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Based on review of medical records, staff and patient interviews, and policy review, it was determined that the facility failed to ensure that patients and/or guardians received a copy of the facility's Patient Rights on admission. Findings include:

A review of ten (10) medical records revealed that the facility failed to provide one patient (Patient #3) the following: consent to treat, acknowledgment of receipt of patient rights, acknowledgement of patient privacy policies, or advanced directive information signed by Patient #3's legal guardian.

Review of the facility's policy RI-001 titled 'Patient Rights', last revised 8/17 revealed that it was the policy of the facility to ensure that all patients received a copy of the Patient Rights form, as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms. As a part of the admission process, Intake staff oriented patients to their rights and responsibilities regarding Access to Treatment, Emergency Procedures, Confidentiality and Complaints/Grievances through a review of the patient handbook. Each patient had access to information about all mental health and substance abuse benefits in the inpatient and outpatient setting. The facility supported and protected the fundamental human, civil, constitutional and statutory rights of the individual patient, foster the individual's right to participate in their own care, and recognize and respect personal dignity of the patient at all times.

Prior to admission, each individual was provided with a copy of the Patient Rights form and a verbal explanation of those rights in their primary language in simple non-technical language. The minor's parent, managing conservator or legal guardian was given the patient's Rights and Responsibilities. If a family member, legal guardian, or friend was available, he or she shall be asked to be present during the explanation. This was done with both voluntary and involuntary patients.

Continued review of the policy revealed that the individual and/or the parent, conservator, or guardian was requested to sign and date a copy of the Patient Rights form prior to admission to acknowledge receiving a written and verbal explanation of those rights and signing an attestation to an understanding of the Patient Rights. The signed copy was witnessed by a family member, legal guardian, or friend (if available) and placed in the patient's medical record. The staff member who explained the rights also signed and dated the copy of the Patient's Bill of Rights. This signed form was filed in the patient's medical record. When the individual receiving services was unable or unwilling to sign the document which confirmed that rights had been orally communicated, a brief explanation of the reason was entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably a family member, legal guardian or friend (if available) or by another staff member. A copy of the Patient Rights was provided to the patient and to the individual's family member, legal guardian, or friend (if available) prior to admission.

A review of the facility policy number RI-032, titled "Patient/Family Involvement in Treatment", original date of issue: 03/2013 reveals that the facility acknowledged the importance of patient and family involvement in the plan of care provided to individual patients. When appropriate and possible, the involvement of the patient and family members is sought and encouraged throughout the course of treatment. At the time of assessment, patient and family expectations for treatment and involvement in treatment will be elicited by the Clinical staff.

Patients are involved in at least the following aspects of their care:
Giving informed consent.
Making care decisions, including managing pain effectively.
Resolving dilemmas about care decisions;
Formulating advance directives; and
Withholding resuscitative services.

Further review reveals that in addition, families may participate in a variety of programs designed to educate them in issues of mental illness and the process of recovery. Programs range in their focus and address the child and adult populations. Sessions are facilitated by doctors, nurses and other professionals during evening and weekend hours to be convenient for families.


A review of the facility policy number RI-033, titled "Patient/Guardian Participation in Treatment Decision - Making Process", original date of issue: 03/2013, revised 08/2017 reveals when appropriate, parent/guardian will facilitate care decisions and approve the care provided.

During an interview with Patient #3 on 9/20/19 at 10:20 a.m. in the adolescent unit nurses station, she stated that she had not been informed of her patient rights on admission. Patient #3 stated that she had not been told how to file a complaint or grievance and was not aware of a Patient Advocate.

During a tour of the adolescent unit on 9/20/19 beginning at 10:05 a.m., it was observed that information about the Patient Advocate and Patient Rights was posted in the day room.

On 9/20/19 at 11:30 a.m., Director BB acknowledged that the medical record did not contain a signed consent to treat and acknowledgement of patient rights.

Based on review of medical records, review of policies, and interviews, it was determined that the facility failed to ensure that drugs were administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice.

Findings included:

A review of ten (10) medical records (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12) revealed that two (2) patients (Patient #6, Patient #11) were administered 'as needed' medications without a reason for the administration of the medication.

Specifically:

A review of Patient #6's medical record revealed that she was administered Benadryl (medicine given for insomnia or allergies) 25 mg by mouth on 5/13/19 at 11:45 p.m. and Haldol (medicine given for anxiety) 2.5 mg by mouth on 5/14/19 at 12:30 a.m. The medical record failed to reveal a reason for the administration of either medication to the patient at the time they were given. Review of the Patient Observation record revealed that Patient #6 appeared asleep in bed from 5/13/19 at 10:45 p.m. through 6:45 a.m. on 5/14/19. The observation record revealed that Patient #6 appeared to be asleep at the time the oral medications were given.

A review of Patient #11's medical record revealed that he was administered an injection of Thorazine on 9/18/19 at 7:50 a.m. Continued review of the record failed to reveal a reason administering the medication to Patient #11 at the time.

Continued review of Patient #6's record revealed that verbal admission orders were taken on 5/11/19 at 11:55 p.m. that included Haldol 2.5 mg by mouth as needed every four hours as needed for agitation and Benadryl 25 mg by mouth every four hours as needed for sleep. A review of the record failed to reveal that the prescribing physician signed the verbal order. A separate verbal order was taken on 5/11/19 at 11:55 p.m. for Zoloft (medicine for depression) 50 mg by mouth once a day. A notation was written on that order that Patient #6's father had consented to the Zoloft on 5/12/19 at 11:30 a.m. The prescriber signed the verbal order, but no date or time was included. The record revealed that there was an order written to increase Patient #6's dose of Zoloft to 100 mg by mouth daily. The nurse noted the order on 5/12/19 at 5:30 p.m. The prescriber signed the verbal order, but no date or time was included. Continued review of the record failed to reveal a consent by Patient #6's father to increase the Zoloft dose. Review of the Medication Administration Record (MAR) revealed that Patient #6 received Zoloft 100 mg by mouth on 5/13/19 and 5/14/19.

