HospitalInspections.org

Based on interview and record review, the facility failed to uphold the rights of 4 of 6 patients admitted involuntarily to request or refuse treatment [informed consent ]- (Patients # 19, 33, 34, 35) .

Four of six patients admitted involuntarily were kept in facility without evidence of an order for protective custody (OPC) or voluntary consent for admission.

The facility failed to follow its policy for patients admitted under an Emergency Detention & Apprehension Warrant (EDW).

Findings included:

TX 00325932

Review of facility policy titled "Rights of Persons Apprehended for Emergency Apprehension for Inpatient Mental Health Services," dated 7/2015, showed a patient admitted under an EDW had the right to be informed of the filing of a petition for court-ordered treatment. The patient is entitled to a judicial probable cause hearing no later that 72 hours ...and the right "not to be detained for more than 24 hours after the initial detention unless an order for further detention is obtained..."

During an interview on 11-06-19 at 11:30 AM with Staff 72, Clinical Services Manager, she stated she was one of the persons involved in the management of the involuntary admission process. She went on to say the person most directly responsible was the Court Liaison; he was not in the facility at the time of interview.

The Clinical Services Manager said if a patient came in on an emergency detention warrant, it was only valid for 48 hours. During the first 24 hours of admission, there must be a medical exam/certification (F-25) and certain papers ( warrant, affidavit) must be filed with the courts. A probable cause hearing was then scheduled and an Order of Protective Custody (OPC) was obtained by the court.

Staff 72 said if an OPC was not obtained and a patient had not signed a voluntary consent for admission, they could not be held involuntarily at the hospital.

On 11-08-19, the Clinical Services Manager and surveyor reviewed six (6) medical records of patients who had been admitted involuntarily. Record review showed the following four (4) patients were admitted involuntarily:

Patient # 35: admitted 10-15-10; discharged 10-25-19;

Patient # 34 : admitted 8-26-19; discharged 09-06-19;

Patient #33: admitted 10-10-19; left against medical advice 10-15-19;

Patient 19: admitted 08-26-19; discharged 09-03-19

The Clinical Services Manager was unable to locate evidence that an OPC or a voluntary consent for admission had been obtained for Patients 19, 33, 34, 35. She stated the OPC should be in the patient's medical record.