HospitalInspections.org

Based on policy and record review and interview the facility failed to provide 1 of 1 patients with special needs (patient #11) and 1 of 3 patients without special needs (patient #19) with information on patient rights resulting in the potential for loss of rights. Findings include:

Facility Policies:

MH-02, "Informed Consent" dated 9/7/12, states:
"It is the policy of Samaritan Behavioral Center that patients, or guardians (when appropriate) will give informed consent for treatment and medications prior to their use."
III. A. "Informed consent will be obtained from the patient (or guardian, if indicated) at the time of admission, treatment or medication use in order to authorize these services."
III. D. "A consent is executed when it is signed by the appropriate individual and witnessed."

ADM 1.23, "Plan of Access to Care- General Accessibility" dated 11/22/12, states:
B.i: "Upon admission, intake staff will determine if a patient has readily identifiable impairments that require accommodations in order for the patient to actively participate in their health care and treatment."
1. "When a hearing impaired patient is being admitted, he or she will be asked if they would like an interpreter to be provided by the hospital."
iii. "Upon determining the patient's preference for accommodation, admitting staff will inform the Nurse Manager, who will make any necessary arrangements."
C. iii. "If admitting staff has determined impairments, nursing staff will provide for the accommodations."

ADM 1.24a, "Plan of Access to Care- Hearing Impaired Patients" dated 8/22/12, states:
III. "During the intake process and upon admission to the hospital, hearing impaired patients or responsible parties will be asked to indicate how they communicate most effectively. Patients will then be offered a range of auxiliary aids. Note writing, lip reading and the use of gestures may be used to aid in communication but will not be used as a replacement for an interpreter, if one is indicated."

The Michigan Department of Community Health booklet "Your Rights: When Receiving Mental Health Services in Michigan," page 1, states: "At the time you make a request for, or when you begin to receive, mental health services you will be given information about the rights guaranteed by Chapter 7 and 7A of the Mental Health Code." This booklet provides a summary of these rights, including complaint and treatment rights.

Patient #11:

Record Review:

On 10/23/12 from 2-4 pm record review revealed the following:
1. Patient # 11 was admitted to the facility on 10/19/12.
2. A fax received by Samaritan, dated 10/19/12, contained a document titled "Crisis Center Assessment." On page 13 it states that patient #11: "is hard of hearing, supplements by reading lips, does not communicate via sign language, per family need eye contact before talking but can not recall which ear...has history of wearing hearing aid in that ear but has not been using it."
3. On 10/19/12 at 9:30 pm a nursing progress note states: "Patient signed voluntary form. Pt hearing impaired, mute,..."
4. On 10/20/12 at 4:45 pm a Social Work progress notes states: "Patient is deaf or very hard of hearing."
5. On 10/22/12 at 4:02 pm a Social Work progress note states: "The patient (#11) has problems hearing. His brother was contacted to gather information and according tot the patient's brother, he has an 80% hearing loss, The way that he communicates is by reading lips. He does not know how to do sign language." This was the first note documenting an attempt to contact a family member since the patient's admission on 10/19/12.
6. Patient #11's clinical record contained a sample of the patient's ability to communicate in writing, dated 10/23/12.
7. The above findings were confirmed by Nurse Manager #2 on 10/23/12 from approximately 2:20-3:00 pm


Consent Form Review:

On 10/23/12 at 2:25 pm, Nurse Manager #2 confirmed the following regarding patient #11's consent forms:

1. A Voluntary Admission form for patient #11 was not found.
2. The following patient admission forms contained notes by MHT #2 stating: "unable to sign"
on the patient signature line:
- "Recipient's Rights Notification"
- "Patient Notice of Substance Abuse Confidentiality"
- "Confidentiality/Recipient's Rights/Medicaid/HIPPA"
- "Self-assessment for adults"
- "Philosophy Regarding the Use of Restraint and/or Seclusion"
- "No Smoking Policy"
3. The section of the "Recipient Rights Notification" form for documenting whether the patient accepted or rejected receipt of a copy of the patient rights booklet ("Your Rights" (When Receiving Mental Health Services in Michigan) was left blank.
4. There was no documentation of any communication method used by MHT #2 in determining that patient #11 was unable to sign to acknowledge receipt of the consent forms listed above nor of post-admission attempts to provide the above forms to patient #11.
5. The above findings were confirmed by Nurse Manager #2 on 10/23/12 from approximately 2:20-3:00 pm

Patient # 19:

Record Review:

1. On 10/23/12 at approximately 2:35 pm, review of patient #19's medical record revealed that the patient form titled, "Recipient Rights Notification," was left blank. Spaces for indicating whether the patient refused or was unable to sign were left blank. Spaces for indicating whether the patient accepted or rejected a copy of the patient rights booklet ("Your Rights") were left blank.
2. On 10/23/12 at approximately 2:35 pm, Nurse Manager #2 confirmed the above findings.

Interview:

1. On 10/23/12 at approximately 2:40 pm, patient #19 provided visual review of all admission paperwork in her possession. The booklet "Your Rights," was not among the documents provided. The patient stated that she didn't remember receiving a booklet.
2. The above interview was confirmed by Nurse Manager #2.

Based on record review, policy review and interview, the facility failed to ensure that 1 of 1 patients with special needs (patient #11) was involved in the development of his master treatment plan. Findings include:


Record Review:
Patient #11 was admitted on 10/19/12. During document review on 10/23/12, the following was noted in the clinical record:

Nursing initial assessment dated 10/19/12, states "Patient is hearing impaired, unable to communicate effectively through conversation. Assessment completed using non-verbal communication and writing down questions."

