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Based on record review and interview, the governing body failed to ensure the medical staff was accountable for the quality of care provided to patients as evidenced by a patient admitted under an involuntary status did not receive a psychiatric consult while in the psychiatric holding area overnight for 1 (#2) of 5 (#1-#5) records reviewed. Findings:
Review of the Medical Staff Bylaws, Rules and Regulation, presented as current, revealed, in part: "A. General Information, Rules of Referral and Consultation: . . . 6.The admitting practitioner shall be responsible for being available for the timely and adequate professional care and treatment of patients he/she admits to the hospital, for the instructions for care of those patients, for prompt and accurate medical records, for communicating with the patient, the patients family and if appropriate the referring physician regarding the care and treatment, and condition of the patient...15. The attending practitioner is primarily responsible for requesting a timely consultation when indicated. 16. The consulting practitioner is responsible for answering consultations within their respective specialty in a timely manner, utilizing current and available means of communication, including electronic clinical information systems and in-person assessment as appropriate to patient condition/circumstances in order to provided assistance to the attending physician in the assessment, diagnosis and treatment of patients. 17. Psychiatric consults are required for all suicidal attempts or questionable suicide attempts."
Review of a policy and procedure entitled Patient Awaiting Psychiatric Evaluation, Number 649-1214, with a revision date of 01/11, presented as current, revealed in part: "Procedure: For all patients holding in the Emergency Department awaiting psychiatric evaluation and/or placement, the following actions will be taken and documented ...8) "For any psychiatric patient holding overnight due to lack of psychiatric bed placement, a psychiatric consult will be placed that morning in order for the patient to be seen that day. "
Patient #2
Patient #2 was a 28-year-old female who presented to the ED on 05/04/15 at 8:48 p.m. with the documented complaint of "Panic Attack." She was placed in the psychiatric holding area on 05/04/15 at 11:40 p.m. per a PEC because there were no psychiatric beds available on the BHU. Patient #2 remained in the psychiatric holding area in the ED until she was admitted to the Behavioral Health Unit on 05/05/15 at 8:34 p.m. Her primary admitting diagnoses were Depression and Anxiety. Patient #2 was discharged from the hospital on 05/07/15.
A review of the medical record for Patient #2 revealed the following explanation by S8ED documented on 05/05/15 at 2:54 p.m. to Patient #2: "Explained PEC to patient. Called S3RN to request that he ask S10Psychiatrist to come down to see this patient. S10Psychiatrist stated that he is unable to come to see the patient, and that we should 'just find placement.' " Further review of the medical record revealed Patient #2 was not seen by a psychiatrist until 05/06/15. The next date documented by S10Psychiatrist in Patient #2's medical record was on 05/07/15 at the interdisciplinary treatment plan team meeting at which time S10Psychiatrist indicated Patient #2 was ready for discharge.
In an interview on 03/22/16 at 3:45 p.m. with S7Quality, she reviewed Patient #2's medical record and confirmed the documentation in the medical record revealed S10Psychiatrist first encountered the patient on 05/06/15, and the second encounter documented with Patient #2 was on 05/07/15, the day Patient #2 was discharged. S7Quality agreed and confirmed there was no further documentation in the medical record indicating interaction between S10Psychiatrist and Patient #2 other than the 2 above-referenced dates, and S7Quality agreed and confirmed the policy and procedure, Patient Awaiting Psychiatric Evaluation, was not followed.
In an interview on 03/22/16 at 4:00 p.m. with S3RN, he reviewed Patient #2's medical record and confirmed there was no further documentation by S10Psychiatrist other than the initial psychiatric evaluation done on 05/06/15 and 05/07/15 at the interdisciplinary treatment plan team meeting.
In an interview on 03/22/16 at 4:15 p.m., S8ED indicated the standard practice in the ED for all patients who present to the ED with psychiatric and/or behavioral issues was the ED staff consults for a psychiatric evaluation to be performed on patients, and the consults are to be completed within 24 hours of the initiation of the consult.
In a telephone interview with Patient #2 on 03/23/15 at 9:00 a.m., she confirmed she met with the S10Psychiatrist around mid-day on 05/06/15 for about 15 or 20 minutes. She further indicated the next time she met with S10Psychiatrist was on 05/07/15 at the interdisciplinary treatment plan meeting, and it was at that time that S10Psychiatrist stated Patient #2 was ready for discharge.

