HospitalInspections.org

Based on a review of documentation, clinical records and an interview with staff, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital.

Findings were:

During a review of clinical records for 6 behavioral health patients (patients #1 through #6), 6 of the 6 patients had not received a psychiatric evaluation containing Axes I through V nor a current and past Global Assessment of Functioning score.

Facility policy WT910810.214 titled "Intake, Admission, and Assessment Process; Admission Assessments" states, in part:
"PROCEDURE:
1. Psychiatric Evaluation
...
d. The psychiatrist's admission evaluation will also include documentation of:
...
8. DSM 5 diagnosis, Axis I, II, III, IV, V and current and past GAF score"

During a review of clinical records for 6 behavioral health patients (patients #1 through #6), 1 of the 6 patients (patient #1) had received psychoactive medication without a properly executed and signed psychoactive medication consent form.

Facility policy WT910810.510 titled "Patient Rights and Responsibilities; Informed Consent for Psychotropic Medication" states, in part:
"POLICY:
Patients, or legal representatives, have the right to make an informed decision to agree to take, or to refuse, antipsychotic/psychotropic medications.
...
PROCEDURE:
...
6. After discussion of the recommended medication, nature and effect and the patient indicates understanding the consent of the informed consent, the patient or legal representative shall sign and date the consent form showing that he or she agrees to the administration of the recommended medication."

In an interview with staff #1 on the afternoon of 12-15-15, staff #1 confirmed that the psychiatric evaluations for patients #1 - #6 had not been performed according to facility policy and that patient #1 had received psychoactive medication prior to execution of a properly executed and signed psychoactive medication consent form.