HospitalInspections.org

Based upon record review and interview, the facility failed to ensure that 14 of 18 (#1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 16, 18) patients and /or their representatives were given the information needed to make informed decisions about mental health treatment. The facility initiated and obtained court ordered mental health services for 14 of 18 patients without providing information to the patient/and or their representative that the patient was receiving court ordered services.

1. Review of medical record of patient #1 revealed patient was an 81 year old female admitted to the facility on 2/23/2010 with a diagnosis of " Dementia with Delusions " . A form titled " Application for Emergency Detention Apprehension " was completed by the facility ' s Nurse Manager. The pre-printed application contained the following statements: " I have reason to believe that (patient #1 name written in) is in need of emergency detention because the proposed patient is mentally ill and presents substantial risk of harm to the person or others. I have reason to believe and do believe that (patient #1 name written in) is mentally ill and that, unless the person is immediately restrained, there is an imminent substantial risk of harm to the person or others. The risk of harm is (describe and specify the harm that probably will occur): dementia with delusions. An " ORDER FOR EMERGENCY APPREHENSION AND DETENTION " was given as a result of the application initiated by the facility on 2/23/2010, signed by the Justice of the Peace.

Further review of the medical record revealed an application dated 2/24/2010 for Court Ordered Mental Health Services that was signed by the Nurse Manager as the Applicant. A form titled " PHYSICIAN ' S CERTIFICATE OF MEDICAL EXAMINATION FOR MENTAL ILLNESS " was in the medical record. The Physician ' s Certificate revealed this was the first time the physician had seen the patient. The brief diagnosis given was " dementia with delusions " . The form contained a section that stated the following " I am of the opinion that the Patient is mentally ill and is likely to cause serious harm to self, to others, and is suffering severe and abnormal mental emotional or physical distress; experiencing substantial mental and physical deterioration of his/her ability to function independently, and is not able to make a rational and informed decision as to whether or not to submit to treatment. The detailed basis of this opinion is as follows: " dementia with delusions" was written in. This was exactly what was written on the form for the diagnosis and was not detailed information. The form was completed in a very neat handwriting and the signature of the Examining Physician did not match the handwriting indicating the form was not completed by the physician.

Review of a form found in the medical record revealed the title was " ORDER FOR PROTECTIVE CUSTODY - MENTAL HEALTH. This order that the patient was to be taken to the hospital to be detained under protective custody was signed by the Justice of the Peace for Titus County. Another court document was found in the medical record titled " PAUPER ' S AFFIDAVIT OF INABILITY TO PAY COSTS " . The form had the patient ' s name written in as the defendant and the form was not completed with financial information that would be used to determine if the patient had the ability to pay court cost for the Order of Protective Custody proceedings. The Nurse Manager had written on the form that the patient was " Unable to complete due to dementia " . The Justice of the Peace for Titus County signed the document which waived the court cost. Further review revealed patient #1 signed a " WAIVER OF PROBABLE CAUSE HEARING BY PATIENT " form that states the following: I, (patient ' s name written in), the proposed patient in the above entitled and numbered cause, and for my own and or others ' protection, hereby waive my opportunity to appear and present evidence at a Hearing on Probable Cause. In this regard I would stipulate that, if a hearing were held, the evidence would support the determination, and a hearing officer could reasonably conclude, that an actual factual basis exists for probable cause to believe that I present a substantial risk of serious harm to myself or others such that my detention in protective custody should continue pending the commitment hearing, if any. This form was dated 2/24/2010 and signed by patient #1. Further review of the medical record revealed patient had been allowed to sign the General Consent to Treatment, 3 Consents for Treatment with Psycho-active Medications, and this Waiver to Probable Cause Hearing related to the Order of Protective Custody.

A telephone interview was conducted with patient #1 ' s daughter on 11/4/10 at 11:30 am. The patient ' s daughter reported that she believed her mother signed in voluntarily to the facility. The daughter reported that she, her father, and her brother had talked with the patient and convinced her she needed the treatment and agreed to go voluntarily. The daughter further reported that she, her father and her brother were not informed of the Emergency Detention Warrant or the Order of Protective Custody by the facility.

