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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0117 A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Based on interviews and document review, the facility failed to ensure patients were advised of their legal status and accompanying rights regarding continued treatment. Specifically, the facility failed to ensure patients were advised of their right to voluntary admission for continued treatment or the need for a short-term certification for involuntary treatment, once the patients' 72-Hour involuntary mental health (M-1) holds expired. This affected two of three patients (#13 and #14) whose records were reviewed.

A-0143 The patient has the right to personal privacy. Based on interviews and document review, the facility failed to ensure the personal privacy of patients quarantined on a designated cohort unit for COVID-19, a highly infectious disease. This affected four of four patients (Patients #1, #2, #3 and #4) in shared rooms on the cohort unit.

Based on interviews and document review, the facility failed to ensure patients were advised of their legal status and accompanying rights regarding continued treatment. Specifically, the facility failed to ensure patients were advised of their right to voluntary admission for continued treatment or the need for a short-term certification for involuntary treatment, once the patients' 72-Hour involuntary mental health (M-1) holds expired.

This failure was identified in two of three medical records reviewed for patients who admitted to the facility under a M-1 hold and subsequently had a second M-1 hold initiated at the facility (Patients #13 and #14).

Findings include:

Facility policies:

The 72-Hour Hold policy read, Purpose: To provide guidelines to ensure compliance with the legal requirements in the event a patient requires a 72-Hour Hold for evaluation and treatment. A patient meets the criteria for a 72-Hour Hold if he or she is considered to be, because of mental illness, an imminent danger to self or others or gravely disabled. If hospitalization is indicated but involuntary hold criteria are not present, the physician must write an order for the patient to sign voluntary admission forms or be discharged.

At the end of the 72-Hour Hold, one of the following must occur: Patient released, patient referred for further treatment on a voluntary basis (patient signs Request for Voluntary Admission and Authorization for Treatment Form), or patient certified for not more than three months of short-term treatment pursuant to CRS 27-10-107.

The Short Term Certification policy read, an individual who is detained for 72-hour evaluation and treatment may be certified for short-term treatment. Prior to the expiration of the 72-hour period, certification for short-term treatment must be filed.

In order to provide involuntary treatment to a mentally ill person who meets legal criteria, the rules and regulations of CRS 27-65 allow a physician to certify the patient for short-term involuntary treatment. Criteria must be met including: The physician had analyzed the person's condition and found the person is, as a result of mental illness, a danger to others or self, or gravely disabled; the individual had been advised of the availability of but has not accepted voluntary treatment.

The Admissions Patient Rights and Organization Ethics policy read, patients have the right to voluntary consents or to refuse to consent to admission to the facility. Only the administrator or the patient's physician may commit a patient to the hospital and only if they meet criteria for involuntary commitment.

1. The facility failed to ensure patients were advised of their legal status, either their right to voluntary admission for continued treatment or the need for a short-term certification for involuntary treatment, once the patients' 72-Hour involuntary mental health (M-1) holds expired.

A. Interviews

Interviews with staff revealed facility policy required one of three actions to occur when a patient's M-1 hold expired: to discharge the patient, to admit the patient for voluntary treatment, or to initiate a short-term certification for involuntary treatment. Interviews further revealed a second M-1 hold could not be initiated, as this would not be in alignment with facility policies and procedures and patient rights.

1. On 9/23/20 at 12:45 p.m., Court Liaison (Liaison) #22 was interviewed. Liaison #22 stated she assisted the provider to complete legal documents, including short-term certifications for involuntary treatment and voluntary admissions for treatment. She stated she was responsible to notify patients of their legal status with regard to continued treatment, to obtain signatures on legal documents, and to ensure patients understood the terms of voluntary admission if the patient consented to voluntary treatment.

Liaison #22 stated if a patient needed a short-term certification for continued involuntary treatment, she and the provider would initiate the certification on the same day the M-1 hold expired. She stated only a physician was able to initiate a short-term certification, and stated that typically, the psychiatrist at the facility was responsible to initiate the certification. Liaison #22 stated a short-term certification was initiated if a patient remained a danger to self or others, or remained gravely disabled.