Social work/psychosocial assessment dated 10/20/12, states "Pt [patient] deaf or very hard of hearing."

Assessment of leisure functioning dated 10/20/12, states "Patient declining to answer - shook head 'no'...patient is hard of hearing."

Initial psychiatric evaluation signed by psychiatrist #1 and dated 10/20/12, states "Records from DMC (Detroit Medical Center) indicate that the patient declined to give information...On interviewing the patient he was mute/selectively mute...did not say one word, and did not answer any questions."

The master treatment plan for patient #11 dated 10/22/12, documents that patient #11 attended the treatment team conference. The box was check marked "no" indicating the patient did not receive a copy of his treatment plan and it was documented, "Patient did not answer question."
The box was check marked "no" indicating the patient did not agree with his treatment plan.
The patient's comments/response to treatment plan was documented, "mute during meeting."
Patient's signature was documented, "unable to sign." The remainder of the document was signed and dated by psychiatrist #1, RN, social worker, and recreational therapist.

The master treatment plan failed to indicate that the patient received adequate information, provided in a manner that the patient can understand, to assure that the patient can effectively exercise the right to make informed decisions.

Facility Policy:
Policy # ADM 3.25 (effective date 9/12/12) Treatment Planning states, "To provide an individualized (patient-centered) interdisciplinary treatment plan for each inpatient...patient problems are identified and prioritized, measurable and attainable goals are established with the patient..."

Interview:
During on interview on 10/24/12 at approximately 12:25 PM, psychiatrist #1 was queried regarding his statement that patient #11 was "selectively mute." Psychiatrist #1 stated he knew the patient (#11) from prior admissions at Detroit Receiving and from reviewing the intake information provided by Detroit Receiving Hospital." The following statement from the 18-page intake document (patient #11) from Detroit Receiving Hospital, fax stamped 10-19-12;11:08 AM, states "...hard of hearing, supplements by reading lips, does not communicate via sign language, per family need eye contact before talking..." Psychiatrist #1 admitted he didn't see that information in the intake documentation and stated, " I missed that."

Based on interview and record review the facility failed to document attempts to ask 1 of 1 patients with a hearing impairment (patient #11) if he would like to have anyone notified of the hospital admission. Findings include:

Policies:

ADM 1.23, "Plan of Access to Care- General Accessibility" dated 11/22/12, states:
B.i: "Upon admission, intake staff will determine if a patient has readily identifiable impairments that require accommodations in order for the patient to actively participate in their health care and treatment."
1. "When a hearing impaired patient is being admitted, he or she will be asked if they would like an interpreter to be provided by the hospital."
iii. "Upon determining the patient's preference for accommodation, admitting staff will inform the Nurse Manager, who will make any necessary arrangements."
C. iii. "If admitting staff has determined impairments, nursing staff will provide for the accommodations."

A policy stating that the facility will assist patients in promptly notifying a family member or representative of the patient's choice of hospital admission was not found.

Record Review:

On 10/23/12 from approximately 2-4 pm review of patient #11's clinical record revealed the following:
1. Patient #11 was an admitted on 10/19/12.
2.A fax received by Samaritan, dated 10/19/12, contained a document titled "Crisis Center Assessment." On page 13 it states that patient #11: "is hard of hearing, supplements by reading lips, does not communicate via sign language, per family need eye contact before talking but can not recall which ear...has history of wearing hearing aid in that ear but has not been using it."
3. Patient #11's record contained no documentation that staff had offered the patient assistance in notifying anybody of hospital admission.
4. The first documented facility contact with family occurred on 10/22/12.
5. The above findings were confirmed by Nurse Manager #2 on 10/23/12 from approximately 2:20-3:00 pm.

Interview:

On 10/24/12 at approximately 2:35 pm the Manager of Social Services stated that the Social Worker who completed patient #11's Social Service Assessment, on 10/20/12, should have contacted the patient's family.

Based on record review and interview the facility failed to ensure that nursing staff develop an individualized up to date nursing care plan for each patient in 1 of 22 (#11 ) medical records; and develop appropriate nursing interventions in response to those needs for 1 of 22 medical records reviewed (#11). Findings include:

During medical record review of patient #11 on 10/23/12, it was noted that patient #11 was transferred from Detroit Receiving Hospital on 10/19/12. The 18-page intake document from Detroit Receiving Hospital, fax stamped 10-19-12;11:08 AM, states "...hard of hearing, supplements by reading lips, does not communicate via sign language, per family need eye contact before talking..." and also under health history it is documented "ear, nose, throat problems: positive" with no further explanation of the term, "positive."

Patient #11 was admitted to Samaritan Behavioral Center on 10/19/12. During medical record review of patient #11 on 10/23/12, the initial nursing assessment dated 10/19/12 at 8:00 PM, documents "Patient is hearing impaired, unable to communicate effectively through conversation. Assessment completed using non-verbal communication and writing down questions." The care plan failed to address the patient's needs, failed to engage him in treatment, and failed to develop appropriate interventions based on the needs of this hearing impaired patient.

During an interview on 10/24/12 at approximately 9:40 AM the Director of Nursing (DON) was queried regarding the nursing care plan for patient #11. The DON acknowledged that nursing failed to develop an individualized care plan with appropriate interventions for patient #11. The DON further stated, "nursing is updating the plan of care right now."