HospitalInspections.org

Based on staff interview, medical record review, and review of facility documentation, it was determined that the facility failed to ensure the following fort he protection and promotion of patient rights: 1) all patients had a signed general consent for treatment (Refer Tag A-0131); 2) patient care is provided in a safe setting due to the presence of breakable windows on behavior health units (Refer Tag A-0144); 3) the discharge of a patient without a physician order (Refer Tag A-0144); 4) follow policy when discharging a patient with suicidal ideation (Refer Tag A-0144); and 5) the confidentiality of personal health information (Refer Tag A-0146). The failure to follow policy when discharging a patient with suicidal ideation resulted in an Immediate Jeopardy (IJ).

Findings include:

On June 22, 2023 at 2:17 PM, an IJ was identified for the facility's failure to assess a patient with suicidal ideation prior to discharging the patient. On June 22, 2023 at 4:46 PM, the IJ template was presented to administration and a removal plan was requested. On June 23, 2023 at 2:20 PM, an acceptable removal plan was received. The IJ was subsequently resolved on June 23, 2023 at 3:07 PM after the State Survey Agency verified immediate corrective actions addressing the IJ. The facility implemented the following for the removal plan: Re-education for all patient care and administrative staff on the Detox Unit (11-3) on the process of the care of a suicidal patient and discharge process. A tour was conducted of the Detox Unit (11-3) to confirm that education was received, and a visual reference of the education was observed posted on the unit.

Cross Reference:
482.13(b)(2): The patient or his or her representative has the right to make informed decisions regarding his or her care
482.13(c)(2): The patient has the right to receive care in a safe setting
482.13(d): Confidentiality of patient record

Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to obtain a signed general consent for treatment for one of one medical records of an incapacitated patient (Patient (P) 8).

Findings include:

On 6/22/23, a review of the medical record of P8 was completed and revealed that P8 presented to the Emergency Department (ED) on 4/10/23, reporting that he/she ingested a whole bottle of acetaminophen with a bottle of vodka. P8 was unable to sign his/her receipt of patient rights in the duration of time spent in the ED due to being incapacitated. Further review of the medical record revealed the following:

P8 presented to the ED on 4/10/23 before transferring to the ITC, the Intensive Care Unit. The General Consent form, dated 4/10/23, which contained information that included Consent, Release of Information, Privacy, Behavior,and the Financial Agreement, had a notation that stated, "Patient Unable to Sign Due to Medical Condition" that Staff (S) 48, a Registrar, had signed and witnessed at 3:15 PM.

Upon receiving medical clearance, P8 was transferred to unit A1, an Adult Psychiatric Inpatient Unit, on 4/12/13. A consent for admission to A1 was signed by the patient on 4/12/23. The Registered Nurse's assessment dated and timed 4/12/23 at 16:56 (4:56 PM) stated, "... + Neuro Assessment ... Orientation ... Oriented x [times] 4 ..." The medical record lacked evidence that a General Consent Form was obtained once the patient was able to sign.

On 6/22/23 at 10:34 AM, S3,Vice President of Quality and Safety, stated that the General Consent Form should have been completed once the patient was moved out of Intensive Care to the A1 Unit.

Review of facility policy titled, "General Consents/Special and Informed Consent," revised 2/23, stated, "... Responsibility of Obtaining Consents ... Admission Consent- It is the responsibility of the admitting staff to have General and HIPAA [Health Insurance Portability and Accountability Act] related consents signed at the time of admission. If unable to obtain consent, the physician and nurse manager on duty must be informed of the inability to obtain necessary consents ... Transfer Consents- It is the responsibility of the receiving unit to obtain necessary consent ..."

