HospitalInspections.org

Based on staff interview, review of one (1) of two (2) medical records, and review of the New Jersey Administrative Code, it was determined that the facility failed to provide all patients with the right to court proceedings for involuntary commitment according to state regulations.

Findings include:

Reference: New Jersey Administrative Code Title 10. Human Services > Chapter 31. Screening and Screening Outreach Program, States, "... 10:31-2.3 Screening process and procedures ... (g) In accordance with N.J.S.A. 30:4-27.9.c, within 72 hours of the psychiatrist's completion of the screening certificate, the following events must occur: 1.The consumer must be admitted to a designated outpatient treatment provider, a short-term care facility, psychiatric facility, or special psychiatric hospital; 2.A psychiatrist on staff at the designated outpatient treatment provider or the admitting facility must complete the clinical certificate; and 3.Staff at the designated outpatient treatment provider or the admitting facility must commence court proceedings for involuntary commitment by filing with the court both the screening certificate (completed by the screening psychiatrist) and the clinical certificate (completed by the treating psychiatrist on staff at the admitting facility). ..."

1. Upon review of Medical Record #14, the following was noted:

a. The "Screening Document For Adults" was completed by a Certified Mental Health Screener on 5/20/2021 at 1:22 PM.

b. The "Clinical/Screening Certificate For Involuntary Commitment Of Mentally Ill Adults" was completed by a psychiatrist on 5/20/2021 at 4:05 PM.

c. The second "Clinical/Screening Certificate For Involuntary Commitment Of Mentally Ill Adults" was completed by a psychiatrist on 5/23/2021 at 4:25 PM.

d. There was no evidence in the medical record that the admitting facility (Virtua Willingboro) did commence court proceedings for involuntary commitment within 72 hours of the psychiatrist's completion of the screening certificate.

2. The above findings were confirmed with Staff #9 on 6/2/2021.

A. Based on review of facility policies, staffing assignments, staff interview and medical record review, it was determined that the facility failed to ensure that a security officer is assigned to patients requiring security 1:1 in order to ensure care in a safe setting is provided.

Findings include:

Reference #1: Facility policy titled, "Observation: Direct Care Observer, Psych/Violent Patient" states, "...PROCEDURE: A. Direct Care observers...iv. For patients that are assessed to be homicidal, the observer may be a security officer. ...D. XVI. Document every 15 minutes on the Observer Form; this form is transferred to the next care observer..."

Reference #2: Facility policy titled, "ASSIGNMENT OF PATIENT CARE AND STAFFING: ACUTE CARE" states, "PURPOSE: To ensure that a sufficient number of qualified persons are scheduled to meet the patient care needs and consistent with the assessed needs of the patient population served. ..."

1. Review of Medical Record #10 on 6/1/2021 revealed the following:

a. Patient #10 was admitted to the STCF (Short Term Care Facility) unit on 5/22/2021. A LIP's (Licensed Independent Practitioner's) order dated 5/22/2021 at 1741 states: "Instructions: Security 1:1 [one-to-one] due to severe aggressive behavior." The 1:1 order was discontinued on 5/25/2021.

2. Review of Medical Record #11 on 6/1/2021 revealed the following:

a. Patient #11 was admitted to the STCF unit on 5/21/2021 and was ordered security 1:1 for assaultive and aggressive behavior on 5/21/2021 at 1759. The 1:1 order was discontinued on 5/23/21 at 2021.

3. Upon review of the Security log dated 5/23/2021, shift 0000 - 0800, only one (1) security officer was assigned to the STCF unit.

4. Upon review of The Observer Form dated 5/23/2021, for Patient #11, Staff #31 stated that the staff signatures and the initials next to the entries did not belong to any of the security officers.

5. Staff #30 confirmed the above findings and stated it has been difficult to cover staffing when there are callouts.

B. Based on review of facility policy, staff interview and review of two (2) of two (2) medical records, it was determined that the facility failed to ensure that safety checks are being completed for patients on 1:1 (one-to-one observation).

Findings include:

Reference: Facility policy titled, "Observation: Direct Care Observer, Psych/Violent" states, "...II. POLICY: A. ...Patients who present as suicidal, homicidal, or are exhibiting violent or aggressive behavior will be managed according to this policy. ...D. Role of the Direct Care Observer...iii. "Safety Check"/room sweep is to be completed during handoff/whenever there is a change in observer. This is to be done together by the on-coming and off-going observer. ..."

1. Medical Record #10 was reviewed on 6/1/2021 and the following was revealed:

a. Patient #10 was on 1:1 (one-to-one) observation for severe aggressive behavior from 5/22/2021 through 5/25/2021.

b. There was no evidence that a Safety Check was performed at the beginning of each shift by the on-coming and off-going observer.

2. Medical Record #11 was reviewed on 6/1/2021 and the following was revealed:

a. Patient #11 was on 1:1 observation for assaultive and aggressive behavior from 5/21/2021 through 5/23/2021.

b. There was no evidence that a Safety Check was performed at the beginning of each shift by the on-coming and off-going observer.