HospitalInspections.org

Based on document review and interview, the hospital failed to ensure 1 of 10 patients (P2) was provided the opportunity to take part in his/her care by means of informed decisions to request or refuse treatment; and failed to ensure the patient was informed of his/her health status for discharge and/or emergency detention.

Findings include:

1. Policy and Procedure review:
The policy titled Patient's Rights and Responsibilities, Last Approved 7/30/18, indicated the following:
(The Hospital) identifies specific Patient's Rights and Responsibilities based upon the following processes and activities:
Respects the patient's right to and need for effective communication, receiving information in a manner that he/she understands.
Promotes consideration of patient values and preferences, including the right to participate in treatment, refusal of treatment and end-of-life decision.
The policy titled Medication Administration: Associates Approved to Administer Medications, Last Approved 1/22/18, indicated the following:
Before administering a new medication, the patient...is informed about any potential clinically significant adverse drug reactions or other concerns regarding administration of a new medication.
The policy titled Emergency Detention Admission, Last Approved 11/6/18, indicated the following:
A person who is believed to be mentally ill and dangerous to self/others or gravely disabled may be detained for evaluation on the Mental Health Unit by an Emergency Detention order or court order.
A physician determines if the patient meets the admission criteria for an ED and a physician order is required to admit the patient by Emergency Detention (ED).
The ED Form must be completed and signed by a petitioner, a physician, and a judge. All signatures are required and efforts are made to obtain these signatures prior to escorting the patient onto the mental health unit.
When it is necessary to initiate an ED on an inpatient who is voluntary status, the attending or covering physician is responsible for initiating the ED...
The policy titled Discharge of Patient and Discharge Home Instructions, Last Approved 1/23/18, indicated the following:
Instruct the patient and/or family on discharge information...
When a patient is discharged...If the patient is ambulatory, he/she may walk unaccompanied at the discretion of the nurse.

2. Medical record (MR) review for patient P2 indicated the following:
The patient presented to the ED via ambulance on 6/23/19 for symptoms related to possible stroke with a fall at home and was subsequently admitted to the hospital on that date. The MR indicated the patient had a history of brain cancer, had had a craniotomy, was not on medication(s) at home, lived alone independently and was his/her own representative.
H&P (History and Physical) documentation on 6/23/19 at 23:36 hours indicated the following: Judgment and insight, memory, mood and affect within normal limits. Assessment and Plan (A/P): I think we will get a follow-up MRI (magnetic resonance imaging) in the morning to rule any TIAs (transient ischemic attacks) or strokes.
MR documentation indicated the following:
On 6/24/19 at 12:56 hours, indicated in the physician's Progress Note A/P, was for the patient to have a carotid US (ultrasound). "If negative, discharge the patient". PT/OT (physical therapy/occupational therapy) for "Walking difficulties; "Long time disorder".
On 6/24/19 at 15:59 hours, physician orders indicated the patient was discharged to: "Home".
On 6/24/19, beginning at 15:52 hours and signed/ending at 19:02 hours, nursing documentation indicated the following:
Patient was super aggressive and hostile at the beginning of shift...Throughout the morning the RN (registered nurse) noticed pt was unsteady and inconsistent with transfers...Doctor was notified that the pt required admission orders, that the pt wanted to see the physician, and that the pt did not look safe to go home. Doctor replied that the pt would probably discharge right after his/her MRI scan. Doctor later saw the patient that morning. He/she (the doctor) decided to d/c (discontinue) the MRI because he/she thought he/she (the patient) was at his/her baseline and ordered a carotid US, and that he/she would be clear to discharge if that was negative
For noon assessment, pt was still pleasant and oriented x4...pt wanted to put his/her street clothes on...RN saw that the pt was unable...without getting flustered and asking for help. PT assessed him/her right after the ultrasound, in which the pt's demeanor became very frustrated and upset. According to PT, he/she was unable to stand or walk without the assist of the therapist...
RN paged the doctor that pt failed PT exam. Doctor replied that he/she needed to stay another night. RN requested the physician speak to the patient because he/she was determined to discharge. Doctor replied that the RN speak on behalf...and he/she would see him/her after his/her paperwork was completed. Upon telling the pt that he/she had to stay, pt immediately became hostile...Pt became so agitated that he/she needed to sit down...and refused to go back to the room until he/she talked with the doctor. Pt continued to say "If that's how I want to live my life it's nobody's f*ing business!"
Doctor was asked to see the pt. He/she conversed with the pt at the nurses' station...The physician stated that it was the nurse's concern that the pt needed to be safely walking to be discharged, but he/she then said this was the pt's baseline and that he/she would put in the discharge order.
SW (Social Worker) was also notified to see if HH (Home Health) services could be provided for the pt at discharge. The pt refused HH services. He/she was told a Lyft ride could be provided when discharge was finalized. He/she requested SW to assist with the ride for discharge. "Pt was told by RNs that he/she wanted to speak with the doctor and that he/she was leaving". Pt started packing up...and began exiting his/her room.
Security was called and arrived at 17:30 hours because pt was noncompliant with staying on the unit.
Doctor was paged to request a "Psych" consult due to his/her erratic behavior, as staff were questioning his/her competency to make medical decisions. "Doctor ordered a psych eval." Security and RN staff escorted pt back to room in a recliner...Doctor was paged and 1mg Haldol was ordered as well as 10mg Geodon Q2H PRN.
On 6/24/19 at 18:36 hours, the Medication Administration Record (MAR) indicated Geodon was administered IM (Intramuscularly).
On 6/24/19 at 5:56 p.m. an "Application for Emergency Detention of a Mentally Ill and Dangerous Person" form was initiated. Page 1 indicated the "Applicant" as Social Worker, S1, with the reason noted as the patient having flight of ideas...and wanting to leave AMA (Against Medical Advice). Page 2, titled "Physician's Emergency Statement" lacked documentation of a physician's name, credentials or statement and was signed by a nurse practitioner, no time was noted. Page 3, titled "Endorsement by Judicial Officer..." was incomplete.
On 6/25/19 at 07:18 hours, the order for discharge was discontinued.
On 6/25/19 at 08:17 hours a "Progress Note - Communication" indicated the following: Plan to discharge yesterday. PT assessed that patient's too weak, unable to walk. Keep patient in hospital. Patient wanted AMA (against medical advice). Assessed by psychiatrist who concluded patient's not competent. Patient is combative, agitated later afternoon yesterday. Patient will be transferred to psych floor today.
On 6/25/19 at 13:07 hours, the physician indicated the following: Does not want medication, said he/she had none meds." The physician added: "Psych floor won't accept the patient, because of cranial surgery long time ago." The A/P on this date indicated the following: Carotid ultrasound unremarkable.