Liaison #22 stated most patients admitted to the facility with an M-1 hold in place. She stated she would monitor a patient's legal status so she knew when the hold would expire. Liaison #22 stated when a patient's hold was close to expiring, the provider and treatment team were responsible for determining whether the patient would be offered voluntary admission, would discharge from the facility, or would require a short-term certification. She stated if the provider felt a patient was able to understand their rights and the concept of voluntary treatment, then the patient would be offered the opportunity to consent to voluntary treatment. Liaison #22 stated if the patient was not able to make this decision or remained at risk to self or others, the provider would initiate the short-term certification.

Liaison #22 stated when she assisted a patient who chose to consent to voluntary treatment, she would have the patient sign a document to verify the patient understood their rights. She stated she was responsible to ensure patients understood their rights when they consented to voluntary treatment.

Liaison #22 stated it was not standard practice at the facility to initiate consecutive M-1 holds for a patient, and stated facility staff avoided initiating multiple M-1 holds in a single admission.

2. On 9/22/20 at 4:45 p.m., Director of Clinical Services (Director) #16 was interviewed. Director #16 stated she regularly was assigned to oversee the initiation of M-1 holds for patients hospitalized at the facility. She stated the treatment team assessed a patient to determine whether the patient met criteria for involuntary treatment, which included suicidal ideation, homicidal ideation, and grave disability. She stated a patient who was gravely disabled could be out of contact with reality, hallucinating, experiencing intense delusions, or unable to care for themselves.

Director #16 stated the physician determined whether a patient met the criteria for initiation of a short-term certification. She stated when a short-term certification was warranted, paperwork would be completed and sent to the courts for approval. Director #16 stated Liaison #22 would notify the patient if a short-term certification was initiated. She stated a short-term certification was initiated if the patient's M-1 hold expired and the patient remained a risk to themselves or others, or if the patient remained gravely disabled.

Director #16 stated a short-term certification could not be initiated on a weekend as the courts were closed. She stated for this reason, it was important to monitor a patient's legal disposition well before a patient's M-1 hold expired. She stated if facility staff were aware a patient's M-1 hold would expire on a weekend, and the physician did not plan to discharge the patient, the physician needed to prepare for either voluntary admission of the patient or the initiation of a short-term certification prior to the weekend.

B. Document Review

Review of medical records for Patients #13 and #14 revealed both patients admitted to the facility on M-1 holds. There was no evidence in the medical records that Patient #13 or Patient #14 consented to continued voluntary treatment or were certified for short-term involuntary treatment when the M-1 holds expired as required.

1. Patient #13's medical record was reviewed. On 8/19/20 an Emergency Mental Illness Report and Application (M-1) hold was initiated at an outside facility prior to Patient #13's admission. The M-1 hold read Patient #13 was gravely disabled.

a. On 8/20/20 at 4:49 a.m., Physician #23 entered an order which read, admit to involuntary. Physician #23 placed an additional order which read Patient #13's M-1 hold would expire on Saturday, 8/22/20.

b. On 8/21/20 Physician #23 completed an Advisement to Person on 72-Hour Hold for Evaluation or Certified for Treatment which read, if at any time during the 72-hour evaluation or treatment the provider requested the person to sign in voluntarily and he elected to do so, the following advisement was given orally and in writing.

i. On the same day, the Consent to Admission and Medical Treatment and the Rights of Patients document were partially completed. Patient #13's name and the date were entered on the documents; however the documents were not signed by the patient or by a facility staff member.

ii. On the same day at 4:03 p.m., Liaison #22 entered a Communication Log note. Liaison #22 documented she was unable to get intake consents signed by Patient #13 because the patient was nonsensical and disoriented. Liaison #22 documented the patient made bizarre statements and was off topic, and she was unable to have a conversation with the patient.

c. On Monday, 8/24/20 at 11:30 a.m., a second M-1 Hold was completed by Nurse Practitioner (NP) #6. The M-1 Hold read Patient #13 continued to be gravely disabled as manifested by his lack of ability to provide for his basic needs.

d. There was no evidence facility staff initiated a short-term certification for involuntary treatment on 8/21/20, when Liaison #22 documented Patient #13 was unable to consent to voluntary admission. Furthermore, there was no evidence in the medical record to demonstrate Patient #13 signed a consent for voluntary admission between 8/22/20 when the initial M-1 hold expired and 8/24/20 when the second M-1 hold was initiated. This was in conflict with facility policy and patient rights, which required either voluntary admission or a short-term certification to occur when the patient's M-1 hold expired.