An interview was conducted with the Program Director on 11/2/10 at 1:30 pm. The Program Director reported that she conducted a pre-admission assessment on patient #1 and determined that the patient #1 was " not competent " to sign in voluntarily. The Program Director further reported that she determines competency based upon the patient ' s memory ability. The Director reported there was no policy for this process or criteria established to determine competency or the capacity to consent. The Director also reported obtaining Protective Orders was done for the majority of the patients that are admitted to the Gero-Psychiatric Unit and that 10 of 11 patients on the unit on this same date were being held on an Order of Protective Custody. The Program Director reported that they were just trying to meet the state regulation that a patient who did not have the capacity to consent could not be admitted voluntarily so if they needed to be hospitalized, a protective order was obtained.

The Program Director determined that patient #1 was " not competent " to be hospitalized voluntarily and was hospitalized under an order of protective custody. However, review of the record for patient #1 revealed patient was allowed to give consent for treatment, sign the patient rights document that she understood her rights, gave consent for treatment with psychoactive medication for three different medications, and signed the waiver for the probable cause hearing relating to the protective custody order.

Further review of medical records revealed 14 of 18 patients reviewed were admitted involuntarily and were allowed to sign their own consents and either signed their own waiver for probable cause hearing relating to the protective custody order or a staff person wrote " unable to sign " or " refused to sign " on the waiver for probable cause hearing form. None of these 14 patients admitted involuntarily were provided the opportunity for a probable cause hearing.

2. Review of the medical record of Patient #2 revealed patient was a 90 year old female involuntarily admitted with a diagnosis of dementia with delusional features. Patient was admitted from the nursing home with increasing confusion and behavior disturbances. Review of court documents revealed the facility Program Director signed the application for court ordered mental health services. There was no documentation that the patient, or her representative had been informed of the court order for mental health services. Review of consents revealed that patient signed the patient rights document that she understood her rights, 6 consents to treatment with psychoactive medication, and patient signed the waiver of probable cause hearing relating to order of protective custody but she was not allowed to give consent to voluntary treatment. Patient #2 was not afforded a probable cause hearing.

3. Review of the medical record of Patient #3 revealed patient was a 79 year old female involuntarily admitted with a diagnosis of dementia with delusional features. Patient was admitted from the nursing home with increasing confusion and behavioral disturbances. Review of the court documents revealed the facility Program Director signed the application for court ordered mental health services. There was no documentation that the patient or her representative had been informed of court ordered treatment. Review of record revealed no consent to treatment, no consents for treatment with psychoactive medications, no patient rights documentation. The copy of the waiver of probable cause hearing relating to order of protective custody revealed " REFUSED to SIGN " written in patient signature area and signed by the Program Manager. Patient #3 was not afforded a probable cause hearing.

4. Review of the medical record of Patient #4 revealed patient was a 87 year old female involuntarily admitted with a diagnosis of dementia with delusional features. Patient lives with sister and was admitted due to increasing confusion and behavioral disturbances. Review of court documents revealed the nurse manager for the unit made application for court ordered mental health services. There was no documentation that the court order for mental health services had been explained to the patient or the patient's representative. Review of consents revealed patient signed the general consent for treatment, patients rights document that she understood her patient rights, 3 consents to treatment with psychoactive medication but she was not allowed to sign consent to voluntary treatment. The waiver of probable cause hearing was not signed and the nurse manager had written in " Refuses to sign " . Patient #4 was not afforded a probable cause hearing.

5. Review of the medical record of Patient #5 revealed patient was a 86 year old female involuntarily admitted with a diagnosis of dementia with delusional features. Patient lives in a nursing home and was admitted due to increasing agitation and behavioral disturbances. Review of court documents revealed the application for court ordered mental health services was initiated by the unit's Nurse Manager. There was no documentation in the medical record that patient or patient's representative had been informed of the court ordered services. Review of consents revealed patient signed the Verbal Information Release, Consent to Photograph, and Patient ' s Bill of Rights but she was not allowed to give consent to hospitalization. The Waiver of Probable Cause Hearing contained the written statement " Unable to sign due to dementia " signed by the Nurse Manager. Patient #5 was not afforded a probable cause hearing.

