HospitalInspections.org

Based on interview, clinical record review and policy review the facility failed to obtain informed consent for treatment from patient's legal guardians and failed to inform legal guardians of patient rights in advance of patient care, for three (3) of eight (8) patients reviewed for patient rights from a total of eleven (11), resulting in the potential for treatments without informed consent and violations of patient rights. Findings include:

During a tour of the fifth (5 th) floor on 5/10/16 at 1030 the hybrid clinical record (partial electronic and partial paper documents) review for patient #3 with Registered Nurse, Unit Manager Staff E, revealed patient #3 was admitted to the facility on 6/12/15 with diagnosis of Schizoaffective disorder, bipolar type. Patient #3 had a court appointed legal guardian (a guardian appointed by a judge for individuals determined to be legally incompetent). Staff E was unable to locate documentation that the legal guardian had received the admission packet information including patient rights. Staff E could not locate documentation that the legal guardian had received or signed an "Authorization for Medical Services" from to consent to treatment. Staff E, stated the record may have been thinned and the information may be in medical records and she would request the information.

A review of the hybrid clinical record for patient #7 on 5/11/16 at 1035 with Staff E, revealed patient #7 was admitted to the facility on 12/3/14 with diagnosis of Schizoaffective disorder, bipolar type. Patient #7 had a court appointed legal guardian. Staff E was unable to locate documentation that the legal guardian had received the admission packet information including patient rights or had received or signed an "Authorization for Medical Services" from to consent to treatment. Staff E, stated the information may be in medical records and she would request the information.

On 5/11/16 at 1330 the facility Performance Improvement (PI) Coordinator Staff B stated the information for patient #3 could not be located in medical records. Staff B provided a letter dated 12/3/14 addressed to patient #7's legal guardian that documented the following: ". . .Enclosed is information pertaining to (name of facility) where your ward, (patient #7) has been admitted today, 12/3/14, for treatment. Please fax back these signed forms via fax number provided or you may return them in the self-addressed envelope provided. Copies of the following forms were included: 'Notification of Patient's Rights. Authorization for Medical Services. Consent for Photographic Identification. Claim Authorization. Important Information from Medicare. Notification of Right to Interpreter/Translator Services. Information Provided upon Admission... (later noted to include Patient Rights booklet)." All of the above documents were attached with the patient's name and were not signed. Staff B stated the signed documents could not be located in medical records. Staff B stated the Admissions Coordinator may be able to provide more information.

On 5/11/16 at 1440 the facility Admission/Transfer Coordinator Staff Y was queried regarding contacting patient #3 and #7's legal guardians for consents and patient rights information on admission. Staff Y stated she mailed the information to patient #7's legal guardian on 12/3/14 but never got it back. Staff Y was asked if there was a policy or procedure for follow up or tracking to assure that patient's legal guardians were aware of the patients rights and signed documents for consent to treatments. Staff Y stated "I didn't track it and we didn't follow up. There is no procedure to track them. It is not like I was trained, it (the job) just evolved and things were added that I needed to do. I didn't get it back. Sometimes I get it back right away, sometimes a week, sometimes months. That one I didn't get back." Staff Y was asked if she had sent a letter and forms to patient #3's legal guardian. She stated "I don't have any letter to show it was sent out for (patient #3). I must have missed it."

On 5/11/16 at 1445 the facility Medical Director Staff Z was queried about the above noted documents including consents for treatment and patient rights information not being documented as provided to legal guardians for patients #3 and #7, and whether the facility had any policy or procedure to insure these documents were obtained and signed by patient's legal guardians prior to treatment. Staff Z stated he was "not aware of any policy or procedure for follow up." Adding "We encourage treatment teams to look for that information during patient reviews, but do not have a written procedure for it. . .We need to correct it. We should send it out again if it is not received back in two (2) weeks. We will address this with the treatment teams and track it."

On 5/12/16 at 1015 a review of the facility admission packet provided to patients/guardians revealed the "Your Rights" booklet that documented the following: "Mental Health Code Sections 706, 706a . . .you are to be given information about the rights guaranteed in Chapters 7 and 7a of the Code. This booklet meets that requirement. . . Mental Health Code Section 100 a [17]; Administrative Rule 330.7003. You must give informed consent in order to receive treatment . . ."

On 5/12/16 at 1030 a review of the facility policy titled Admission to the Hospital, dated effective 3/11/16 revealed the following:
"Policy/Standard/Rule/Regulation/Law:
All admissions, both voluntary and involuntary, must comply with applicable sections of the Mental Health Code and the Michigan Department of Health and Human Services. . .
Procedures:
. . .15. Admission Coordinator - Gives Admission Folder and explains to the patient/guardian the following legal and (facility name) documents. . . Your Rights booklet. . .Patient Advocacy List. . .Interpreter Services. . . Safety Concern Brochure. Cost of Care Letter. Complaint and Grievance Resolution Process Information. Mental Health Code. . .Advance Directive Information. Patient Privacy Notice. Notification of Right to Interpreter/Translator Services. Grievance Form. . .
16. Contacts the guardian, if any, and requests their presence to sign consent forms at the time of admission. Obtains the patient/guardian's signature on the Consent From in the EMR (electronic medical record) for the following documents: Receipt of the Admit Packet (including patient rights). Medicare Rights Message. Photographic and Disposal ID photo. Obtain Advance Directive Organ/Tissue form. Consent for Treatment form. . .
If guardian is not present at time of admission:
Consent Forms: Telephone guardian to verify consent and writes on signature line 'guardian consented via telephone'. Second staff confirms consent with guardian on telephone. Both staff signs as witness.
Mails Admission Packet along with consent forms . . . to the guardian for signatures. Maintains a list of guardians to whom the consent forms are sent.
If signed consent forms are not returned in 2 weeks, mails another packet of consent forms to the guardian. . .
18. Mails consent forms to guardian two weeks before the patient's admission anniversary date every year for their signature and scans into the 'Consents/HIPPA' folder upon receipt."




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Additionally, review of patient #9's medical record with the Director of Nursing and PI Coordinator, on 5/11/16 at approximately 1500, revealed that the patient was admitted on 4/22/04 with Schizoaffective disorder, bipolar type. The patient had signed the initial consent forms for treatment and patient rights forms upon admission in 2004. Later, the patient had been designated a legally incapacitated individual on 7/30/12 by the court and had a designated guardian through 9/24/16. The only consents found signed by the guardian were 'Consent for Medications' on 10/10/13, and ' Vaccine Administration Consent Form' for an influenza vaccine on 8/6/15. There were no other patient right consent forms by the guardian on the anniversary of admission per the above stated facility policy and procedure. On 5/12/16 at approximately 1100, the PI Coordinator verified that the forms could not be located, stating "We looked again and can't find it."