2. Patient #14's medical record was reviewed. On 8/20/20 at 12:59 p.m., an M-1 hold was initiated at an outside facility prior to Patient #14's admission. The M-1 hold read Patient #14 was gravely disabled.

a. On 8/20/20 at 7:46 p.m., a High-Risk High Alert Handoff document was completed by facility intake staff which read Patient #14's legal status was involuntary. On the same day at 8:08 p.m., Physician #23 entered an order which read Patient #14's M-1 Hold would expire on Sunday, 8/23/20 at 12:59 p.m.

b. The medical record included multiple consent forms, including the Consent to Admission and Treatment. However, the consents were signed by the patient on 8/20/20 when she was admitted to the facility with involuntary legal status.

c. The medical record revealed on Monday, 8/24/20 at 11:45 a.m., NP #6 initiated a new M-1 hold. The M-1 hold read Patient #14 remained gravely disabled as manifested by her inability to provide for her basic needs.

d. There was no evidence in the medical record Patient #14 was advised of and signed a consent for voluntary admission and treatment between 8/23/20 when the initial M-1 hold expired and 8/24/20 when the second M-1 hold was initiated. Furthermore, the medical record did not include documentation a short-term certification for involuntary treatment was initiated during this time period. This was in conflict with facility policy and patient rights, which require one of these actions to occur when the patient's M-1 hold expired.

In summary, review of the medical records for Patients #13 and #14 revealed the M-1 holds for both patients expired during a weekend. The M-1 hold for Patient #13 expired on Saturday 8/22/20, and the M-1 hold for Patient #14 expired on Sunday 8/23/20. The facility was unable to provide evidence Patient #13 or Patient #14 signed the "Request for Voluntary Admission and Authorization for Treatment Form" once the M-1 holds expired. Likewise, the patients' medical records did not reveal evidence staff initiated a short-term certification for involuntary treatment for either patient prior to the weekend. These findings conflict with Director #16's interview, as Director #16 stated if a patient's M-1 hold expired on a weekend, staff were responsible to ensure either voluntary admission or a short-term certification were in place prior to the weekend.

C. Provider Interviews

Interviews with facility providers revealed if a M-1 hold expired and either voluntary admission or a short-term certification were not in place, the patient no longer had legal status to remain hospitalized for continued treatment. Provider interviews further revealed continued hospitalization of a patient without legal status amounted to a violation of the patient's rights.

1. On 09/23/20 at 3:08 p.m., NP #6 was interviewed. NP #6 stated although he was able to initiate M-1 holds, he did not do so often and believed he had only initiated five in the last year. NP #6 stated a patient met the criteria for a M-1 hold if the patient presented a danger to self or others, or was gravely disabled. He stated he considered this criteria seriously before initiating a hold because he believed a hold represented taking somebody's freedom away from them.

NP #6 stated a short-term certification for involuntary treatment needed to be in place before an M-1 hold expired. NP #6 stated only a psychiatrist could initiate a short-term certification when a patient's M-1 hold expired. NP #6 stated for example, on the Monday prior to the interview, he attended to four or five patients who had M-1 holds which were near expiration. He stated he suggested the psychiatrist see the patients on that day in order to ensure the psychiatrist was able to initiate a short-term certification if needed prior to the expiration of the M-1 holds.

NP #6 stated before a patient's M-1 hold expired, either the patient consented to voluntary treatment or the physician initiated a short-term certification. He stated, if the patient did not need continued hospitalization, the treatment team would plan to discharge the patient when the M-1 expired. NP #6 stated if one of these actions did not occur, the patient had no legal status to remain in the hospital because the patient was neither there voluntarily nor certified for a short-term involuntary treatment.

