HospitalInspections.org

Based on document review and interview, the facility failed to document that the notice of patient rights was provided to a patient or the patient's representative at the time of admission for 4 of 11 medical records (MR) reviewed (patient #'s 1, 2, 7 & 8).

Findings include:

1. The policy/procedure Patient Rights (approved 1-15) indicated the following: "Patients shall be fully informed of the various steps and activities involved with receiving service, as well as the right to refuse any recommended course of treatment... If a patient is unable to make decisions about his or her care, treatment, or services, a surrogate decision maker will be involved."

2. Review of the MR for patient #'s 1, 2, 7 & 8 indicated that verbal or telephone consent was obtained for each patient admission and no MR documentation indicated that the facility provided a copy of the notice of Patient Rights to the patient's representative as identified on the Consent for Treatment.

3. On interviews on 8-5-16 at 1405 and 1445 hours, the PI and risk manager, staff A3 confirmed the MR for patient #1, #2, #7 and #8 lacked documentation indicating the patient's representative was provided a copy of the notice of Patient Rights at the time of admission and confirmed no other documentation was available.

Based on document review and interview, the facility failed to ensure each patient or the patient's representative was informed on admission of the facility's grievance process including an address and phone number for submitting a grievance with the State agency for 4 of 11 medical records (MR) reviewed (patient #'s 1, 2, 7 & 8).

Findings include:

1. The policy/procedure Patient Rights (approved 1-15) and notice of Patient's Rights (revised 4-12) indicated the following: "Patients and families have the right to access the services of the Patient Advocate should they feel the need ...Any written or verbal claim by a patient regarding alleged violations of his/her rights will be investigated by the Patient Advocate... The identity and location of the Patient Advocate shall be detailed to each patient on admission." The policy/procedure and notice of Patient's Rights lacked the name, address or phone number of the State Advocacy agency for lodging a grievance and no other documentation indicating Patient Advocate contact information was identified or provided prior to exit.

2. Review of the MRs for patient #'s 1, 2, 7 & 8 lacked documentation indicating the State Advocacy agency's name, address and phone number for submitting a grievance was provided to the patient's representative at the time of admission.

3. On interviews on 8-5-16 at 1405 and 1445 hours, the PI and risk manager, staff A3 confirmed the MR for patient #1, #2, #7 and #8 lacked documentation indicating the State Advocacy agency's name, address and phone number for submitting a grievance was provided to the patient's representative at the time of admission and no other documentation was available.

Based on document review and interview, the center failed to ensure a valid consent for treatment was obtained from the patient or the patient's representative for 1 of 11 MR (medical records) reviewed (patient #4).

Findings include:

1. Review of the MR for patient #4 indicated an LPN (licensed practical nurse) signed the consent for treatment and review of the Facesheet for patient #4 failed to indicate the LPN was identified a contact person or a listed patient representative.
2. On interview on 8-5-16 at 1445 hours, the PI and risk manager, staff A3 confirmed the individual signing the consent for treatment for patient #4 was a nursing home staff who did not have the authority to sign the consent and confirmed the MR failed to indicate that proper consent for treatment was obtained.

Based upon document review and interview, the nurse executive failed to ensure that the policy/procedures for patient assessment and reassessment, incident reporting, or abuse and neglect reporting were followed and a registered nurse evaluated the nursing care of a patient for 1 of 11 MR (medical records) reviewed (patient #1).

Findings include:

1. The policy/procedure Reassessment & Change in a Patient's Condition (revised 3-14) indicated the following: "It is the policy of Options Behavioral Health System to assess the patient at time of admission... re-assessment occurs on an ongoing basis via daily assessment... by a Registered Nurse every 24 hours at a minimum... reassessment includes yet is not limited to the following circumstances... physical complaint... If other medical staff members or ancillary staff members notice a change in the patient's condition, the charge nurse will be notified."

2. The policy/procedure Incident Reporting (approved 1-15) indicated the following: "The responsibility for completing an incident report rests with any facility staff member who witnesses, discovers or has direct knowledge of an incident... An incident report should be filed for any incident including, but not limited to... Observed or alleged physical abuse of a patient..."

3. The policy/procedure Assessing and Reporting Abuse and Neglect (reviewed 1-14) indicated the following: "Any staff member who suspects or becomes aware of abuse must inform their supervisor immediately and the following protocols should be followed... contact the risk manager to inform of suspected abuse...... complete an incident report."

4. Review of the MR for patient #1 indicated the following:
A. On 6-8-16 at 1130 hours, the intake therapist, staff A5 notified the registered nurse, staff N11 about a report by patient #1 of rib pain. The MR entry indicated the patient reported that his/her ribs felt like they are broken as a result of abuse experienced by a staff at a nursing home prior to admission to the facility.
B. The MR indicated patient #1 reported they were having a lot of pain in their back and rib area on multiple occasions during the day and no documentation indicated the patient was examined by a nurse, nurse practitioner, or a physician following the allegation of abuse or indicated a nurse practitioner on-call and/or the psychiatrist, MD11 were contacted and notified of the patient's complaint of pain that they felt like their ribs had been broken.

5. On interview on 8-5-16 at 1345 hours, the PI and risk manager, staff A3 confirmed the MR for patient #1 lacked documentation indicating a nurse re-assessed the patient after the report of abuse or indicated a physician or nurse practitioner was contacted and informed about the report of abuse and complaint of pain that his/her ribs felt like they were broken.

6. Review of incident reports for June 2016 failed to indicate an incident report dated 6-8-16 corresponding to the report of abuse by patient #1.

7. On interview on 8-5-16 at 1335 hours, the PI and risk manager, staff A3 confirmed they were not notified by any staff about the patient's allegation of abuse prior to the current complaint investigation and confirmed that an incident report had not been prepared or submitted by either the therapist, staff A5 or the registered nurse, staff N12 regarding the allegation of patient abuse.