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Based upon reviews of 1 of 7 medical records (patient #6), hospital policy and procedures, administrative and staff interviews the hospital failed to follow their policies for patient rights by ensuring each patient's right to notify his/her private psychiatrist upon admission into the hospital as evidenced by the lack of patient #6's request to have his personal psychiatrist notified addressed by hospital staff. Findings:

Review of patient #6's medical record, maintained by Hospital A, revealed he had experienced a new onset of seizure activity on 10/28/2010 and was admitted for evaluation of this seizure activity at Hospital A, an acute care hospital. Review of the emergency room record from Hospital A revealed patient #6 had a history of Schizophrenia and Bipolar disorder and complained that someone was trying to poison him. Continued review of patient #6 (Hospital A's) medical record revealed he was admitted, 10/29/10, under a Physician's Emergency Certificate (PEC) for generalized seizure and psychosis until he could be medically cleared. On 10/30/10 a Coroner's Emergency Certificate (CEC) was obtained by Hospital A and patient #6, once medically stable, was transferred to Brentwood, a psychiatric hospital, for evaluation and treatment of his psychosis.

Review of the Physician's Admission Orders, dated 10/31/09, revealed Registered Nurse (RN) S24 had obtained verbal orders and documented "ADMISSION DIAGNOSIS: Schizophrenia, Bipolar"; "TYPE OF ADMISSION: INVOLUNTARY".

Review of the Psychiatric Evaluation, dated 11/01/09, documented by Psychiatrist S14, revealed, "JUSTIFICATION FOR ADMISSION: The patient has been referred to Brentwood on a Physician's Emergency Certificate and Coroner's Emergency Certificate from (name of Hospital A) for psychosis and unstable mood...The patient reported landlord and neighbor were trying to poison him in his home and patient tried to barricade himself in his home...DIAGNOSTIC IMPRESSIONS: AXIS I: 1. Schizophrenia, paranoid type with psychosis 2. Rule Out Schizoaffective Disorder 3. Rule Out Bipolar Disorder...".

Continued review of patient #6's medical record revealed the patient had handwritten a request to the attention of attending psychiatrist S25 for a request to sign a voluntary admit and to allow "my private treating" doctor (identified as private psychiatrist S29) input to help with patient #6's treatment plan. Further review of patient #6's handwritten notes revealed he did not document the dates on the notes when he wrote them.

Review of "Nursing Progress Notes" revealed the following relative to patient #6's admission and his request for discharge: 1) 11/07/2009, 1700 (5pm) RN S26 documented, "Disorganized speech...Poorly focused...speaks of conducting business... 'I've contacted a lawyer though, he'll get it straight'..." 2) 11/08/2009, 0045 (12:45am) RN S27 documented, "Delusional. Irritable. Grandiose. Hyperverbal. Demands to contact lawyer at this unusual hour. 'It's my right!' Allowed to place call. Becomes increasingly loud-speech pressured...continue to monitor..." 3) 11/08/2009, 0900 (9am) RN S26 documented "...(patient #6 name) is very focused on 'removing those precautions by my name', its 'not accurate at all'..." and 4) 11/08/2009, during the 3pm-11pm shift, RN S26 documented "1700 (5pm) Hyper-religious, ruminating on events of admission to hospital. Pressured speech repeating some statements over and over, unable to move forward. Currently unable to process information staff is providing him because he is hyperfocused on 'Toe nail clippers, being a marine and carrying a rifle. Whose going to protect my family from a killer?' Tangential."

Further review of patient #6's medical record revealed on 11/01/09, 9am, social worker S30 documented "focused on getting in touch with Mental Health Advocacy so he can 'argue the case and get out of here'...".

Review of Physician Progress Notes, dated 11/01/09 through 11/09/09, documented by attending psychiatrist S25, revealed there lacked documented evidence that he (S25) acknowledged the hand written request by patient #6's to have his private psychiatrist S29 notified of his admission and to be involved in his treatment plan.