NP #6 stated at the end of August he had observed problems with staff's monitoring of patients' M-1 holds. He stated he was aware of one or two patients whose M-1 holds expired and the holds were not addressed in a timely manner, but he could not recall who these patients were.

NP #6 reviewed the M-1 hold which he initiated for Patient #14 on 8/24/20. He stated the facility should have initiated a short-term certification for Patient #14 if she remained gravely disabled. He stated it was possible Patient #14's M-1 hold had expired over a weekend and it was overlooked.

NP #6 stated a patient could only be hospitalized voluntarily or if an involuntary hold was in place. He stated the patient's legal status could only be determined under one of these two conditions. He stated it was a problem if a patient's M-1 hold expired and the patient remained at the hospital without legal status. NP #6 stated all patients had the right to understand why they were hospitalized, and stated it was important to ensure a patient either consented to remain at the hospital, or understood why they were kept against their will.

2. On 9/23/20 at 2:06 p.m., Psychiatrist (MD) #8 was interviewed. MD #8 stated when a patient was admitted to the facility with an M-1 hold in place, patients often were placed on short-term certifications at the end of the M-1 hold. He stated the criteria for short-term certification was grave disability, danger to self or danger to others. MD #8 stated when an M-1 hold expired, a patient could also sign in voluntarily and remain at the hospital, or could discharge. He stated if a patient consented to voluntary treatment, the patient would sign a form to verify their voluntary status. MD #8 stated the treatment team monitored the status of the M-1 hold and assessed the patient's condition to determine the patient's disposition when the M-1 expired.

MD #8 stated it was not ideal to initiate a second M-1 hold during a patient's hospitalization and he did not believe it was standard practice for consecutive M-1 holds to be initiated for a patient. He stated the treatment team was responsible for reviewing a patient's hold and legal status in order to ensure there was no confusion regarding the patient's anticipated disposition when the M-1 hold expired.

MD #8 stated no time could elapse between the expiration of an M-1 hold and initiation of a short-term certification if the certification was warranted. He stated if this occurred and the patient did not alternatively consent to voluntary admission, the patient was considered to be "in limbo" with no legal status. He stated this could not happen because patients had rights. He stated either a patient consented to voluntary treatment or the patient received involuntary treatment under a hold, and there was no other option. MD #8 stated if a patient did not have legal status for continued hospitalization, it was similar to kidnapping and was an infringement on a patient's right to freedom and choice.

3. On 9/27/20 at 3:00 p.m., Chief Medical Officer (CMO) #7 was interviewed. CMO #7 stated he was the acting medical director for the facility, and stated he was responsible to oversee the psychiatric and medical care provided to patients.

CMO #7 stated patients had a right to know their legal status for hospitalization. He stated all patients were advised of their legal rights while at the hospital.

CMO #7 stated if a patient was able and desired to leave at the end of the M-1 hold, the patient would be released. However, CMO #7 stated if a patient was still demonstrating signs of psychosis, or posed a danger if released and needed further treatment, a short-term certification would be initiated for the patient.

CMO #7 stated when a patient's M-1 hold expired, the facility was required to immediately initiate either the patient's voluntary admission or a short-term certification. CMO #7 stated if a patient was held at the hospital for continued treatment, the patient had the right to understand their legal status and the basis for their continued hospitalization.

Based on interviews and document review, the facility failed to ensure the personal privacy of patients quarantined on a designated cohort unit for COVID-19, a highly infectious disease. This affected four of four patients (Patients #1, #2, #3 and #4) in shared rooms on the cohort unit.

Findings include:

Facility policies:

The Care, Treatment and Privacy policy read, every effort should be made to protect each patient's right to confidentiality and privacy. Staff will not discuss patients or events with any person not authorized to receive patient information. Patient privacy shall be maintained during treatment. Other patients should not be able to hear discussions regarding patient treatment, including medications, assessments, discharge and individual discussions regarding patient care.

References:

The facility Patient Bill of Rights read, Patients have the right to be treated with respect and dignity. Patients have the right to personal privacy to the extent possible during their stay.

1. The facility failed to ensure the personal privacy of Patients #1, #2, #3 and #4 during medication and therapy sessions conducted by the psychiatric provider.

