HospitalInspections.org

Based on interview and document review the facility failed to ensure that patients rights requirements were met in one (#20) of 21 medical records reviewed resulting in the potential to have unmet patient rights. findings include:

On 02/24/2016 at 1000 medical record review for patient #20 revealed the document titled "In-Patient Mental Health" states, "I acknowledge receiving a copy of "Your Rights in a Psychiatric Hospital or Community Facility. I have read the summary and: (Please check which ones apply to you)--" Patient #20 checked, "I request to talk with the Rights Advisor..." it was signed and dated 1/8/16 at 2000.
Staff D who was the "super user" helping to navigate the electronic medical record review (EMR) was unable to locate documentation that the Rights Advisor had ever responded to the patients request to be seen.
On 02/24/2016 at 1100 Staff R and Staff S (recipient rights officers) were asked if they had documented that they had ever responded to patient #20's request, they stated, "We did not open a case for investigation, and that would be our only documentation."

Based on interview and record review, the facility failed to obtain consent for treatment for 1 (Patient #3) of 21 patients reviewed for patient rights, from a total sample of 21 patients, resulting in the potential for patients to be uninformed of their rights and not having given consent for treatment received.

Findings:
Review of Patient #3's medical record on 2/23/16 at 1115 revealed a 33 year old female who was admitted to the facility on 2/21/16. The medical record was reviewed with Assistant Director of Medical Surgical (Staff F) and Director of Accreditation and Regulatory Compliance (Staff B), who were unable to locate a consent for treatment, signed by the patient. Staff F verified the consent for treatment was not in medical record for Patient #3.

In an interview on 2/23/16 1120, Staff B reviewed Patient #3's medical record and stated Patient #3 was alert and oriented upon admission and should have signed a consent for treatment when she was admitted.

In an interview on 2/23/16 at 1125, Staff F stated she called the nurse who had admitted Patient #3 and the nurse did not have the patient sign a consent for treatment.

Review of the facility "Informed Consent" policy on 2/23/16 at 1430 revealed, "A general consent, authorization for treatment, is obtained prior to any medical treatment at the time of registration. This does not replace or eliminate the need for obtaining informed consent for medical or invasive procedures, if required..."