HospitalInspections.org

Based on clinical record review, policy and procedure review and interview, it was determined, of the patients reviewed for placement of a 72 hour hold, the Facility failed to provide evidence as to why one (#12) of three (#1, #5 and #12) patients were placed on a 72 hour hold. The failed practice did not protect the patient's right for refusal of treatment and had the potential to affect all patients placed on a 72 hour hold. The findings follow:

A. Review of the policy "Voluntary and Involuntary Admissions" on 09/21/16 revealed, "C. Request to leave: If at any time the person who has voluntarily admitted himself/herself to the hospital makes a request to leave before the time that has been determined necessary for recovery and improvement, and the physician on duty or the physician on call determines that the person meets the criteria for involuntary admission ('a clear and present danger to himself/herself or others'), then the person shall be considered to be held by detention and the involuntary admission procedures set forth herein shall apply ..."

B. The findings of A were confirmed in an interview with the Director of Risk Management and Performance Improvement on 09/21/16 at 1400.

C. Review of Patient #12's clinical record on 09/22/16 revealed the patient was placed on a 72 hour hold on 09/20/16 at 1455. There was no evidence as to why Patient #12 was placed on a 72 hour hold.

D. The findings of C were confirmed in an interview with the Chief Nursing Officer on 09/22/16 at 1115 and with the Director of Risk Management and Performance Improvement on 09/22/16 at 1130.