The MR lacked documentation a physician having determined that the patient met admission criteria for an ED and lacked documentation of a physician's order to admit the patient by Emergency Detention (ED).
The MR lacked documentation of a psychiatrist having seen the patient.
The MR lacked documentation of the patient having been informed they were placed under an emergency detention and that he/she was not being discharged due to the ED prior to the patient attempting to leave the hospital and being escorted back to his/her room.
The MR lacked documentation of a proper/complete ED having been in place at the time the patient was detained.
The MR lacked documentation of the patient having been informed about any potential clinically significant adverse drug reactions or other concerns regarding administration of a new medication (Geodon).

3. On 7/30/19 between approximately 12:30 p.m. and 3:30 p.m., A1, Risk Manager, confirmed MR findings for patient P2, including lack of documentation as noted.

Based on document review and interview, the hospital failed to promptly notify 1 of 10 patient's (P2) own physician of his/her admission to the hospital prior to detaining the patient on an Emergency Detention for incompetence of medical decision making.

Findings include:

1. Review of the MR for patient P2 indicated the patient was admitted on 6/23/19 for symptoms of a stroke. The MR indicated the patient had a history of brain cancer, had had a craniotomy, was not on medication(s) at home, lived alone independently and was his/her own representative. The MR lacked documentation of the patient's own physician having been promptly notified of his/her admission. The MR indicated that on 6/24/19, the patient was placed on an Emergency Detention due to: Patient ...having "flight of ideas and is very aggravated and wanting to leave AMA (against medical advice)... "patient can not make medical decisions". The MR indicated the patient's physician/PCP (Primary Care Provider) was first contacted on 6/25/19. The MR indicated the PCP's office described the patients' baseline as confused, combative, peculiar, and gets stuck on one topic.

2. On 7/29/19 between approximately 12:30 p.m. and 3:30 p.m., A1, Risk Manager, verified the MR findings of patient P2.