient was not forced to do so.

Findings include:

1. On 10/24/13 at 2:00 PM, policy # E103, titled, "Patients' Rights and Responsibilities", effective date 4/10, was reviewed. The policy required, "Purpose: To respect the right of the patient... To affirm the patients' right to make decisions regarding his/her medical care, including the decision to discontinue and/or withhold treatment..."

2 On 10/22/13 at 10:35 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 13 year old female, admitted on 8/21/13, with a diagnosis of Psychosis. Pt. #1's emergency department assessment dated 8/21/13 at 8:45 PM, included, Pt #1 was recently discharged from another psychiatric hospital and "was brought in today because she put the cat in the freezer." Pt. #1 "is screaming... is combative... is reporting some homicidal ideation..."

3. On 10/23/13 at 11:00 AM, written documentation from Pt. #1's "Sitter" (E #1) on 9/5/13 day shift was reviewed. The documentation included, "9/5/13... I was informed that [Pt. #1]... needed to shower and that she could not come to the day room without doing so... [Pt. #1] and I spoke on her taking one but she refused but agreed to wash up in her bathroom. When she was told to go ahead and get cleaned up in the bathroom she then became upset. I'm not sure why... she didn't want to wash in the bathroom either so I stated that its been over three days since she last showered, so that if she didn't wash on her own that I would wash her up. I asked [Pt. #1]... to wash more than 3 times and she continued to refuse, so I got everything prepared to wash her up myself. I let [Pt. #1] know that I was 'gonna' wash her face and as I did she began to yell profanity and say she didn't want to wash. I tried washing her legs and face as well. She kicked at me and ran out of the room..."

4. An interview was conducted with the Manager of the Behavioral Units on 10/24/13 at 10:15 AM. The Manager stated that there is no protocol for requiring psychiatric patients to bath/shower and no physician order for a shower or bath was found in Pt. #1 record.