Review of a hospital policy titled "Patient Rights", Policy Number: RI.003 revealed the following: "I. POLICY It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form, ...We will strive to abide by and respect all patient rights...maintains zero tolerance for coercion of any individual during the admission process...III. THE PATIENT'S BILL OF RIGHTS WITH APPROPRIATE PROCEDURES FOR ACCESSING THEM. ...14.0 Right to be visited and examined at his own expense by a physician designated by him, by a member of his family, or by interested party...".

There failed to be documentation in patient #6's medical record that the hospital/staff acted upon patient #6's hand written request to have his private psychiatrist, S29, notified of his admission so that he (S29) may participate in the treatment plan per patient #6's request. There also failed to be documented evidence the hospital staff acted upon patient #6's request to sign a voluntary admission form.

Interviews, on 06/08/2010, 12:45 PM, with 2 licensed healthcare (Confidential) individuals revealed they were not aware the patient's request to have his private psychiatrist notified had not been addressed.

Interview, on 06/08/2010, 2:30 PM, with Director of Nursing S2 revealed he was not aware patient #6 had requested to have his private psychiatrist (S29) notified. Further questioning of S2 confirmed usually when a patient has a request to have anyone in particular notified the hospital usually does so, unless in the opinion of the attending psychiatrist it would not be in the best interest of the patient.

During interviews, on 06/09/2010, 2:30 PM, with Administrator S1 and Director of Nursing S2, confirmed patient #6's right to have his private psychiatrist (S29) notified of his admission was not addressed.

Based upon reviews of 1 of 7 medical records (#6), hospital policies, Hospital's Quality Assurance Plan and meeting minutes, Medical Staff Meeting Minutes, and Administrative and staff interviews the hospital failed to ensure all patients under the care of staff Psychiatrists were assured the Psychiatrists quality of care would be monitored and evaluated as evidenced by the lack of the hospital's Quality Assurance committee and/or Medical Staff monitoring psychiatrist (S25) discharge of patients (#6) when Mental Health Advocacy Services or regulatory agencies were notified. Findings:

Review of the hospital's Quality Assurance Meeting Minutes, Oct 2009-March 2010, and Medical Staff Meeting Minutes, Oct 2009-March 2010, revealed Quality/Performance Improvement indicators had been established and were as follows:
" 1. Psychiatric Evaluation-Orientation testing; memory testing; Intelligence testing; Assets specific and treatment beneficial; 2. Activity therapy assessments performed within 72 hours after admission ...National Patient Safety goals detailed for Performance Improvement of patient populations ie. Child, adolescent, adult and geriatric. Specifics for medication variances, seclusion, restraints, falls, elopement, and risk/management ...Environmental/physical structure, cleanliness of hospital ". There failed to be documented evidence risk/management monitored and/or evaluated patient discharges relative to Mental Health Advocacy Services and/or regulatory agency notification by patients or their family members.

Review of the Medical Staff meeting minutes,Oct 2009-March 2010, revealed there failed to be documentation that physician, specifically psychiatrists, quality of care issues relative to patient discharge were monitored and evaluated. A peer review was conducted for consultant healthcare providers who performed the medical History and Physicals (H&P) for the timeliness of H&P completion; however, there lacked documented evidence the staff Psychiatrists were monitored and evaluated for quality of care issues related to patient discharge. Specifically Psychiatrist S25's alleged practice of discharging patients abruptly when Mental Health Advocacy Services or other regulatory agencies were notified of patient complaints regarding admissions.

Interview, 06/08/10, 9:45 am, with Licensed Practical Nurse (LPN) S15 revealed when asked if patients were discharged from the hospital while they still had physician orders for suicide, violence, withdrawal, seizure, and cognitive impairment precautions, he responded, usually the psychiatrist discontinues all precautions and the patient stays at least a day so they can be monitored to ensure that they are stable and ready for discharge.

Interview, 06/08/10, 11:30 am, with Confidential interviewee #1 revealed Psychiatrist S25 has "a practice of discharging patients abruptly if Mental Health Advocacy Services or if the 'state' had been called by a patient or family member". Confidential interviewee #1 was asked if the concerns for Psychiatrist S25's practice of discharging patients had been reported to the Director of Nursing, Administration, or to LCSW S3 (Director of Social Services) and the reply was "they know, but nothing is done".

