HospitalInspections.org

Based on interview and record review, the facility failed to ensure three of three sampled patients (Patient 1, Patient 11, and Patient 14) completed informed consent forms prior to administration of psychotropic medications (drugs that affect brain activity and are used to treat mental health conditions). This failure had the potential for patients to not have all the information needed to make an informed decision.

Findings:

During an interview on 6/18/25 at 8:55 a.m. with Chief Nursing Officer (CNO), CNO stated the hospital did not have an informed consent policy.

During a review of Patient 1's "Discharge Summary" (DS), dated 6/12/25, the DS indicated, Patient 1 had an admission diagnosis of Schizoaffective disorder (mental health condition characterized by hallucinations and delusions), bipolar (mental health conditions characterized by extreme shifts in mood) type.

During a review of Patient 1's "Physician Orders" (PO), dated 6/5/25, the PO indicated, Patient 1 was prescribed Tegretol (seizure medication also used to treat bipolar disorder) 100 mg twice a day, Zyprexa (used to treat manic or mixed episodes) 10 mg at night, and Ativan (treatment for anxiety) 0.5 mg daily as needed.

During a review of Patient 1's "Medication Administration Record" (MAR), dated June 2025, the MAR indicated, Patient 1 was given the following:

Tegretol 100 mg on 6/5/25 at 9:50 a.m.
Tegretol 100 mg on 6/5/25 at 9 p.m.
Zyprexa 10 mg on 6/5/25 at 9 p.m.
Ativan 0.5 mg on 6/5/25 at 8:43 p.m.
Tegretol 100 mg on 6/6/25 at 9 a.m.
Tegretol 100 mg on 6/6/25 at 9 p.m.
Zyprexa 10 mg on 6/6/25 at 9 p.m.
Tegretol 100 mg on 6/7/25 at 9 a.m.
Tegretol 100 mg on 6/7/25 at 9 p.m.
Zyprexa 10 mg on 6/7/25 at 9 p.m.
Ativan 0.5 mg on 6/7/25 at 8:37 p.m.
Tegretol 100 mg on 6/8/25 at 9 a.m.
Tegretol 100 mg on 6/8/25 at 9 p.m.
Zyprexa 10 mg on 6/8/25 at 9 p.m.
Tegretol 100 mg on 6/9/25 at 9 a.m.
Tegretol 100 mg on 6/9/25 at 9 p.m.
Zyprexa 10 mg on 6/9/25 at 9 p.m.
Ativan 0.5 mg on 6/9/25 at 8:58 a.m.
Tegretol 100 mg on 6/10/25 at 9 a.m.
Tegretol 100 mg on 6/10/25 at 9 p.m.
Zyprexa 10 mg on 6/10/25 at 9 p.m.
Ativan 0.5 mg on 6/10/25 at 8:08 p.m.
Tegretol 100 mg on 6/11/25 at 9 a.m.
Tegretol 100 mg on 6/11/25 at 9 p.m.
Zyprexa 10 mg on 6/11/25 at 9 p.m.
Ativan 0.5 mg on 6/11/25 at 9:42 p.m.
Tegretol 100 mg on 6/12/25 at 9 a.m.

During a review of Patient 1's "Medication Information & Consent" (MIC), dated 6/5/25, the MIC indicated, Patient 1 did not sign the box that indicated, "I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider."

During a review of Patient 11's DS, dated 4/23/25, the DS indicated, Patient 11 had an admission diagnosis of Psychosis (mental health conditions characterized by loss of touch with reality), unspecified.

During a review of Patient 11's PO, dated 4/19/25, the PO indicated, Patient 11 was prescribed Remeron (treatment for depression) 15 mg every night, Prozac (treatment for depression) 40 mg every morning, and Seroquel (treatment for psychosis)100 mg every night.

During a review of Patient 11's MAR, dated April 2025, the MAR indicated, Patient 11 was given the following:

Prozac 40 mg on 4/19/25 at 1:25 p.m.
Remeron 15 mg on 4/19/25 at 9 p.m.
Seroquel 100 mg on 4/19/25 at 9 p.m.
Prozac 40 mg on 4/20/25 at 9 a.m.
Remeron 15 mg on 4/20/25 at 9 p.m.
Seroquel 100 mg on 4/20/25 at 9 p.m.
Prozac 40 mg on 4/21/25 at 9 a.m.
Remeron 15 mg on 4/21/25 at 9 p.m.
Seroquel 100 mg on 4/21/25 at 9 p.m.
Prozac 40 mg on 4/22/25 at 9 a.m.
Remeron 15 mg on 4/22/25 at 9 p.m.
Seroquel 100 mg on 4/22/25 at 9 p.m.
Prozac 40 mg on 4/23/25 at 9 a.m.

