HospitalInspections.org

Based on interview and record review, the facility failed to meet the Conditions for Participation for Patient Rights by failure to 1). Obtain consent for use of psychotropic medications for and 2). Implement their policy and procedure for identifying abuse and neglect, resulting in the potential for loss of rights for all patients served by the facilty.
Findings include:

(See A- 131): Failure to obtain consent for use of psychtropic medications
(See A-145): Failure to implement their policy for abuse and neglect

Based on interview and record review the facility failed to obtain informed consent for the administration of a psychotropic medications for 1 (#1) of 6 patients reviewed for psychotropic medication consent, resulting in the withholding of information as required by the patient (#1) to make informed decisions regarding her care. Findings include:

On 09/20/2021 at 1130 a review of the medical record revealed patient #1 was a 22-year-old-female admitted to the facility on 8/23/2021 per a document titled "Formal Voluntary Admission Application-Adult". The patient's diagnoses included Major Depressive Disorder.

Further review of the record revealed the patient was administered the following medications on the following dates and times:

Trazodone 100 milligram (mg) was given on 8/23/2021 at 2253; on 8/24/2021 at 2033; on 8/25/2021 at 2058; and on 8/26/2021 at 2146.

Divalproex 250 mg was given on 8/24/2021 at 2033; on 8/25/2021 at 0856 and at 1616.

Ziprasidone 20 mg was given on 8/24/2021 at 2101; on 8/25/2021 at 0856 and at 1616.

However, the medical record contained no evidence that patient (#1) consented to the medications.

Further record review revealed 2 documents titled "Clinical Certification" dated 8/26/2021 at 1215 and 8/27/2021 at 0945 respectively, that documented the patient was mentally ill and there was the likelihood of injury to others when not taking regular medications due to poor insight and judgement making her act impulsively. However, the patient had not been court processed. The hearing was scheduled for 9/8/2021.

During an interview with Psychiatrist Staff G on 9/20/2021 at 1400, Staff G said the patient (#1) was provided education with the medication regime. Staff G said nursing staff was responsible for obtaining the patient's consent for the aforementioned medications.
However, there was no evidence that it was done.

During an interview with the Chief Administrative Officer (Staff A) and the Director of Quality (Staff C) on 9/21/2021 at 1000, after reviewing the patient's medical record confirmed there were no consents for the administration of the aforementioned medications. At that time, Staff C said, we've looked there are no consents for those meds.

Review of the facility's "Written Informed Consent for Psychotropic Medications" policy, dated July 2020 documented:
"IV. Procedures:
The attending physician will:
A. Obtain written informed consent prior to or within 24 hours of the administration of psychotropic medications. (Medication may be given without informed consent when so ordered by an appropriate court.
B. Will review the following information with the patient, or empowered guardian prior to obtaining the informed consent:
1. The type of medication used.
2. The expected benefits.
3. The possible risks.
4. Available alternative treatments and their possible risks and side effects.
5. The consequences of refusing medication
C. Will provide to the patient a patient medication instruction sheet (provided by pharmacy or other printed patient medication...) A signed Informed Consent for one of the following medication classifications shall be deemed valid medications of the same class:
" Neuroleptics
" Cyclic Antidepressants
" SSRI-NSRI
" Monoamine Oxidase Inhibitors
" Benzodiazepines
" Anti-Parkinsonian
" Hypnotics
" Anti-Manic/Mood Normalizers
All others psychotherapeutic agents must be obtained individually

D. Will document the reason for the use of psychotropic medication in the patient's medical record in specific terms.
However, this was not done.

Based on interview and record review, the facility failed to implement their policy and procedure for identifying abuse and neglect for 1of 1 patients (#1), resulting in the potential for loss of rights for all patients served by the facility.
Findings include:

On 09/20/2021 at 1130 a review of the medical record revealed patient #1 was a 22-year-old-female admitted to the facility on 8/23/2021 per a document titled "Formal Voluntary Admission Application-Adult". The patient's diagnoses included Major Depressive Disorder.