Interview, 06/09/10, 9:45 am, with Confidential interviewee #2 revealed when questioned if the confidential interviewee was aware of issues relative to psychiatrist S25 discharging patients abruptly, the response was, "yes, he tends to discharge patients if the patient or family member calls and complains to Mental Health Advocacy Services or the state". Confidential interviewee #2 was asked if this had been reported to Administration or to any other person, the reply was, "Administration and (name of LCSW S3) should be aware because it has been mentioned before, but I think they just ignore it".

Interview, 06/09/2010, 10:10 am, with Licensed Clinical Social Worker (LCSW) S3 revealed when questioned about patient #6's discharge on 11/09/09 and that the medical record indicated patient #6 was still on Suicide, Violence, Seizure, Withdrawal, and Cognitive Impairment precautions, was it clinically acceptable/or in accordance with hospital protocol to discharge this patient, he replied," this patient may have been discharged prematurely". LCSW S3 also stated " typically after the precautions are discontinued by the physician, we keep the patient at least 24 hours to make certain they are stable". LCSW S3 was questioned if he was aware of Psychiatrist S25 discharged patients before investigations could be performed by Mental Health Advocacy Services (MHAS) or any regulatory agency and he replied, he "was not aware Psychiatrist S25 discharges patients before MHAS or other agencies could investigate".

Interview, on 06/09/10, 11:30 am, with Director of Nursing S2 revealed he was not aware of any practice issues relative to psychiatrist S25 discharging patients before the patient was stable for discharge just to avoid an investigation by Mental Health Advocacy Services or the
state regulatory agency. S2 further stated he had not been informed by any staff members regarding psychiatrist S25's practice; however, he did state that he was aware of "some issue", and psychiatrist S25 was "no longer admitting Adult patients, he admits Adolescent and Geriatric patients".

There failed to be documented evidence the hospital's Medical Staff/Quality Assurance committees had identified issues specific to Psychiatrist S25's quality of care practice as related to the discharge of patients to avoid possible investigation by Mental Health Advocacy Services or other regulatory entities.

Based upon review of 1 of 7 medical records (#3) and staff interviews, the hospital failed to ensure the nursing care of each patient was evaluated as evidenced by failing to ensure the Registered Nurse evaluated patient #3's complaint's of jaw pain on 11/21/09 and 11/22/09. Findings:

Review of patient #3's medical record revealed during the admission process, the patient began exhibiting aggressive combative behaviors which resulted in the staff having to at times, physically carry the patient to the in-patient Youth Enhanced Adolescent Unit. During this transport, the patient twice tripped the staff with her feet causing the patient and staff to fall forward to the floor.

Review of the nursing progress notes dated 11/20/09, 9:12 PM, revealed Registered Nurse S12 documented "(Patient #3) was brought to the unit via MHT's (MHT names identified) and accompanied by Nursing Supervisor (RN S20). She had to be physically carried through the doors. She sat in the hallway and refused to move to her room. After 5 minutes she was asked to get up and refused again and was assisted off the floor by (two Mental Health Technicians) without difficulty. She stood up and was transported to room 213 via CPI (Crisis Prevention/Intervention) 2 person technique. Complaining of jaw hurting - 625 milligrams Tylenol PO (by mouth) given as ordered. Patient rates pain as 10 on a scale of 0-10. Offered ice pack. Patient refused. Patient has a small amount of swelling on her chin. Patient sitting on the floor with knees drawn up to her chest, head down. Refuses to get in the bed..."

Review of the forms titled "PRN Medication" revealed on 11/20/09, 9:35 PM, RN S12 documented the patient was given 650 Milligrams of Tylenol "Justification for PRN: complaining of jaw hurting secondary to patient falling to the floor and hitting her chin." On 11/21/09, 11:30 AM, the Registered Nurse documented Tylenol 650 milligrams was given and "Justification for PRN: complaining of jaw hurting". On 11/22/09, 6:10 AM, the Registered Nurse again administered Tylenol 625 milligrams and documented "Justification of PRN: complaining of bruise on chin hurts".