A review of the facility policy number PHR-115, titled "Prescribing and Administration of Medication", original date of issue: 04/2013, revised: 08/2014 reveals that only a physician (MD or DO) with clinical privileges may prescribe medications in the facility. A nurse practitioner (ARNP) or physician assistant (PA) may prescribe medications provided a relationship exists with a physician. Medications may be administered by the following:
4.1.1 Physician (MD, DO)
4.1.2 Registered Nurse (ARNP, RN)
4.1.3 Licensed Practical Nurse (LPN)

A review of the facility policy number PHR-140, titled "The Role of Nursing in Medication Administration", original date of issue: 04/2013, revised: 08/2014 revealed that the intent of this policy is to provide needed medication in an efficient, safe manner, and to provide a complete and accurate up-to-date record of all medications a patient receives.

Further review revealed that complete medication therapy records are found in the patient's medical record, Medication Administration Record and medication machine e-records. Medication administration practices will be compliant with state/federal regulations and accepted standards of practice. Medication administration and preparation will be consistent with accepted standards of practice based on guidelines or recommendations issued by nationally-recognized organizations with expertise in medication preparation and administration.

Further review revealed that safe and timely administration of medication is based on the nature of the medication and its clinical applications. Hospital approved medication times will take into account the complex nature and variability among medications; the indications for which they are prescribed; the clinical situations in which they are administered; and the needs of the patients receiving them. The medical staff recognizes that certain medications require administration at the exact time prescribed, or within a narrow window of its prescribed scheduled time, to avoid compromising patient safety or achievement of the intended therapeutic effect. However, the therapeutic effect of many other medications is uncompromised by a much broader window of time for administration.

Further review also revealed that nursing administration shall conduct a monthly review of medication administration times and report findings on a quarterly basis to the Pharmacy & Therapeutics Committee. The nurse shall record the exact time of administration when each medication is given. Administration of eligible medications outside of their scheduled dosing times and windows: In the event that the patient misses a dose of a scheduled medication, the nurse shall notify the practitioner and document the notification in the patient record.

A review of the facility policy number PHR-159, titled "Medication Administration and Records", original date of issue: 04/2013, revised: 11/2015 reveals the purpose is to establish procedures for timely, accurate, and safe administration of medication.

Further review reveals the following:
CONSENT PROCEDURE:
4.1.1 All patients who are able to provide express and informed consent for psychotropic medications will do so prior to the initial dose.
4.1.2 Patients who are able to provide expressed and informed consent will do so; otherwise consent will be obtained from the guardian/parent/guardian advocate; or an Emergency Treatment Order by the attending licensed practitioner will be necessary.
4.1.3 Documentation of expressed and informed consent will be verified by the Nursing Staff and recorded on the Specific Authorization for Psychotropic Medications. The log is placed in front of the MAR. In addition, the MAR will reflect that consent has been documented.

Further review revealed:
4.3.1.17 IM injection sites should be recorded by a nurse with the location of the injection site.
4.3.1.18 To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time.
4.3.1.19 If a scheduled medication is refused or not given, then the medication time is circled; and the nurse's initials are written directly to the right of the refused time. In addition, the nurse will place the appropriate note in the chart
4.3.1.20 All nurses administrating medications must sign and initial the designated area on the bottom of the patient's MAR to allow for easy identification of the nurse who administered the medication.

A review of the facility policy number RI-032, titled "Patient/Family Involvement in Treatment", original date of issue: 03/2013 reveals Riverwoods Behavioral Health System to acknowledge the importance of patient and family involvement in the plan of care provided to individual patients. When appropriate and possible, the involvement of the patient and family members is sought and encouraged throughout the course of treatment. At the time of assessment, patient and family expectations for treatment and involvement in treatment will be elicited by the Clinical staff.

Patients are involved in at least the following aspects of their care:
Giving informed consent.
Making care decisions, including managing pain effectively.
Resolving dilemmas about care decisions;
Formulating advance directives; and
Withholding resuscitative services.

Further review revealed that in addition, families may participate in a variety of programs designed to educate them on issues of mental illness and the process of recovery. Programs range in their focus and address the child and adult populations. Sessions are facilitated by doctors, nurses and other professionals during evening and weekend hours to be convenient for families.

A review of the facility policy number RI-033, titled "Patient/Guardian Participation in Treatment Decision - Making Process", original date of issue: 03/2013, revised 08/2017 revealed when appropriate, parent/guardian will facilitate care decisions and approve the care provided.

Based on a review of medical records, policies, and observations it was determined that the facility failed to ensure that a comprehensive history and physical examination was done within 24 hours of admission for inpatients.

Findings included:
A review of ten (10) medical records (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12) revealed that one record (Patient #4) did not contain a completed History and Physical examination.

Review of the facility's policy number CTS-157 titled 'Plan for Provision of Care', initiated 3/13, last reviewed 8/17 revealed that all inpatients admitted had a Medical History and Physical performed by a physician assistant or physician within 24 hours of admission and is reviewed by attending psychiatrist. Includes a review of all symptoms, history of previous medical problems, present illness, family medical history, and review of systems. All neurological examinations must include a descriptive narrative of negative findings to ensure baseline neurological findings are explicit and subsequent changes are clear.