6. Review of the medical record of Patient #7 revealed patient was a 97 year old female involuntarily admitted with a diagnosis of dementia with delusional features. Patient was transferred from another unit of the hospital due to agitation, aggression, and behavior disturbances. Review of court documents revealed an application for emergency apprehension and detention was made by the unit Nurse Manager. The Nurse Manager also made application for court ordered mental health services. There was no documentation that the patient or her representative had been informed of the court ordered mental health treatment. Review of record revealed no general consent, no consent for treatment with psychoactive medications, no patient rights documentation. The Waiver of Probable Cause Hearing contained the " Unable to sign " written on patient signature line and signed by the Nurse Manager. Patient #7 was not afforded a probable cause hearing.

7. Review of the medical record of Patient #8 revealed patient was a 54 year old female involuntarily admitted with a diagnosis of schizoaffective disorder. Patient was brought in on an emergency detention warrant from another facility and had been experiencing manic and psychotic symptoms. An application for Court Ordered Mental Health Treatment was initiated by the Nurse Manager. There was no documentation that the patient or her representative had been informed of the court ordered treatment. Review of record revealed no general consent. The patient signed the Patients Bill of Rights, Verbal Information Release, Consent to Photograph, and 2 Consents to Treatment with Psychoactive Medications but was not allowed to be hospitalized with her own consent. The Waiver of the Probable Cause Hearing was not signed by the patient. Patient #8 was not afforded a probable cause hearing.

8. Review of the medical record of Patient #9 revealed patient was a 79 year old male involuntarily admitted with a diagnosis of dementia with delusional features. Patient was admitted due to confusion and behavioral disturbances. Review of court documents revealed an application for Apprehension and Detention was initiated by the Program Director. An application for Court Ordered Mental Health Services was also initiated by the Program Director. There was no documentation that the patient or his guardian had been given about court ordered services. Review of record revealed no general consent. The patient had signed Patient Rights form that he had been explained and understood his rights, and a consent to treatment with psychoactive medications. The Waiver of Probable Cause Hearing contained the phrase " refused to sign " on the patient signature line and signed by the Program Director. The record contained guardianship documents that patient ' s wife had been granted guardianship of the patient due to his mental incapacity. No hospital consents were signed by the guardian. Patient #9 was not afforded a probable cause hearing.

9. Review of the medical record of Patient #10 revealed patient was a 43 year old male involuntarily admitted with a diagnosis of delusional disorder, impulse control disorder, and cognitive disorder. Patient was admitted from a nursing home because he was experiencing delusional and threatening behavior. Patient had a history of brain surgery for a brain tumor in the right front temporal area. Review of court records revealed patient was brought to the facility on an emergency detention warrant. There was also a court order for Mental Health services initiated by the facility. There was no documentation in the medical record that the patient or the patient's representative had been informed of the court ordered treatment. Review of consents revealed the Patient ' s Bill of Rights was signed by the patient. There were no consents to treatment with psychoactive medication even though patient was on 8 psychoactive medications. There also was no general consent or waiver for probable cause hearing in the medical record. Patient was not afforded a probable cause hearing. Also found in the medical record was a Request for Voluntary Admission dated 6/4/10 which was 2 days after admission. There was no documentation found in the medical record to indicate that patient was allowed to become a voluntary patient.

10. Review of the medical record of Patient #12 revealed patient was a 53 year old male involuntarily admitted with a diagnosis of Major depressive disorder and a history of a recent stroke. Patient was admitted due to depression related to his change of life situations resulting from the stroke. Review of court documents revealed an application for emergency apprehension and detention initiated by the Program Director. There was also the court order for the emergency apprehension and detention signed by the Justice of the Peace. There was also an application for court ordered mental health services initiated by the Program Director and the Court Order for Mental Health Services signed by the Justice of the Peace. There was no documentation in the medical record that the patient or patient's representative had been given any explanation about court ordered treatment. Review of consents revealed there was no general consent in the medical record. The patient had signed the Patient Bill of Rights and 2 consents for treatment with psychoactive medications. The patient had also signed his treatment plan. The waiver to a probable cause hearing had " refused to sign" written near the patient signature line. Patient #12 was not afforded a probable cause hearing.