During a review of Patient 11's MIC, dated 4/19/25, the MIC indicated, Patient 11 did not sign the box that indicated, "I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider."

During a review of Patient 14's "Facesheet," undated, the "Facesheet" indicated, Patient 14 had an admission diagnosis of Bipolar disorder.

During a review of Patient 14's PO, dated 6/4/25, the PO indicated, Patient 14 was prescribed Depakote (medication used to treat bipolar disorder) 500 mg twice a day and Zyprexa 10 mg twice a day.

During a review of Patient 14's PO, dated 6/7/25, the PO indicated, Patient 14's Depakote dosing was increased to 1000 mg every night and 500 mg in the morning.

During a review of Patient 14's MAR, dated June 2025, the MAR indicated, Patient 14 was given the following:

Depakote 500 mg on 6/4/25 at 8 p.m.
Zyprexa 10 mg on 6/4/25 at 8 p.m.
Depakote 500 mg on 6/5/25 at 9 a.m. and at 8 p.m.
Zyprexa 10 mg on 6/5/25 at 9 a.m. and 9 p.m.
Depakote 500 mg on 6/6/25 at 9 a.m. and at 8 p.m.
Zyprexa 10 mg on 6/6/25 at a.m. and 9 p.m.
Depakote 500 mg on 6/7/25 at 9 a.m. and 1000 mg at 9 p.m.
Zyprexa 10 mg on 6/7/25 at 9 a.m. and 9 p.m.
Depakote 500 mg on 6/8/25 at 9 a.m. and 1000 mg at 9 p.m.
Zyprexa 10 mg on 6/8/25 at 9 a.m. and 9 p.m.
Depakote 500 mg on 6/9/25 at 9 a.m. and 1000 mg at 9 p.m.
Zyprexa 10 mg on 6/9/25 at 9 a.m. and 9 p.m.
Depakote 500 mg on 6/10/25 at 9 a.m. and 1000 mg at 9 p.m.
Zyprexa 10 mg on 6/10/25 at 9 a.m.

During a review of Patient 14's MIC, dated 6/4/25, the MIC indicated, Patient 14 did not sign the box that indicated, "I have discussed and received a copy of this information. Risks, benefits, side effects, alternatives, and the risks of not taking this medication have been explained to me. I understand that this consent may be withdrawn at any time. I consent to the medication prescribed by my provider."

During an interview on 6/19/25 at 1:53 p.m. with Quality and Risk Manager (QRM), QRM stated the consent box should have been checked by patients who agreed to take the psychotropic medications and acknowledged they received risks, benefits, and alternatives to the medication use, even if they refused to sign the consent form.

During a review of the facility's policy and procedure (P&P) titled, "Consent to Psychotropic Medication," dated 3/12/25, the P&P indicated, "4. If patient gives verbal consent, and is unable to sign due to a disability or is unwilling to sign due to symptoms, this will be indicated on the consent form and signed by the RN witness. . .7. Written documentation of the patient's decision to consent must be maintained."

Based on interview and record review, the hospital failed to:

1. Ensure non-clinical employees refrained from making clinical interventions.

2. Follow their policy and procedure (P&P) titled, "72-Hour Hold for Evaluation and Treatment" for four of 30 sampled patients (Patient 13, Patient 19, Patient 20, and Patient 21). This failure had the potential for Patient 13, Patient 19, Patient 20, and Patient 21 to not fully understand their rights.

3. Ensure the hospital's Clinical Liaison was qualified for the position.

These failures had the potential to result in unsafe care settings.

Findings:

1. During an interview on 6/18/25 at 9:30 a.m. with Chief Nursing Officer (CNO), CNO stated Patient 30 was brought to the hospital on 5/16/25 on a 5150 hold (an involuntary 72-hour psychiatric hold for individuals who are deemed a danger to themselves or others, or who are gravely disabled due to a mental health disorder), from a remote city around two hours away from hospital. CNO stated Patient 30 scored as a "high risk" for suicide during the intake process. CNO stated Patient 30 became highly agitated because she did not think she would be so far from home. CNO stated an intake Registered Nurse (RN) 1 and Licensed Marriage and Family Therapist (LMFT) were in the Interview Room with Patient 30 and were unable to deescalate Patient 30's agitation. CNO stated the Director of Intake (DOI) was not in the hospital and the intake staff had been instructed to notify the Chief Executive Officer (CEO) for any issues when DOI was not available. CNO stated the intake team contacted the CEO, as instructed, and the CEO along with Director Human Resources (DHR) responded to the Interview Room and spent "quite some time" with Patient 30. CNO stated CEO made assessment notes over RN 1's notes. CNO stated CEO's assessment indicated Patient 30 was no longer a danger to self (DTS) and she instructed RN 1 to call Physician 1 to have Patient 30 discharged. CNO stated CEO had already informed Patient 30 that she would be able to go home prior to Physician 1 being notified. CNO stated RN 1 called Physician 1, as instructed, and Physician 1 gave orders to discharge Patient 30. CNO stated RN 1 did not feel safe discharging Patient 30 and then notified CNO. CNO stated she notified DOI of CEO's clinical interventions, and that DOI and CEO got into a "heated conversation." CNO stated DOI instructed RN 1 to notify Physician 1 of Patient 30's DTS score and Physician 1 gave orders to cancel his discharge orders and admit Patient 30 on a 5150 hold status. CNO stated RN 1 asked CEO to inform Patient 30 that she would not be discharged, but CEO refused because CEO "did not feel safe" going in to speak with Patient 30. CNO stated Patient 30 was informed that she would not be discharged she began to exhibit assaultive behavior toward the staff and interventions to deescalate Patient 30's behavior did not work. CNO stated Patient 30 required administration of emergency medications to calm her behavior. CNO stated she reviewed Patient 30's medical record (MR) with LMFT after the event and LMFT stated the notes made in the margins of the "Intake Assessment" were made by CEO. CNO stated LMFT stated CEO's assessment of Patient 30 "was inaccurate."

During a concurrent interview and review of Patient 30's MR on 6/18/25 at 9:40 a.m. with CNO the "Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" dated 5/15/25, indicated Patient 30, "Didn't want to live anymore and that she has no purpose" after taking 180 iron pills. The "Intake Assessment" (IA), dated 5/16/25 at 12:54 p.m. indicated Patient 30 arrived at the hospital, "Pt [patient] is on a 5150 for DTS [danger to self] for overdosing on iron pills." The IA, page 8, subheading "Step 3" indicated Patient 30 scored 25 out of 25 for "Specific questioning about Thoughts, Plans, and Suicidal Intent." CNO stated a score of 25 indicated Patient 30 was at a "High Risk" for suicide. CNO stated the IA (page 8) handwritten documentation in the right margin (highlighted by hospital staff) was documented by CEO as a "reassessment" at 4:05 p.m. The highlighted documentation by CEO indicated "benefit of D/C [discharge] outweighs risk [of suicide]." The "Nurses Progress Notes" (NPN) dated 5/16/25, at 4:30 p.m. indicated, "Intake nurse voiced concern to the CEO that this [discharging Patient 30] is not a safe discharge as the patient has not been evaluated by a psychiatrist in person and discharging a patient on a 5150 hold [with a telephone order] is not appropriate. The CEO responded that similar patients are often discharged without a psychiatrist assessment. Following this, the CEO spoke with the patient [Patient 30] again at length and recommended to continue discharging the patient. CEO notified the patient that [the hospital] can provide transport for pt. [Physician 1] contacted and notified of nursing concerns regarding this being an unsafe discharge as the patient has not been evaluated by a psychiatrist at [the hospital]. Physician 1 agreed with nursings [sic] concerns and gave order to cancel the previous [discharge orders and] 5150 hold remained in place."

During an interview on 6/18/25 at 9:22 a.m. with Chief Medical Officer (CMO), CMO stated CEO continually tried to overrule MD orders. CMO stated CEO has tried to change "treatment plans" during interdisciplinary team meetings.

During an interview on 6/19/25 at 11:43 a.m. with CEO, CEO stated she was called to the Intake Room for Patient 30 when RN 1 told her Patient 30's behavior and agitation could not be deescalated. CEO stated she had "No clinical say-so." CEO stated her documentation on the IA form was not an assessment but her attempt to show "two separate perspectives." CEO stated she makes decisions to protect the hospital.

During an interview on 6/18/25 at 11:05 a.m. with Regional Vice President of Operations (RVPO), RVPO stated CEO was not hired to perform any clinical work.

