HospitalInspections.org

Based on interview and record review, the governing body failed to be accountable and aware of the conduct of the hospital and ensure the quality of care provided to one (P-1) of 10 sampled patients, resulting in delayed treatment and the potential for less than optimal outcomes.

Review of the medical record for P-1 on 09/19/2024 at 1000 revealed he was a 40-year-old-male who was voluntarily admitted to the facility on 07/15/2024. Review of his psychiatric admission evaluation dated 07/15/2024 revealed justification for admission to include anxiety, depression, significant decline in functioning, dangerous to self, others, or property with a need for structured environment, psychiatric drug therapy, requires 24-hour supervision, failure of social or occupational functioning, inability to meet basic life and health needs, failure of treatment at a lower level of care, emotional or behavioral conditions and complications requiring 24-hour medical and nursing care, and that P-1 had a guardian. The note indicated P-1 no longer felt safe at home as he had been having suicidal ideations to drink bleach and does feel like he wants to die.

Review of medical records from transferring facility for P-1 which were located in the receiving psychiatric facility's chart for P-1 revealed a fax cover sheet dated 07/14/2024 at 10:10:02pm with P-1's medical records.

In an interview on 09/18/2024 at 1500, Staff D (Admission Nurse) stated she recalled when P-1 arrived via ambulance at the facility on the night of 07/14/2024. Staff D stated P-1 did not have his guardian with him to sign him in, so she had to send him back to the acute care hospital. Staff D stated P-1 had been accepted for admission, but a guardian must be present to physically sign the consent. Staff D stated she told the guardian who was on the phone, that P-1 could not be admitted without her physically present to sign the paperwork. A verbal consent cannot be given. She (Staff D) did make the ambulance crew take P-1 back to the acute care hospital and did not allow P-1 to be admitted to the facility that night. Staff D stated she checked with the Supervisor (Staff H), and he agreed with her.

In an interview on 09/18/2024 at 1515, Staff H (RN Supervisor) stated he did not recall a patient being refused admission due to no guardian being present. Staff H said he would never do that, especially if the guardian was on the phone, because the facility policy allows for a verbal consent to be given with two staff member witnesses to sign the consent.

In an interview on 09/19/2024 at 0955 Staff F (Chief Nursing Officer) stated she was not aware of the incident when P-1 was not allowed into the facility. It is her expectation that the admission nurse should have obtained a verbal consent and completed the admission. That is the facility policy. During the interview, Staff F reviewed the chart of P-1 and agreed that P-1 had been admitted to the psychiatric facility the next morning with admission paperwork signed by P-1's guardian.

In an interview on 09/19/2024 at 1020, Staff E (Chief Medical Officer) stated he was not sure what the policy was for obtaining consent. He had only been the medical director for one month and he didn't feel he should comment on that.

In an interview on 09/19/2024 at 1035, Staff B (Chief Executive Officer) stated he was not aware of a patient not being allowed into the facility for admission until now. Staff B stated it was his expectation that if anything abnormal happens, staff should be calling the leader of their department or the administrator on call with any questions. Staff B said a guardian does not need to be present for admission or to sign consent. A verbal consent is accepted per the facility policy.

On 09/19/2024 at 1120, review of facility "Informed Consent to Treatment and Services" Policy dated 12/2022 revealed, D. When a legal parent or guardian is unavailable to physically sign the consent(s), a verbal consent, witnessed by 2 staff members and documented in the medical record, is permissible. Efforts will be made to obtain signed consent as soon as the responsible signatory becomes available.