Further review of the nursing progress notes for 11/21/09, 7:00 AM-3:00 PM shift and 11/22/09, 11:00 PM to 7:00 AM shift revealed the Registered Nurse failed to document as assessment of patient #3's chin/jaw even though the nursing staff had to administer Tylenol for the patient's complaints of pain.

Based on reviews of 1 of 7 medical records (patient #6), hospital policies/procedures, administrative and staff interviews the Registered Nurses failed to ensure nursing staff followed hospital policy (TX.015) relative to suicide precautions and Multi-Disciplinary Progress Report Documentation (TX.006) by keeping current and documenting the nursing care plans and Interdisciplinary Treatment Plan/Problem List for patient #6 relative to suicide, violence, and cognitive impairment precautions as ordered by the admitting psychiatrist (S14). Findings:

Review of patient #6's medical record revealed Physician's Admission Orders, dated 10/31/09, documented by Registered Nurse (RN) S24 and co-signed by psychiatrist S14. Continued review of the physician orders revealed under "PRECAUTIONS" there was a check mark placed next to "SUICIDAL, SEIZURE, VIOLENCE, WITHDRAWAL" and "COGNITIVE IMPAIRMENT".

Further review of patient #6's medical record revealed "Interdisciplinary Treatment Plan", dated 10/31/09, revealed Registered Nurse (RN) S24 documented the following: "ADMITTING DIAGNOSIS" under "Axis I" RN S24 documented "1. Schizophrenia Paranoid Type; 2. R/O (rule out) Schizoaffective D/O (disorder); 3. Bipolar Mood..." Under the heading of "PATIENT'S ASSETS:" there lacked documentation. Listed under "PROBLEM LIST", RN S24 documented "I. Altered Thoughts; II. Medication Noncompliance"; "Medical Issues: New onset seizure activity..." There failed to be documented evidence that patient #6 had received assessments or treatment plans for suicide, violence, or cognitive impairment precautions.

Under "TREATMENT PLAN-PROBLEM SHEET" RN S24 documented the following goals and interventions for "1) altered thoughts: Short Term Goals: (name of patient #6) will Demonstrate stabilization in mood, thinking, and behavior x (times) 3 consecutive days...Intervention: MD (physician) will evaluate altered thoughts and prescribe antipsychotics and mood stabilizers to manage... 2) medication noncompliance: Short Term Goals: (name of patient #6) will take all medications as ordered x 3 consecutive days...Intervention: SS (social service) will educate on medical/med (medication) noncompliance and consequences of compliance" ; continued review of the Treatment Plan-Problem Sheet revealed precautions for suicide, violence, and cognitive impairment issues were not documented.

There failed to be documented evidence nursing personnel had formulated, implemented and maintained goals and interventions directed at the precautions (suicidal, violence, and cognitive impairment) as psychiatrist S14 had ordered upon patient #6's admission; nor was there documented evidence patient #6 had received on-going nursing assessments for suicidal ideation, violence or cognitive impairment.

Review of a hospital policy titled "Suicide Precautions, Policy Number: TX.015" revealed: "POLICY It is the policy of this hospital to provide preventive measures to protect patients who exhibit self-destructive behavior...PROCEDURE 1.0 ASSESSMENT ...1.7. Patient will be assessed and assessment will be documented in progress notes every shift patient remains on suicide and safety status...1.8. Clinical staff will assess patient's suicidality every 24 hours for the need for continued suicide precautions. Suicide precautions will remain in effect until discontinued by physician order...2.0 INTERVENTION 2.1. Clear assignment must be made of staff member responsible for precautions implementation and monitoring...2.3. Search patient twice daily...3.0 DOCUMENTATION 3.1. Patient's Observation Record Graph--15 minute checks. 3.2. Narrative notes--give specific reasons for placing patient on Suicide Precautions and may include mood, affect..."