On 9/21/2021 at 1230, during an interview with Recipient Rights Advisor (Staff I) she explained she met with the patient (#1) on 8/25/2021. She said the patient had written and submitted multiple complaints. Staff I said the patient complained about how she was treated by her Psychiatrist (Staff G). Staff I was asked to explain how she addressed the patient's complaint about Staff G. Staff I replied, "I spoke to the Doctor (Staff G) and she confirmed that she told the patient (#1) to 'Shut up'." Staff I said the allegation was substantiated.

Staff I was asked if she filed an incident report or escalated those findings with anyone else. Staff I replied, "I emailed the Chief Executive Officer (CEO) Staff L." Staff I was asked if there were any follow-up from the CEO and she replied there had not been. Staff I said she did not file an incident report because the complaint was substantiated.

During an interview with Social Worker (Staff K) on 9/21/2021 at 1300, when queried regarding the patient of concern (#1) course of stay and to her knowledge if the patient had expressed any maltreatment. Staff K replied that she was present during a telehealth visit that was conducted by the Psychiatrist Staff G. Staff K explained that she overheard Staff G say to the patient (#1) "Could you shut up so I can finish, so I can finish asking you some questions." Staff K was asked how/if she responded to what she overheard Staff G say to the patient. Staff K said she was "surprised" and consoled the patient (#1). She said the patient was upset and left the conference room where the telehealth visit was held. Staff K said she did not recall the exact date. Staff K said she did not file an incident report or report it to anyone. Staff K said she recalled hearing Staff G asking the patient repeatedly to listen to her (Staff G). Staff K was asked if she had ever heard Staff G tell other patients to "Shut up" and she replied that she had. Staff K was asked if she had reported those incidents. Staff K explained that she generally tells the patients to report their concerns to the Recipient Rights Advisor.

An interview was conducted with the Director of Quality and Patient Safety (Staff C) on 9/21/2021 at 1330. She explained there were no incident reports submitted for the patient of concern (#1). Staff C was asked if staff were present and witnessed a patient being subjected to maltreatment by a staff member, or if a patient reported allegations of staff maltreatment or concerns for their safety if an incident report should have submitted. At that time, Staff C confirmed an incident report should have been submitted for any allegations of maltreatment. However, that was not done.

An interview was conducted with the CEO Staff L on 9/21/2021 at 1410. When queried regarding his receipt of an email from the Office of Recipient Rights regarding grievances submitted by patient #1, he said he was made aware of the concerns yesterday (9/20/2021).
Staff L said he may have received an email in regard to the patient (#1's) grievance.

However, there was no evidence that documented the CEO had addressed the patient's grievance regarding Patient Rights that was substantiated by the Office of Recipient Rights.

Review of the facility's "Identifying Abuse and Neglect" policy dated May 2020 documented:
III. Definitions:
Abuse: Non-accidental physical or emotional harm to a recipient, or sexual contact with, or sexual penetration of a recipient as terms are defined in Sec.520a of the Michigan Penal Code, 1931 PA 328, MCL 750.520a, that is committed by an employee or volunteer of the department a Community Health (CMH) services program, or licensed hospital or an employee or volunteer of a service provider under contract with the department, CMH services program or licensed hospital...IV Procedures:
A. Employee:
ANY employee who witnesses, discovers, or are notified of an incident concerning patient abuse or neglect will:
a). Immediately take actions to protect, comfort , and assure treatment of the patients as necessary.
b). Verbally notify the charge nurse immediately. If Charge Nurse not available notify Recipient Rights Officer, CEO, COO, CNO, or Medical Director.
c). File an incident report on HMS before the end of the shift and complete a Recipient Rights Complaint Form (including the patient statement), being as descriptive as possible (including observations and statements heard relating to the allegation of abuse of neglect).
However, this was not done.