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Based on review of medical records, facility policy and procedure, staff and physician interviews, it was determined that the facility failed to inform the patient that when he/she became a voluntary patient and requested discharge, the physician had up to three (3) days to review the patient's record and make a decision whether the patient would be discharged or not for 1 (#1) of 3 patients whose records were reviewed.

Review of the facility policy entitled, "Patient Rights and Responsibilities" SPP#: RI-02, revised October 2007, indicated that patients had a right to: 4. Participate in Treatment Decisions: Be informed and participate in decisions concerning their care. Be given a clear and understandable explanation of procedures.

Review of the patient's medical record revealed that the patient was admitted to the facility on a 1013 (involuntary admission) due to threatening to kill his/her friend and feeling that the friend was trying to kill him/her. The record revealed that the patient received an evaluation by a psychiatrist, a neuropsychological evaluation by a psychiatrist, and a medical exam by a medical doctor. The patient was alert and oriented and was able to make informed decisions. The patient was involved in the master treatment plan and an individualized plan of care. The record revealed that the patient was treated, stabilized, and discharged back to the patient's home. The patient was given a follow up appointment with a psychiatrist for the next day along with a prescription for medications and instructions to follow up with his/her private physician for his/her medical condition. The record noted that the patient was discharged on the patient's hospital day #6 by the chief medical officer.

The record revealed that also on hospital day #1 the physician signed a 1014 form (Physician's Certificate Authorizing Transfer To Evaluating Facility - a form that indicated that the physician had evaluated the patient and concluded that the patient required involuntary treatment due to having presented a substantial risk of imminent harm to self or others). The signing of this form by a physician allowed the patient to stay in the facility for up to five days (not counting Saturdays, Sundays, or holidays). The above information revealed that the patient could have been held in the hospitals legally until 6/30/10. The patient completed a 1012 form (Request to Transfer to Voluntary Status) on hospital day # 2.

Further review of the medical record revealed that on day #3 the patient completed a 1010 form (Request for Discharge) which included in the form, a request for AMA (leaving Against Medical Advice). The patient signed and dated the form. The patient again completed, signed and dated a 1010 form on hospital day #5 and requested a withdrawal for discharge.

The record revealed that a 1011 form (Notice of Voluntary Patient's Right to Request a Discharge) was in the patient's record. This form was to be given to involuntary patients who were transferred to voluntary status. The form was not signed or dated. The record lacked evidence of the patient having received the form, having been given an explanation of the form, or having been reviewed by the patient. The form indicated the following information: a). that the patient could ask for discharge at any time, b) the discharge must be in writing, and that within three days (not counting holidays Sundays and legal holidays) after the chief medical officer of the hospital received the patient's written request, the patient was to be discharged unless the physician believed that the patient's discharge was unsafe to the patient or to others. If the patient was not released, the process for voluntary hospitalization began. If that process happened, the patient was to be told of his/her rights. The form also stated that the patient could be discharged without asking for release if the chief medical officer found that the patient no longer needed hospitalization. The form noted that the patient would sign if he/she had received the information and had a chance to ask questions.

During a telephone interview (#2) on 8/11/10 at 2:05 pm in the conference room, the psychiatrist stated that that the patient was a 1014 (document signed by a physiatrist that allowed the facility to hold a patient for 5 business days to get an evaluation). The psychiatrist explained that during this five (5) day period the patient could request an AMA after the patient signed for a voluntary status. The physician stated that if somebody was a voluntary status, he/she had the right to request discharge, but that it must be in writing. The psychiatrist verbalized that there was a form that was filled out called a 1010 (Request for Discharge) and on that form there was a place for the physician to complete and sign that the patient was: a. suitable for discharge, b. not suitable or c. not committable (means that the patient was not well but was not a threat to self or others, in which case they could be discharged against medical advice). The physician stated that in the patient's case, the patient completed a 1010 form on hospital day #3 to be discharged against medical advice and on hospital day #6 the physician signed for the patient to be discharged. The patient was not discharged against medical advice and it was a coincident, according to the physician, that the form was signed the day the patient was discharged. The physician stated he/she had 72 hours to get the request for AMA form signed. The psychiatrist stated that patients were informed of their rights on the 1011 form but sometimes not at the same time that the physician signed the 1012.

During an interview (#3) on 8/11/10 at 3:20 p.m. on the Behavior Health Unit, the nurse who was assigned to the patient, stated that the Registered Nurse (RN) was the person responsible to have the patient sign the 1011 form and explain the form to the patient. The nurse stated that he/she had not remembered if he/she had talked with the patient about the 1011 form. The nurse stated that the staff was trained yearly on the legal forms and the procedures involved.

During an interview (#4) on 8/11/10 at 4:00 pm, the nurse manager stated that the RN was not the only person that could have explained the 1011 form to the patient. The mental health and/or social workers could have also explained it to the patient but it was noted that the form was not signed by the patient.

During an interview (#5) on 8/11/10 at 4:05 pm on the Behavior Health Unit, the risk manager stated that he/she reviewed the patient's medical record and had also noted that the 1011 form had not been signed by the patient, or have a signature of the person responsible.