Review of hospital policy titled "Multi-Disciplinary Progress Report Documentation, Policy Number TX.006" revealed: "I. POLICY It is the policy of all clinical staff to communicate regarding the patients' status and course of treatment via the medical record on a routine basis...medical record is a continuing documentation of the patients' diagnosis, treatment, assessment, care and the patients' response throughout the entire hospitalization. II. PROCEDURE 1.0 NURSING: ...1.2 RN staff will reassess all patients at least once per 24 hours and more often if warrented...1.2.3 Specific events will always be assessed and documented by an RN. These are: 1.2.3.1 Significant change in patient status - behavioral, emotional, or physical, and actions taken in these cases...2.0 SOCIAL SERVICE: 2.1 Social Service staff will document significant information...2.2 In addition, Social Service staff will reassess the patient on a regular basis...2.2.2 Treatment planning information as this is updated...2.2.5 Any significant event or information regarding the patient...3.0 PHYSICIAN...3.1.1 Patient's response to treatment/medication including justification for changes in treatment and medication..."

Interview, 06/09/2010, 9:15 am, with Licensed Practical Nurse (LPN) S15 revealed when questioned how the patients were to be monitored and assessed when it was ordered for them to have suicide, violence, and cognitive impairment precautions, he responded that the patient would receive close observation and receive nursing assessments regarding each precaution. LPN S15 was asked how nursing staff would document the monitoring process and the assessments, he replied it should be documented on the Progress Notes and Close Observation Record. After LPN S15 reviewed patient #6's medical record, he confirmed there lacked documentation for monitoring and a nursing assessment relative to patient #6's ordered suicide, violence and cognitive impairment precautions.

Interview, on 06/09/2010, 1:30 pm, with Director of Nursing (DON) S2 confirmed there lacked documentation of assessments and treatment plans relative to patient #6's precautions for suicide, violence and cognitive impairment. DON S2 further confirmed the nursing staff did not follow the hospital's policies for 1) Suicide Precautions, Policy Number TX.015 as evidenced by a lack of documentation of suicide assessments every 24 hours; and 2) Multi-Disciplinary Progress Notes Documentation, Policy Number TX.006 by lack of documented re-assessments for suicide, violence and cognitive impairment.

Based upon review of 1 of 7 medical records (#1), hospital policies and procedures for drug administration, and staff interviews, hospital nursing personnel failed to follow drug administration policies and procedures as evidenced by: 1) failing to document in the nursing progress notes from 06/02/10 to 06/06/10 patient #1's refusal to take Celexa 10 milligrams as ordered by the physician on 06/02/10, and 2) failing to appropriately document the patient's refusal of the medication Celexa 10 milligrams on the Medication Administration Record for 06/05/10 and 06/06/10. Findings:

Review of patient #1 open medical record revealed the patient was admitted to the hospital on 06/02/10 with the diagnosis of Major Depression, recurrent-severe. On 06/02/10, the psychiatrist ordered for the patient to begin receiving Celexa 10 milligrams by mouth every day. Review of the Medication Administration Record (MAR) revealed on 06/02/10 and 06/03/10, the Licensed Practical Nurse circled her initials on the 9:00 AM medication time block and documented "refused" next to her initials. Further review of the MAR revealed for the 9:00 AM medication time block on 06/05/10 and 06/06/10, the nurse circled her initials; however, there failed to be further documentation.

Interview with the Adult Unit Charge Registered Nurse S6 on 06/07/10, 11:15 AM, revealed if a patient refused any medication ordered by the physician, the nurse was to place her initials on the medication time block for that date, then circle the initials and document "refused". The nursing staff were to also document in the nursing progress notes the patient refused the medication. Review of patient #1's nursing progress notes revealed there was an area for the staff to check mark the effectiveness of medications administered to the patient. From 06/02/10 to 06/06/10, the nursing staff would sometimes check the medication was effective, even though the patient was not taking the medication, the patient was selective on the medications he would take, or the area was left blank. Further review of the nursing progress notes revealed the nursing staff failed to document the patient refused the medication or that the physician was notified.