Based on record review and interviews, the hospital failed to ensure patients' rights were identified, addressed, and implemented regarding reasonable expectations for care and services as evidenced by the hospital failed to follow and/or act upon a patient's complaint/grievance for 1 (#2) of 5 (#1-#5) medical records reviewed. Findings:
Review of a policy and procedure entitled Rights and Responsibilities of Patients, Number 670-30, with a revision date of 06/00, presented as current, revealed, in part: "...6. Information. The patient has the right to obtain, from the practitioner responsible for coordinating his care, complete and current information concerning his/her diagnosis (to the degree known), treatment, and any known prognosis. . . .8. Consent. The patient has the right to reasonable informed participation in decisions involving his/her healthcare. To the degree possible, this should be based on a clear, concise explanation of his/her condition... The patient has the right to be informed about and involved in the plan of care. 10. Refusal of Treatment. . . .The patient has a right to voice a complaint regarding the care received, and to expect action and follow-up."
Review of a policy and procedure entitled Patient/Patient Representative Grievance Procedure, Number 670-34B, with a revised date of 01/11, presented as current, revealed, in part: "Policy. Patients and/or their patient representatives have a right to voice their requests, needs, complaints and/or grievances, and to expect a timely investigation and response. . . Definitions: Patient Complaint: is not a grievance if it can be resolved promptly by staff present or at a departmental level (i.e. charge nurse, house supervisor or department director). For example, complaints related to bedding, housekeeping, food and beverages can ordinarily be resolved quickly and are not usually considered to be grievances. A complaint is considered resolved when the patient/patient representative is satisfied with the actions taken on their behalf. Staff Present includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, etc.) to resolve patient's complaint. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution then the complaint is a grievance. Patient Grievance: is a formal or informal, written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect , issues related to the hospital's compliance with the CMS Hospital Conditions of Participation... Procedure: . . . 2. Hospital staff members will attempt to resolve all patient and/or patient representative complaints promptly. A. If unable to resolve a complaint promptly and to the satisfaction of the patient/patient representative, staff will notify their respective supervisor and/or Department Director during normal weekday hours (after hours or on weekends or holidays, staff will notify the House Supervisor). B. Departmental Directors and/or House Supervisors should initiate 'service recovery' in an effort to resolve the issue. 3. If a complaint cannot be resolved satisfactorily by staff and/or the department director/, house supervisor, the complaint, which is now considered to be a grievance, will be documented on a Patient Grievance Report Form and forwarded to the Quality Management Director by the next business day for monitoring and and tracking purposes. 4. The Department Director is responsible for investigating the grievance and sending a complete set of investigative materials, etc. to the Quality Manager...The involved Department Director and/or Administrative Representative will be responsible for identifying, recommending, and implementing actions and interventions for appropriate follow-up resolution."
Review of the log of grievances for the entire hospital for the year 2015 revealed no documented evidence that a grievance was filed on behalf of Patient #2.
Patient #2
Patient #2 was a 28-year-old female who presented to the ED on 05/04/15 at 8:48 p.m. with the documented complaint at the triage assessment of "Panic Attack." She was placed in the psychiatric holding area in the ED on 05/04/15 at 11:40 p.m. Patient #2 was admitted to the Behavioral Health Unit on 05/05/15 at 8:34 p.m. Her primary admitting diagnoses were Depression and Anxiety. Patient #2 was discharged from the hospital on 05/07/15.
A review of the medical record for Patient #2 revealed a PEC was completed by S9Physician on 05/04/15 at 9:20 p.m. with the justification documented as "gravely disabled." Patient #2 was assessed and evaluated as not being suicidal, homicidal, or violent by all staff members involved in her care. Patient #2 was moved to the psychiatric holding area, due to no bed availability, located in a separate part of the ED on 05/04/15 at 11:40 p.m. to await admission to the BHU. Patient #2 remained in the psychiatric holding area throughout the night. On 05/05/15 at 2:53 p.m., Patient #2 requested to speak with a physician to discuss her release from the ED. Review of the medical record revealed no documented evidence that a physician spoke to the patient at that time. On 05/05/15 at 2:54 p.m., Patient #2 verbalized to S8ED that she was depressed and having anxiety due to marital problems, the anniversary of her father's untimely death, financial concerns, and issues concerning her mother. The patient verbalized to the staff she had been speaking with her husband and was feeling better, was not suicidal, homicidal, or violent and felt she did not need an inpatient admission to address her issues, and she wanted to be released from the ED. At that time, Patient #2 requested to speak with S10Psychiatrist to discuss her discharge from the ED/admission to the BHU. Further review of the documentation revealed S8ED: "Explained PEC to patient. Called S3RN to request that he ask S10Psychiatrist to come down to see this patient. S10Psychiatrist stated that he is unable to come to see the patient, and that we should 'just find placement.' " S8ED explained this to Patient #2, and she was very upset. Further review of Patient #2's medical record revealed no documented evidence the ED physician informed Patient #2 she was being admitted to the BHU under an involuntary status.
In a telephone interview on 03/23/16 at 9:00 a.m., Patient #2 indicated no staff member, including any physician, discussed Voluntary Admission Status versus Involuntary Admission Status, and confirmed she was not aware she was placed under a PEC by S9Physician until S8ED explained that information to her on 05/05/15 at 2:54 p.m. Patient #2 was under the assumption that she was to be voluntarily admitted to the BHU. Patient #2 also indicated she asked to file a grievance with administration at that point, and she never received any further information regarding her request to file a grievance with the hospital when the involuntary admission status was discovered by Patient #2.
In an interview on 03/23/16 at 1:30 p.m., S3RN reviewed Patient #2's medical record and confirmed this issue should have been considered a grievance, and the hospital's policy and procedure was not followed.
In an interview on 03/23/16 at 1:40 p.m., S7Quality reviewed Patient #2's medical record, the grievance log for 2015, and she confirmed there was no documentation Patient #2's complaint/grievance had been addressed for the 5/4/15 admission. S7Quality further confirmed that the hospital's policy and procedure for complaints and grievances was not followed.
In an interview on 03/23/16 at 1:50 p.m., S8ED confirmed she had no documentation of a complaint or grievance filed in/by the ED staff on behalf of Patient #2's complaint/grievance for the 05/04/15 admission.

