HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to ensure the belongings of Patient # 1 were not initially catalogued or returned to him upon discharge.

Findings were:

Facility policy entitled, "Patient Valuables and Belongings" stated, in part, "Patient's belongings that are placed in the custody of the hospital will be logged in and secured and returned to the patient on discharge. Procedures:
1. In the admissions area, a safety check is conducted and patients are asked to turn in all contraband items ...
2. The items are placed in a container and remain with the individual conducting the admission assessment until the assessment is complete and the patient is taken to the unit.
3. When the patient is taken to the unit, the patient and any items confiscated are kept under constant observation until the unit admission process is initiated
4. The patient is taken to the exam room where two staff members are present and a search is conducted per the Search policy.
5. The person conducting the safety check removes any contraband or valuables that are not allowed on the unit and places them in a bin in the presence of the patient.
6. The patient and the staff then return to the unit, the staff inventories all items that will not be kept in custody by the patient during their stay ...
10. The patient or parent / guardian will review the inventory list and sign it; staff member doing the inventory will sign and date it."

Austin Oaks Hospital Adult Unit Patient Belongings Inventory dated 10/4/14 revealed items that were removed from Patient # 1's possession and stored. They included "1 jacket, 1 pair of shorts, 1 empty wallet, 2 pairs of headphones, 1 long sleeve white T shirt, and 1 pair of black sports pants." The form stated "Upon admission, the above items have been reviewed with me. I understand all items not in my possession will be returned to me upon discharge. Austin Oaks Hospital is not responsible for any permitted items kept in my possession." This was signed and dated by a staff member but not by the minor patient or his mother.

Discharge Plan for Patient # 1 dated 10/28/14 stated "I have received personal items and valuables___." A zero with a slash through it was written in the area reserved for patient/family signature, indicating that no personal items were returned to the patient upon discharge. This document was signed by a CPS agent, an RN and the patient's Therapist. The form was also signed by ATCIC (local mental health authority). Patient # 1 refused to sign the document.

In an email with Staff Member # 4 (Risk Manager) dated 2/4/15 it was admitted that the staff did not catalogue items that Patient # 1 brought into the facility nor document items that were taken with the patient upon discharge. She wrote "It appears that staff did not follow proper procedure, and there is no documentation of the items that the patient was allowed to keep."

Based on review of documentation and interview, it was discovered that 10 of 10 medical records of minor patients reviewed failed to reveal involvement of family members/guardians in Treatment Team meetings.

Findings were:

Facility policy entitled "Treatment Planning" stated in part "Treatment planning is a multidisciplinary process involving the patient and their families or significant others and other members of the treatment team to include the Attending Physician, Registered Nurse, Therapist, Mental Health Worker and Activity Therapist. Additional participants may include the Registered Dietician, Spiritual Advisors, External Care Workers, Probation Officers, Court-Appointed Advocates and Educators.

...The patient and family, as indicated, shall be involved in treatment planning. To facilitate patient/family involvement in treatment planning the patient, the patient's family or legal representative may attend the Master Treatment Plan meeting or a portion thereof, unless contraindicated and ordered otherwise by the attending physician.

...The patient/family will (at a minimum) have the Master Treatment Plan reviewed with them by the therapist in language which the patient/family can understand. The review shall include the nature and extent of the treatment plan. The therapist shall provide the patient/family with the opportunity to ask questions, make suggestions and make comments relative to the treatment plan

...The patient/family shall be provided with the opportunity to attend the treatment plan update meetings. If unable to attend, they will be provided with an explanation of the review and be granted the opportunity to provide feedback."

Facility policy entitled "Patient and Family Involvement in Treatment Planning and Care" stated in part "Patient and family participation will be encouraged to participate in treatment from the point of the initial assessment, treatment planning, on-going reassessments and treatment planning updates and discharge planning.

Every effort will be made to inform the family of minors and as allowed by adults, of treatment planning to be done by the interdisciplinary treatment team so they may attend in person or review by telephone.

Patient or family will sign the treatment plan indicating their understanding, participation and agreement with the treatment plan. If the patient and /or/ family is unable to do so, staff will document the reason, time and date on the Treatment Plan."

Review of the medical records of Patients # 1 through 10 revealed no indication that the parents or guardians of these minor patients participated in treatment team meetings. Patient # 8's medical record indicated that the mother was privy to the initial treatment team meeting but was not included in further meetings.

In interviews with the Interim CEO, the Divisional Clinical Director and the Risk Manager on February 3, 2015, the lack of parental involvement in treatment team meetings was confirmed.