Review of the policy titled "Use of Medication Administration Record" #MM.050, Part II. Procedure, 13.0 "In the event that a medication is not given: 13.1 Make a note in the progress note and notify the physician. 13.2 Indicate rational code on MAR as follows: 13.2.4 Refused."


Review of the policy titled "Medication Administration" # MM.024, 4.8 "Report to the Physician and record in the progress notes instances in which a patient refuses or vomits a medication and when a patient receiving a medication shows any unusual signs."

There failed to be documented evidence the nursing staff followed the Medication Administration policies and procedures and correctly document on the MAR when patient #1 refused his medications as indicated in hospital policy. The nursing staff also failed to document in the nursing progress notes the medication refusal or that the physician was notified.

Based on reviews of 1 of 7 medical records (#6), hospital policy and procedures relative to documentation of patient assets, and administrative interviews, psychiatrist (S14) failed follow hospital policy by failing to assess and document the list of patient #6's assets during the psychiatric evaluation. Findings:

Review of patient #6's medical record revealed an Initial Clinical Assessment, dated 10/31/2009, 8:30 pm. Intake Counselor S22 documented the following:
"INITIAL DATA BASE-PRESENTING PROBLEM According to Patient: Patient transferred to Brentwood on PEC (Physician's Emergency Certificate) and CEC (Coroner's Emergency Certificate) from (name of Hospital A) due to paranoid behavior, suspicious and delusions." (Once the patient was medically stable as he had been admitted into Hospital A for treatment of new onset of seizures, patient #6 was transferred for psychiatric treatment.) "Patient was brought to (name of Hospital A) by his girlfriend/'common law wife' after stating that the landlord and neighbors were out to get him and they had used the master key...and poison him...During assessment patient is hyperactive, rambling, repeating himself and has inappropriate laughter...MENTAL STATUS: General appearance:" check marks were placed next to "hospital gown" and "Disheveled & Unkempt"; "Cooperativeness:" check mark placed next to "Cooperative".

Intake Counselor S22 documented under "SUICIDAL THOUGHTS/ATTEMPTS: " patient denied thoughts, attempts, or plan. S22 also documented under "HOMICIDAL THOUGHTS/ATTEMPTS:" patient denied thoughts, attempted, or plan. Continued review of the Initial Clinical Assessment revealed Counselor S22 documented patient #6 denied chemical dependency issues, denied alcohol use/abuse, nor were there issues with withdrawal symptoms; patient #6 did relate previous admissions for psychiatric illness/treatment in 2 other area psychiatric facilities and presently received outpatient psychiatric treatment with his private psychiatrist S29.

Continued review of patient #6's medical record revealed a Psychiatric Evaluation, dated 11/01/2009, and documented by psychiatrist S14. Review of the Psychiatric Evaluation revealed the following: "JUSTIFICATION FOR ADMISSION: The patient has been referred...on a Physician's Emergency Certificate and Coroner's Emergency Certificate from (name of Hospital A) for psychosis and unstable mood...PAST PSYCHIATRIC HISTORY: The patient reports a history of Bipolar Disorder and Schizophrenia and sees (name of private psychiatrist S29) in outpatient treatment. The patient has been treated with Seroquel, Risperdal, Ambien, and hydrocodone...ASSETS: The patient entered treatment involuntarily and does not appear to be very willing to cooperate with the treatment to help stabilize his condition...TREATMENT PLAN: ...The patient will be placed on suicide, seizure, and withdrawal precautions as well as cognitive impairment precautions...".