During a review of "Chief Executive Officer Job Description" (CEOJD), the CEOJD indicated, "Principal Duties and Responsibilities: 1. Create and communicate a vision for the hospital. 2. Identify, develop and direct the implementation of business strategy. 3. Plan and direct the hospital's activities to achieve stated/agreed targets and standards for financial and trading performance, quality, culture and legislative adherence. 4. Define measurable goals that develop and enhance processes, systems and practices and provide the means and resources needed to accomplish the goals. 5. Manage and develop key administrative team members. 6. Effectively delegate goals and responsibilities of key executive staff. 7. Direct functions and performance via the administrative team. 8. Review and monitor organizational development."

2. During a review of Patient 13's "Certification Review of Hearing Minutes" (CRHM), dated 5/29/25, the "CRHM" indicated, Patient 13 was willing to stay in the hospital voluntarily.

During a concurrent interview and record review on 6/18/25 at 11:50 a.m. with RN 2, Patient 13's MR, dated May 2025 was reviewed. The MR indicated, there was no voluntary admission consent. RN 2 stated staff should have had a consent signed for the voluntary admission.

During a concurrent interview and record review on 6/18/25 at 11:54 a.m. with RN 2, Patient 13's "Physician Orders" (PO), dated May 2025 was reviewed. The PO indicated, there was no physician orders made for Patient 13's voluntary admission. RN 2 stated staff should notify the physician about the voluntary admission and get an order.

During a concurrent interview and record review on 6/18/25 at 11:26 a.m. with CNO, Patient 19's MR was reviewed. CNO stated Patient 19 was brought to the hospital on 6/6/25 on a 5150 hold for DTS. The "Notice of Certification" (NC) dated 6/9/25 indicated Patient 19 continued to be "A danger to himself or herself" at the end of the 5150 hold. The "Certification Review of Hearing Minutes" (CRHM), dated 6/9/25 indicated Patient 19 agreed to stay in the hospital as a voluntary admission. CNO stated there was no PO to admit Patient 19 as a voluntary admission and there was no signed consent for Patient 19 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 19 was discharged from the hospital on 6/14/25 at 12:31 p.m.

During a concurrent interview and record review on 6/18/25 at 11:33 a.m. with CNO, Patient 20's MR was reviewed. CNO stated Patient 20 was brought to the hospital on 5/22/25 on a 5150 72-hour hold for DTS. The CRHM, dated 5/24/25 indicated Patient 20 continued to be a "danger to self" and "Will stay voluntarily? YES" as a voluntary hospital admission. CNO stated there was no PO to admit Patient 20 as a voluntary admission and there was no signed consent for Patient 20 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 20 was discharged from the hospital on 6/2/25 at 5:48 p.m.

During an interview with RN 2, RN 2 stated when a patient wins their court order to be discharged after a 5150 hold, but decides to stay as a voluntary admission, the RN must get a PO for the admission and the patient must sign a consent for voluntary admission.

During a concurrent interview and record review on 6/18/25 at 12:11 p.m. with CNO, Patient 21's MR was reviewed. CNO stated Patient 21 was brought to the hospital on 5/24/25 on a 5150 72-hour hold for DTS. The CRHM, dated 5/26/25 indicated Patient 21 continued to be a "danger to self" and "Will stay voluntarily? YES" as a voluntary hospital admission. CNO stated there was no PO to admit Patient 21 as a voluntary admission and there was no signed consent for Patient 21 to stay in the hospital on a voluntary basis. The Facesheet indicated Patient 21 was discharged from the hospital on 6/1/25 at 10:10 a.m.

During a review of the hospital's P&P titled, "72-Hour Hold for Evaluation and Treatment" dated 3/12/25, the P&P indicated, "Prior to the end of the 72 hours detention one of the following dispositions must be arranged: [1] Unconditional release.[2] The patient consents to Voluntary Treatment and signs Request for Voluntary Admission and Authorization for Treatment Form."

3. During a concurrent interview and review of Court Liaison's (CL) personnel file (PF) on 6/19/25 at 10:37 a.m. with DHR, the PF indicated CL did not meet qualifications for the CL position. The PF indicated CL had neither a bachelor's degree or a master's degree in any field of study. DHR stated applicants, for any posted hospital job, complete an electronic application on the hospital's website. DHR stated applications are automatically rejected if the applicant does not meet the minimum requirements. DHR stated CL was hired as a "Care Coordinator" which did not involve any patient care interaction. DHR stated CL was promoted to the CL position internally. The "Personnel Action Request" (PAR), dated 3/12/25 was reviewed. The PAR indicated CL was hired on 11/4/24 and a change in status was initiated in March 2025. DHR stated CL was promoted to a new position (CL) in another department after only four months of being hired at the hospital. DHR stated there was no interview documentation in CL's PF. DHR stated CL had no prior experience as a court liaison. DHR stated CL's training for the CL position was "two-hour" education presentation by a county patient's rights advocate.

