HospitalInspections.org

Based on record reviews and interview, the hospital failed to inform each patient of the patient's rights. This deficient practice was evidenced by failing to ensure patients presenting to the emergency department with a chief complaint psychiatric evaluation were offered a copy of the Mental Health Patient Rights for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients.
Findings:

Review of the hospital policy Title: Care of the Psychiatric Patient in the Emergency Department, Effective Date 03/03/2023 revealed, in part:
I. Purpose. This policy provides guidance for the patient presenting with a psychiatric complaint in the Emergency Department, patients documented on a Psychiatric Hold, patients assessed at risk for suicide, homicide, and/or patients gravely disabled and patients requiring psychiatric observation.
III. Policy Statement. 5. Every patient that presents to the Emergency Department will receive a medical screening exam by the Emergency Department provider. If it is determined by the ED provider that the patient is in need of inpatient psychiatric care and the patient is deemed a harm to self, others or gravely disabled, a Psychiatric Hold will be executed by the ED provider.
e. All PEC/Psychiatric Hold patients will be offered a copy of the Mental Health Patient Rights, as per State law, and will be asked to sign an Acknowledgment that they have received these.
Note: If Patient is unable or unwilling to sign the Mental Health Patient Rights form, medical personnel will document the reason in the patient's medical record.

1. Review of Patient #1's medical record revealed the patient presented to the emergency department on 03/23/2024 with a chief complaint psychiatric evaluation and was a PEC/Psychiatric Hold patient. Further review of Patient #1's medical record revealed no evidence the patient received or offered a copy of the Mental Health Patient Rights.

2. Review of Patient #2's medical record revealed the patient presented to the emergency department 02/20/2024 with chief complaint psychiatric evaluation and was a PEC/Psychiatric Hold patient. Further review of Patient #1's medical record revealed no evidence the patient received or offered a copy of the Mental Health Patient Rights.

In an interview on 03/26/2024 at 11:13 a.m., S3Quality Director confirmed there was no evidence Patient #1 and Patient #2 offered a copy of the Mental Health Patient Rights.