A. Provider Interview

An interview revealed a facility provider conducted treatment and discussed patient health information with other patients present, specifically patients in shared rooms on the designated COVID-19 cohort unit.

1. On 9/21/20 at 10:45 a.m., Nurse Practitioner (NP) #6 was interviewed on the 300 Unit. NP #6 confirmed the 300 Unit was a designated cohort unit for patients suspected of exposure to COVID-19 and said he had conducted psychiatric treatment for multiple patients on the unit today.

a. NP #6 stated that today, he provided treatment for Patients #1, #2, #3 and #4. He stated the patients' roommates were present at the time of the treatment sessions. NP #6 stated before he provided treatment to a patient, he instructed the patient's roommate to turn on the shower so the roommate would not overhear his discussion with the patient. NP #6 stated this practice was "not ideal."

B. Patient Interviews

Interviews with Patients #1, #2, #3 and #4 confirmed NP #6 instructed the patients to put their heads in the shower while he conducted treatment with their roommates. Interviews further revealed one patient was able to overhear the content of NP #6's discussion with his roommate.

1. On 9/21/20 at 11:30 a.m., Patients #1, #2, #3 and #4, all quarantined in their rooms due to potential exposure to COVID-19, were interviewed. Patients #1 and #2 were interviewed in the room they shared on the 300 Unit. Patients #3 and #4 were interviewed in the room they shared.

a. Patient #1 stated he was present in the room when NP #6 conducted treatment with Patient #2. He stated he put his head in the shower while NP #6 spoke with Patient #2; however, he stated he was still able to hear what was discussed.

b. Patient #2 stated he put his head in the shower while NP #6 spoke with Patient #1, and stated he, too, was able to hear their voices as they spoke.

c. Patient #4 stated she was present in the room when NP #6 conducted treatment with Patient #3. She stated she did not go into the shower, but she and Patient #3 remained in their beds when NP #6 spoke with them. She stated during her discussion with NP #6 she discussed "how she was doing."

C. Document Review

Review of medical records for Patients #1, #2, #3 and #4 confirmed on 9/21/20, when NP #6 conducted medication and therapy sessions in the patients' rooms with their roommates present, the NP discussed multiple aspects of the patients' care plan and treatment. This included discussion of medications, symptoms, plans for discharge and the patients' current thought content and mood.

This conflicted with facility policy which read patient privacy must be maintained during treatment, and other patients should not hear discussions regarding treatment, medications, assessments, discharge or other discussions regarding patient care.

1. Patient #1's medical record was reviewed. The medical record revealed on 9/21/20, NP #6 entered a Psychiatric Progress Note. The date of service on the note was 9/21/20 at 10:20 a.m. NP #6 documented he saw Patient #1 for a medication and therapy session and he examined the patient during this session.

a. The progress note read, NP #6 met with Patient #1 in the patient's room. NP #6 documented Patient #1 reported high levels of depression, anxiety, and agitation, and the patient was able to describe the reason for his hospitalization and discuss the treatment regimen. He further documented Patient #1 endorsed occasional auditory and visual hallucinations, as well as occasional ideations of self-harm. NP #6 documented Patient #1's thought content included ideas of guilt, hopelessness and worthlessness.

2. Patient #2's medical record was reviewed. The medical record revealed NP #6 entered a Psychiatric Progress Note with the same date of service as Patient #1, 9/21/20 at 10:20 a.m. NP #6 documented he saw Patient #2 for a medication and therapy session and examined the patient.

a. NP #6 documented Patient #2 denied suicidal and homicidal ideation, paranoia, or hallucinations. He further documented Patient #2 was open to discussing the treatment regimen and plan, and was stable on medications with no adverse effects. NP #6 documented the plan was to await the result from a Lithium level (a measurement of the chemical Lithium, used to treat psychiatric conditions, in an individual's blood) prior to the patient's discharge, and he reviewed this plan with Patient #2.