Based on record review and interview, the hospital failed to ensure the patients' right to receive care in a safe setting. This was evidenced by a staff member having their personal cell phone accessible to patients and a patient used the cell phone to strike a staff member. This deficient practice had the potential to negatively impact the 20 patients on census.
Findings:

Review of the Behavioral Health Unit Safety on Site Occurrence Reporting records with S7Quality on 03/23/16 at 9:35 a.m. revealed the following:

On 03/07/16 there was an incident involving Patient R3. The patient was on a physician emergency commitment to the behavioral health unit. The patient had the diagnosis of unspecified psychotic disorder, was exhibiting bizarre behavior and was non-compliant with taking medications.

Review of the details of the incident revealed, in part: Patient approached nurses station, complained of a headache and while the nurse was in the medication room, getting her medication, the patient reached behind the desk and took his (S15RN) cell phone and ran toward exit door, while calling 911. When a female staff (S16BHT) approached her, she swung the phone toward the staff member, striking her (S16BHT) on the chin. All 5 staff members approached her (patient R3) and she put herself on the floor, she was carried by 4 staff members to the Seclusion Room.

Review of the hospital's Telephone Usage/Personal Visits & Mail policies and procedures revealed, in part: 2. The use of cell phones falls under the same guidelines as the "land-based" phones. Cell phone usage is prohibited in patient care areas.

In an interview on 03/23/16 at 10:29 a.m., S7Quality indicated the hospital needed to do a better job of holding all behavioral health unit staff members accountable. S7Quality indicated staff members should not have personal cell phones in patient care areas, including the nurses' station desk.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised the nursing care for each patient on an ongoing basis. This was evidenced by BHTs not attending patient group sessions, and staff members (S12RN and S11BHT) eating, drinking and using a personnel cell phone in patient care areas. This deficient practice had the potential to negatively impact the 20 patients on census.
Findings:

On 03/22/16 at 11:00 a.m., the surveyor reviewed hospital video recordings of the behavioral health unit group session room with S7Quality.

Review of the hospital's Behavioral Health Unit group session room video recording for 02/18/16 at 9:30 a.m. revealed there was a Social Worker and a maximum of 10 patients present during the session.

Review of the hospital's Behavioral Health Unit group session room video recording for 02/20/16 at 10:00 a.m. revealed there was a Social Worker and a maximum of 5 patients present during the session.

Review of the hospital's Behavioral Health Unit male hall video recording for 02/20/16 at 10:00 a.m. revealed S11BHT was sitting in a chair at the end of the hall drinking a cup of coffee. S14BHT was seen walking down the hall and went over to S11BHT and started conversing with S11BHT. Shortly after that, S12RN was seen walking down the hall and was eating a bag of chips. S12RN went over to S11BHT and S14BHT and conversed with them for a period of time. Further review of the video recording revealed S12RN and S14BHT left the area where S11BHT was sitting. S11BHT continued to drink coffee and proceeded to take out and use his personal cell phone.

Review of the hospital's Telephone Usage/Personal Visits & Mail policies and procedures revealed, in part: 2. The use of cell phones falls under the same guidelines as the "land-based" phones. Cell phone usage is prohibited in patient care areas.

Review of the hospital's Behavioral Health Unit group session room video recording for 02/20/16 at 11:00 a.m. revealed there was a Social Worker and a maximum of 10 patients present during the session.

Review of the hospital's Behavioral Health Unit group session room video recording for 02/20/16 at 1:00 p.m. revealed there was a Social Worker and a maximum of 8 patients present during the session.

In an interview on 03/22/16 at 10:22 a.m., S13SW indicated she was assigned to conduct patient group sessions on a regular basis. S13SW indicated a BHT was supposed to be present in the group room during the sessions. S13SW indicated there were occasions that a BHT was not present in the group room during sessions. S13SW voiced concerns with the safety of patients and staff members by not having a BHT present during group sessions. S13SW further indicated she had seen BHTs using personal cell phones during group sessions and congregating at the end of the hall instead of attending group sessions.

In an interview on 03/22/16 at 12:30 p.m., S7Quality confirmed that staff members should not be eating, drinking, and using personal cell phones on the behavioral health unit. S7Quality indicated a BHT should be present in the group room when sessions were being conducted.

In an interview on 03/22/16 at 12:34 p.m., S3RN confirmed that staff members should not be eating, drinking, and using personal cell phones on the behavioral health unit. S3RN indicated the behavioral health unit had staff assignments and a BHT was assigned to attend group sessions. S3RN indicated the RNs on the unit should monitor the BHTs to ensure their duties were being carried out.