Interview, on 06/09/10, 9:15 am, with psychiatrist S14 revealed when questioned as to why patient #6 was admitted with precautions of "suicide, violence, and withdrawal" when there lacked documented evidence, psychiatrist S14 stated "when I am on-call and a patient is transferred under a PEC or CEC and the patient has a psychosis I (S14) feel it justifies placing the patient on suicide, violence, seizure, withdrawal, and cognitive impairment precautions." Psychiatrist S14 continued and stated he felt "it would be a matter of malpractice" if he had not placed patient #6 on these precautions, "specifically because patient #6 was psychotic and could possibly become violent and try to hurt other people or himself". The surveyor asked Psychiatrist S14 if all patients who were admitted under a PEC or CEC and were psychotic had these same precautions ordered on admission; S14 stated "if I am on call that is what I do, don't know if others order the same precautions but I feel they should, it should be the standard" protocol. S14 was questioned relative to what he had documented for patient #6's Assets, ("The patient entered treatment involuntarily and does not appear to be very willing to cooperate with the treatment to help stabilize his condition"), S14 did not respond.

Interview, 06/09/2010, 2:30 PM, with Administrator S1, Director of Nursing S2, and Licensed Clinical Social Worker S3 revealed all admitting psychiatrists had been given an in-service (conducted by the Director of Health Information Management, Registered Health Information Administrator S32) "just a couple of months ago" along with a written list of "Strengths and Assets" which were to be used/and or assist the psychiatrist with descriptions of patient assets when they performed the Psychiatric Evaluation.

The above interviews confirmed psychiatrist S14 failed to follow: 1) the requirement under this regulation and 2) the hospital's accepted practice of the use of descriptive words/statements to document patient #6's Assets on the Psychiatric Evaluation.

Based upon review of 1 of 7 medical records (#1), hospital policies and procedures, and staff and patient interviews, the psychiatrist (S14) failed to accurately record patient #1's response to the drug therapy modality as evidenced by identifying in the physician progress notes the patient's response to the psychotropic medication trial when in fact the patient had refused all psychotropic medications. Findings:

Review of patient #1's medical record revealed the patient was admitted to the hospital on 06/02/10 with the diagnosis of Recurrent, Severe Major Depression. Upon admission to the hospital on 06/02/10, the physician ordered Pristiq 50 milligrams to be administered at night. On 06/02/10, the Pristiq was discontinued and Celexa 10 milligrams was ordered to be administered to the patient every day. Review of the physician progress notes by psychiatrist S14 revealed on 06/03/10, S14 documented for the Updated Diagnosis and Problem List/Treatment Changes "Continue the patient's current psychotropic medication and strongly encourage the patient to attend group psychotherapy for greater support. The client is on day 2 of his current psychotropic medication trial." On 06/04/10, S14 documented in the physician's progress notes the patient's refusal of the psychotropic medication and discussed with the patient the benefits and risks associated with the medication Celexa. On 06/05/10, S14 documented "Plan: We will continue to monitor the patient closely and continue group and milieu therapy. We will also continue to titrate medications." On 06/06/10, S14 further documented in the progress notes "Plan: Continue to monitor the patient closely and continue to titrate medications." Interview with patient #1 on 06/07/10, 11:30 AM, revealed during the daily visits with the psychiatrist he had told the psychiatrist he only wanted to participate in the therapy sessions and was refusing all medications because he felt that he did not need them. The psychiatrist had explained to him what the medications were for; however, the patient felt he was doing better after participating in the group and individual therapy so he refused the medication. Patient #1 further stated during subsequent visits, the psychiatrist would ask him how he was doing on the psychotropic medications and he would have to remind the psychiatrist he was not taking any.

On 06/07/10, 11:10 AM, the Director of Nursing S2 was provided patient #1's medical record for review. It was confirmed through interview with S2 the psychiatrist failed to consistently document the patient's refusal of drug therapy versus the psychiatrist's documentation to continue to titrate the medications.

Review of the policy titled "Multi-Disciplinary Progress Report" #TX.006, 3.0 Physician, 3.1 "Physicians will reassess the patients at least 5 times a week and enter a progress note in the medical record which should address the following: 3.1.1 Patient's response to treatment/medication including justification for changes in treatment and medication. 3.1.2 Proposed treatment plan changes, 3.1.3 Significant changes in patient status and actions taken..."

There failed to be documented evidence the psychiatrist S14 followed hospital policy and procedure and accurately document treatment plan changes and the actions taken when patient #1 refused the physician ordered psychotropic medication Celexa.