Facility policy titled,"Rights/Responsibilities of Patients/Residents and Forensic Patients," reviewed 8/2/21, states, "... 2. In addition, all patients/residents or their representative will sign, time and date a General Consent for Treatment and Financial Term Agreement when registered as a patient. This document outlines; acknowledgement of receipt of the Patient/Resident Bill of Rights and Privacy Practices, Release of Information practices, Privacy Restrictions ... 3. If on admission a patient/resident is unable or unwilling to sign a General Consent for Treatment and Financial Term agreement, it shall be so noted on the form, dated and witnessed by staff, and placed within the patient's/resident's record. Once the patient/resident becomes able or willing to sign such an acknowledgement, unit staff should make every effort to present the patient/resident with this form and obtain a signature ..."

Based on document review and staff interview, it was determined that the facility failed to ensure: 1) patient care is provided in a safe setting due to the presence of breakable windows on the behavior health units; 2) a discharge order is given from a medical provider prior to patient discharge from the facility; and 3) an appropriate assessment of a suicidal patient prior to discharge for one of one patient discharged with complaints of suicidal ideation.

Findings include:

1. On 6/22/23, a review of the Environmental Risk Assessment (ERA) dated 5/24/23, windows/glass was identified as a risk. The ERA states, "Interior and exterior should not yield sharp shards of glass when broken that can be used as a weapon." The ERA states the location of these windows as, "Most exterior walls and interior doors." The ERA states, "Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient acuity."

During an interview at 2:15 PM, Staff (S) 41, Director of Facilities, confirmed the ERA language from the 5/24/23 report is the same language that was included in the ERA that was in effect during the calendar year 2022.

A review of incident reports from 2022 and 2023 detailed the following incidents where windows were broken on the Behavior Health Units:

10/5/22, Unit BH-AG, Patient (P) 17 threw a chair though a window in the TV Room causing the window to shatter.

12/8/22, Unit BH-B1, P18 requested to go to the seclusion room to calm down. After leaving the seclusion room, the patient went to the Solarium and threw a chair at a window, causing the window to shatter.

12/20/22, Unit BH-A1, P19 threw a chair into the Day Room window breaking the glass. This appeared to be unprovoked.

4/27/23, Unit BH-AG, P23 was discovered missing during the Q15 minute check. Staff discovered the window to the bedroom had been broken. The patient had removed the broken glass and eloped. The patient was found on a nearby baseball field and returned to the Emergency Department for treatment. The patient was brought to the Operating Room for treatment and eventual return to the BH Unit.

6/2/23, Unit BH-AG, P7 was placed on a 1:1 (one-to-one) in the Seclusion Room. The patient used their elbow to shatter the seclusion room door window causing lacerations to the patient's arm.

During an interview at 2:15 PM, S41 stated, "New windows are made with laminated glass. There is no plan to replace older windows with laminated glass. Windows are replaced as they are broken."


47131


2. On 6/21/23 at 9:45 AM, a review of the medical record for P1 was conducted in the presence of S37, Director of Health Information Management. The following was noted:

On 3/30/23 at 19:44 (7:44 PM), P1 arrived at the facility's Emergency Department (ED) with a chief complaint of suicidal ideation due to heroin withdrawal. S34, Chief of Behavioral Health Services, completed a psychiatric evaluation on 3/30/23 at 22:25 (10:25 PM) and "recom (recommend) inpatient rehab C2/F1, will be evaluated in am by rehab team."

On 3/31/23 at 8:28 AM, in a 'ED Observation Only' progress note, S33, a Resident Physician, psychiatrically cleared P1 for medical detox on Unit 11-3 (Addiction Treatment Unit [ATU]) and P1 was admitted to the ATU on 3/31/23 at 10:15 AM.

At 19:24 (7:24 PM), S38, Registered Nurse (RN), documented "Group Note: Found pt [patient] has contraband (2 small films wrapped in plastic suspected to be illegal narcotics). ADN [Assistant Director of Nursing] & Security came and searched again. No other contraband found."

On 3/31/23 at 19:59 (7:59 PM), a medical order written by S42, a Resident Physician, stated "Patient is psychiatrically cleared."