3. Patient #3's medical record was reviewed. The medical record revealed NP #6 entered a Psychiatric Progress Note with a date of service 9/21/20 at 10:30 a.m. NP #6 documented he saw Patient #3 for a medication and therapy session and examined the patient.

a. NP #6 documented Patient #3 refused to complete a CORE assessment (a self-reported questionnaire used to determine an individual's level of psychological distress). NP #6 documented when questioned regarding levels of depression, anxiety and agitation, Patient #3 responded she was "OK." He documented Patient #3 was open to discussing her treatment regimen and plan and was able to describe the situation and reason for her hospitalization.

4. Patient #4's medical record was reviewed. The medical record revealed NP #6 entered a Psychiatric Progress Note with a date of service of 9/21/20 at 10:35 a.m. NP #6 documented he saw Patient #4 for a medication and therapy session and examined the patient.

a. NP #6 documented Patient #4 reported low levels of depression, anxiety and agitation. He further documented Patient #4 denied suicidal or homicidal ideation and hallucinations. NP #6 documented Patient #4's Lexapro (a medication used to treat depression and anxiety) would be increased to 15 milligrams to treat mood, and this plan was reviewed with the patient.

D. Staff and Leadership Interviews

Interviews with facility staff and leadership revealed the facility had not implemented processes to maintain personal privacy for patients quarantined in their rooms on the COVID-19 cohort unit. Interviews further revealed when treatment was conducted in the presence of another patient, this constituted a potential breach of patient privacy.

1. On 9/23/20 at 3:08 p.m., NP #6 was interviewed. NP #6 stated when he conducted patient treatment sessions on a unit not designated as a COVID-19 cohort unit, he would speak with patients in an area which was not in proximity to other patients. He stated he often met with patients outside in the courtyard or in the unit day room to ensure distance from other patients. NP #6 stated until recently, he was also able to speak with patients in their rooms because the unit had not previously housed two patients in the same room.

NP #6 stated that ever since the 300 Unit was designated as a COVID-19 cohort unit, he had to conduct conversations with patients while another patient was in the room because patients on the cohort unit were restricted to their rooms. NP #6 repeated that when he conducted treatment with a patient while the patient's roommate was in the room, he asked the roommate to go into the bathroom and turn the shower on so they would not overhear the conversation.

NP #6 stated he was unsure whether a breach of patient privacy occurred when he conducted treatment with a patient's roommate in the bathroom. He stated it "may not have been the best thing to do" because it was possible the patient's roommate overheard his conversations.

NP #6 stated he had not received any guidance regarding how to conduct treatment with patients in shared rooms on the COVID-19 cohort unit. He stated his guidance for treating patients on the COVID-19 unit was limited to the personal protective equipment (PPE) required to be worn on the unit.

NP #6 stated he had significant concerns regarding conducting patient treatment while a patient's roommate was present. He stated patients had a right to as much privacy as possible. He further stated patients were not as forthcoming with information if they did not have privacy, and it was more difficult to evaluate a patient if they did wish to share information in front of their roommate. NP #6 stated he did not know how to maintain privacy effectively if patients on the COVID-19 cohort unit were not allowed out of their rooms.

2. On 9/27/20 at 3:00 p.m., Chief Medical Officer (CMO) #7 was interviewed. CMO #7 stated it was important to respect patient privacy. He stated if patient privacy was not ensured, staff could get in trouble due to "HIPAA (the Health Insurance Portability and Accountability Act, which regulates the protection and confidentiality of health information) rules and all that nonsense."

CMO #7 stated it was important to keep patient information confidential and private to avoid embarrassing a patient. He further stated if patient privacy was not maintained, patients might not share important information with a provider, which could impact their care, such as whether the patient was suicidal.

3. On 9/27/20 at 10:54 a.m., CEO #1 was interviewed. CEO #1 stated she was aware NP #6 had instructed patients' roommates to go into the shower when PHI (protected health information) was discussed with the other patient in the room. She stated NP #6 should not have done so. She stated NP #6 was allowed to bring one patient at a time out of the room to conduct conversations and treatment.

CEO #1 stated protection of patient health information was part of the initial training staff received regarding HIPAA and she stated she expected staff to follow these practices to maintain patient privacy. She agreed, however, that staff including NP #6 had not received specific education on how to maintain patient privacy on the COVID-19 cohort unit.