During a review of the hospital's job description for the job description indicated, "Basic Purpose of Position: Attend court hearings. Track and oversee completion of holds and represent the hospital at legal hold hearings. LPS conservatorship [Lanterman-Petris-Short conservatorship, legal process that allows for the involuntary treatment and care of adults with severe mental illness who are deemed "gravely disabled" and unable to care for their basic needs] applications. Serve patients with Physician ordered legal holds and work with social workers to ensure that all legal holds are kept up to date over the weekends. Assist and train psychiatrist with writing holds and legal documents including 5250 [up to 14-day hold for involuntary psychiatric treatment following a 72-hour hold], 5270 [additional 30 days of involuntary detention], 5260 [allows for continued intensive treatment beyond the initial 5250 hold], Riese [legal process to determine if a person on an involuntary mental health hold can refuse antipsychotic medication], and WRIT [legal action that can be used to challenge the legality of someone's detention], conservatorship paperwork. Provide prompt response to persons in crisis with the goal of stabilizing the crisis in the least restrictive way, facilitating access to mental health services, and/or performing clinical and legal investigation and evaluation for involuntary detention to psychiatric facilities. . . Job Requirements: Minimum Education Bachelors Degree in Psychology or related field or equivalent experience and education. Master's degree in Social Work preferred. Minimum Work Experience: Three (3) years experience in mental health or related field with knowledge of Patients Rights, Court Hearings, CMS [Centers for Medicare and Medicaid Services] mental health system title 9 and Title 22 regulations along with TJC [The Joint Commission- an accreditation agency] Standards."



47734

During a concurrent interview and record review on 6/18/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN), Patient 23's "Notice of Certification Acknowledgement" (NCA)," dated 6/8/25 was reviewed. The NCA indicated, "a certification review hearing will be held within four days of the date on which the certification was completed." LVN stated this meant a hearing would have been scheduled for Patient 23, LVN stated there was no Court Hearing Minutes in Patient 23's MR.

During a concurrent interview and record review on 6/18/25 at 4:04 p.m. with Quality and Risk Manager (QRM), the hospital's "Involuntary Patient Data Sheet" (IPDS- court hearing schedule), undated was reviewed. The IPDS indicated, on 6/9/25, Patient 23 had a court hearing scheduled with a decision made. QRM stated Patient 23 was on the schedule for a court hearing and was admitted voluntarily after the hearing.

During an interview on 6/18/25 at 4:06 p.m. with LVN, LVN stated the CL was responsible to file the Court Hearing Minutes for Patient 23 and LVN stated the Court Hearing Minutes were not filed, and the hospital was unable to locate the missing document.

During a review of the hospital's P&P titled, "Employee Transfer," dated 7/27/22, the P&P indicated, "TRANSFERS WITHIN THE SAME FACILITY 1. Job changes will be considered only after an employee completes six months of employment with one department."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Discharge Planning" for one of 30 sampled patients (Patient 23). This failure had the potential for an interruption in provision of care and unmonitored patient treatment progress.

Findings:

During an interview on 6/17/25 at 11:54 a.m. with Chief Nursing Officer (CNO), CNO stated
discharge planning was completed by the hospital's Case Managers (healthcare professionals who coordinate and manage patient care, acting as a liaison between patients, families, and the healthcare team). CNO stated discharge planning starts within 24 hours of the patient's admission.

During a concurrent interview and review of Patient 23's medical Record (MR), on 6/18/23, at 2:37 p.m. with CNO, the "Facesheet" indicated Patient 23 was admitted to the hospital on 6/5/25 at 9:30 p.m. The "Social Service Progress Note" dated 6/7/25 at 8:23 a.m. indicated Case Manager 1 made the initial case management note. CNO stated the case management note was more than 24 hours after Patient 23's admission.

During a review of the hospital's P&P titled, "Discharge Planning" dated 3/25/22, the P&P indicated, "Discharge planning is intended to maintain continuity of care, maintain progress achieved during treatment, and minimize the risk of relapse or readmission . . . PROCEDURE: 1. The Case Manager will see every patient within the first twenty-four hours of admission."


47734