At 20:31 (8:31 PM), a Progress Note (Addiction Service) signed by S15, Addiction Counselor Intern, documented, " ...Patient was told (he/she) was being discharged, then patient stated (he/she) was suicidal. ED stated (he/she) had a psych eval earlier that day and to discharge (him/her). Patient was walked off the unit and given (his/her) belongings."

On 3/31/23 at 20:15 (8:15 PM), S38 documented in the nursing discharge summary, "Patient transferred/discharged to: Non-compliant [sic] discharged. Pt [patient] is psychiatrically cleared. Discharge diagnosis: Substance dependence." The nursing discharge summary included documentation that discharge instructions were provided to Patient #1.

Upon request for the "Administrative Discharge Policy," the facility was unable to provide the document. An interview with Staff #50 (S50), Detox Unit RN, was conducted on 06/22/23 at 12:15 PM. During the interview, S50 explained that when a patient is discharged for non-compliance, the leadership of the unit and LIP [Licensed Independent Practitioner] are contacted. S50 stated "The LIP on the Detox Unit will enter the discharge order and note."

Medical Record #1 lacked evidence of a medical discharge order or discharge note from a physician upon patient discharge from the facility.

On 6/22/23 at 1:40, S34 confirmed the above findings and stated, "The patient was discharged for noncompliance. We (the facility) do not have an administrative discharge policy. I am not seeing a discharge order or discharge note written by a physician in the medical record."

Facility document titled, "Medical and Dental Staff General Rules and Regulations," states, " ... ARTICLE I ADMISSION OF PATIENTS ... Section 7 Patient Discharge Patients shall be discharge only on a written order of the LIP [Licensed Independent Practitioner] ..."

3. On 6/21/23 at 9:45 AM, a review of the medical record for P1 was conducted in the presence of S37, Director of Health Information Management. P1 presented to facility Emergency Department (ED) on 03/30/23 at 19:44 (7:44 PM) for a complaint of "Suicidal ideation: On and off for months with a plan to overdose on drugs, abuses heroin and cocaine." Patient had a psychiatric consult on 03/30/23 at 22:23 (10:23 PM) in the ED and was determined to be at low risk for suicide. The patient was psychiatrically clear for admission to the facility detox unit on 03/31/23 at 10:15 AM. On 3/31/23, P1 was found to be in possession of contraband. Due to violation of the unit rules, the patient was administratively discharged from the unit. At 19:59 (7:59 PM), there was an order written that the patient was "psychiatrically clear." Upon discharge, at 20:15 (8:15 PM), P1 stated that he/she was feeling suicidal to S15, the unit counselor.

Upon interview with S15, on 6/22/23 at 11:30 AM, S15 stated that if a patient complained of suicidal ideation prior to discharge, he/she would notify his/her supervisor and the director of nursing, and that a patient with suicidal ideation would not be discharged without being seen. S15 stated that the notification would be "DAP (Data Assessment Plan)" progress notes and an email would also be sent. The medical record did not contain evidence that the counselor reported the complaint to another team member for the patient to be reassessed prior to leaving the facility. At 14:05 (2:05 PM), when asked where S15 had documented the reporting of the patient's complaint, S15 stated that he/she verbally told his/her supervisor, but had not documented it. S15 stated that his/her supervisor told the Director of Nursing (DoN) and the charge nurse. S15 also stated that the Charge Nurse relayed the information that he/she had spoken with a provider in the ED and the ED provider cleared the patient based off of the previous psychiatric assessment.

The medical record of P1 lacked documentation that the patient received a psychiatric assessment conducted by a resident/staff psychiatrist, C-SSRS assessment, or Individualized Safety Plan after expressing suicidal ideation to S15 and prior to the patient leaving the unit.