11. Review of the medical record of Patient #13 revealed patient was a 73 year old male involuntarily admitted with a diagnosis of dementia with delusional features. Patient was admitted from a nursing home for increasing confusion and agitation. Review of consents revealed the patient signed the general consent to treatment, Patient Bill of Rights, and 3 consents to treatment with psychoactive medications. Patient signed a request for voluntary admission on the date of admission, 6/22/10. However, an Order for Emergency Detention was issued on 6/22/10. On 6/23/10, an application for court ordered mental health services was made by the Program Director. The waiver for probable cause hearing had " refused to sign " written on the patient signature line and signed by the Program Director. The patient was not afforded a probable cause hearing. There was no documentation in the medical record that the patient or patient's representative had been given any explanation about court ordered treatment.

12. Review of the medical record of Patient #14 revealed patient was a 61 year old male involuntarily admitted with a diagnosis of dementia with delusional features and behavioral disturbances. Patient was in a nursing home and reportedly was physically threatening, angry, and paranoid. Review of court documents in the medical record revealed an application for emergency apprehension and detention was initiated by the Program Director of the unit. There was an order for the emergency detention requested. There was also an application for court ordered mental health services initiated by the Nurse Manager and the signed order for mental health services by the Justice of the Peace. There was no documentation that the patient or the patient's representative was informed of the process for court ordered mental health services. Review of consents revealed no general consent found in the medical record. The patient had signed the Patient Bill of Rights and 3 Consents for Treatment with Psychoactive Medications. The patient was also allowed to sign the Waiver to a Probable Cause Hearing.

13. Review of the medical record of Patient #16 revealed patient was a 73 year old female admitted involuntarily with a diagnosis of Dementia with Delusional Features. Patient was admitted from the nursing home due to aggressive behaviors, uncooperative, hostile and confused. Review of court documents in the medical record revealed an order for Emergency Apprehension and Detention was signed by the Justice of the Peace. An application for Court Ordered Mental Health Services was initiated by the Nurse Manager of the unit and the Court Order was signed by the Justice of th Peace. There was no documentation that the patient or patient's representative was informed of the court ordered treatment. Review of the consents revealed no general consent was signed but the patient ' s husband was allowed to sign the Patient ' s Bill of Rights, Consent to Photograph, Verbal Information Release, and 5 Consents to Treatment with Psychoactive Medications. The Waiver for Probable Cause Hearing had " unable to sign due to dementia " written by the patient ' s signature line and signed by the nurse manager. Patient was not afforded a probable cause hearing.

14. Review of the medical record of Patient #18 revealed patient was a 75 year old male involuntarily admitted with a diagnosis of dementia with delusional features and behavior disturbances and Mental Retardation. Patient had been physically violent and aggressive in the nursing home, hitting staff and residents. Review of court documents in the medical record revealed an application for Emergency Apprehension and Detention was initiated by the Nurse Manager of the unit. There was an order for Emergency Detention signed by the Justice of the Peace. There also was an application for Court Ordered Mental Health Services initiated by the Nurse manager of the unit. The court order for mental health services was signed by the Justice of the Peace. There was no documentation that the patient or patient's representative was informed of the court ordered treatment. Review of consents revealed Patient ' s Bill of Rights and 6 Consents for Treatment with Psychoactive Medications had " Unable to sign " written on the signature line. There was no general consent or Waiver for Probable Cause Hearing found in the medical record. There was no documentation that patient was afforded a probable cause hearing.

An interview was conducted on November 9, 2010 at 10:45 am with the Justice of the Peace for Titus County who is responsible for protective orders and mental hearings. The Justice of the Peace (JP) reported that the " hospital " told the court that no facility will take a patient without an order of protective custody. The JP also reported that she believes what the hospital tells about the patient and issues the order. A representative from the psychiatric unit brings the application for emergency detention or protective custody, and the JP signs the order. The JP stated she has been in office since 1999, and " I have never conducted a mental health hearing. " The JP stated " If I have ever denied any requests for orders of protective custody, it wasn ' t many. The reason hearings are not conducted is that it all boils to politics and it boils down to money " .