Facility policy titled, "Suicide Risk Assessment/ Management" revised 11/22, states, "... REASSESSMENT a. Reassessment of a patient's risk of suicide will continue during the course of treatment for patients determined at risk for suicide and treated at the acute level of care. b. Upon discharge, patients at risk for suicide are reassessed by the resident/staff psychiatrist ... COUNSELING AND FOLLOWING-UP AT DISCHARGE a. Patients will have the following upon discharge: i. A psychiatric assessment conducted by a resident/staff psychiatrist, including a C-SSRS [Columbia Suicide Severity Rating Scale] assessment; ii. Appropriate follow-up for next level of care; and iii. Individualized Safety Plan for behavioral health patients ..."

The above findings were confirmed on 6/21/23 at 1:50 PM with S30, the ATU Manager, and S34.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that personal health information is released only to persons designated by the patient for one of one patient who was incapacitated during the initial part of their admission.

Findings include:

On 6/22/23, a review of Patient (P) 8's medical record was completed. P8 presented to the Emergency Department (ED) on 4/10/23 reporting that he/she ingested a whole bottle of acetaminophen with a bottle of vodka. P8 was transferred to the ITC, the Intensive Care Unit. P8 was unable to sign his/her consents for treatment and authorization for release of health information in the duration of time spent in the ED due to being incapacitated. The General Consent form dated 4/10/23, which contained information that included Consent, Release of Information, Privacy, Behavior,and the Financial Agreement, had a notation that stated, "Patient Unable to Sign Due to Medical Condition" that Staff (S) 48, a Registrar, had signed and witnessed at 3:15 PM. Upon receiving medical clearance, P8 was transferred to unit A1, an Adult Psychiatric Inpatient Unit, on 4/12/13.

Upon request for P8's documentation of who was given permission to receive personal health information, S3, Vice President of Quality and Safety was able to obtain and provide a copy of three different "Authorization For Release of Health Information" for P8. An "Authorization For Release of Health Information" signed by P8 and dated for 4/13/23 that provided permission to release information to the patient's mother, was reviewed and was found to have an "X" through the form with the date "4/17" next to it. The "Authorization For Release of Health Information" contained a section that stated, "... D. ACKNOWLEDGEMENTS ... *I understand that I may revoke this authorization at anytime in writing ..." The medical record lacked documentation that the release of information to the patient's mother was revoked on 4/17/23 by the patient and with which nursing staff member the revocation was discussed. The second "Authorization For Release of Health Information" was signed by the patient and dated for 4/17/23 that allowed for the release of information to a designated outpatient provider. The third "Authorization For Release of Health Information" was signed by P8 and dated for 4/20/23 to allow a release of information to the patient's father.

A Progress Note, written by S49, Social Worker, dated and timed for 4/19/23 at 12:36 PM stated, "... Patient approached this writer this morning and accusing this writer of violating [his/her] HIPAA [Health Insurance Portability and Accountability Act] rights. Patient informed this writer that [he/she] rescinded [his/her] ROI [Release of Information] for [his/her] mother, [Mother's name] on the evening of Monday, 4/17/23, with RN, [Name of RN]. Writer checked the patient's chart and confirmed this information. It should be noted that this writer spoke with the patient's mother, [Name of mother] on 4/18/23 to inform her about the patient's anticipated discharge on 4/20/23, the patient's aftercare treatment plan, and who would transport the patient home upon discharge. It should be noted that the patient nor the RN notified this writer or the treatment team that the ROI was rescinded prior to this morning. ..."

Facility policy titled, "Clinical Documentation (Non-Provider)" states, "... It is the policy of ... manager and operator of [facility] will be accurate, pertinent and comprehensive information concerning the condition of the patient, the patient's need, the interventions and the patient's response ... RESPONSIBLE PERSON: Clinical Staff PROCESS/PROCEDURE: I. Documentation A. Complete documentation in a timely manner, during or as soon as possible after the care or event ... L. Patient documentation should contain subjective or summary statements by the patient, objective data or information that supports the subjective or summary statement, and assessment of the situation, and a plan for interventions ..."