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Based on the manner and degree of the standard level deficiency, it was determined §482.13 Condition of Participation: Patient Rights was out of compliance.

A-0115- A hospital must protect and promote each patient's rights. Based on interviews and document review, the facility failed to allow patients to make informed decisions regarding their treatment. Document review and interviews indicated 2 of 2 patients who requested their Global Positioning Satellite (GPS) ankle monitors removed were not educated regarding the clinical rationale for the monitors and were not given alternative options to fulfill their clinical needs (Patient # 6 and Patient #9).

Based on interviews and document review, the facility failed to allow patients to make informed decisions regarding their treatment. Document review revealed 2 out of 2 patients with GPS ankle monitors who requested to have their GPS ankle monitors removed were not given alternative options to fulfill their clinical needs. (Patient #6 and Patient #9)

Findings include:

Facility policies:

The Global Position Satellite (GPS) Patient Monitoring policy read , the purpose of the policy was to provide patients the opportunity for privileges while maintaining public safety.

The Patients' Rights policy read, when patients participated in treatment planning decisions and understood treatment options optimal outcomes would be achieved. The policy also read the medical staff was responsible for explaining treatments including benefits, risks and alternatives.

Reference:

The Patients' Orientation Handbook read, patients had a right to refuse any medication or treatment and the only exception was treatment by order of the court.

1.The facility failed to educate patients on alternatives to GPS ankle monitoring devices and to remove GPS devices upon patient requests .

a.The facility policies (see above) read, the medical staff were responsible for explaining treatments including benefits, risks and alternatives since patient participation in their treatment plan would achieve optimal outcomes. Additionally, the GPS ankle monitor provided patients the opportunity for privileges. The facility was unable to provide a reference for a clear guideline and protocol for staff use of GPS ankle bracelet placement or removal.

b. Medical Record review of two patients indicated the facility did not allow patients to make an informed decision regarding wearing GPS ankle monitors.

i. Patient #6's medical record was reviewed. Patient #6's treatment plan read, he would demonstrate compliance with his GPS ankle monitor as a short-term goal on 9/15/20. Patient #6 filed a grievance to have his GPS ankle monitor removed on 8/18/20. Throughout the grievance process, Patient # 6 was never given the opportunity to have the GPS ankle monitor removed. There was no evidence a discussion was had with Patient #6 to discuss the GPS ankle monitor could be removed if additional privileges were also revoked. The grievance was closed on 9/25/20. On 10/9/20, Patient #6 asked again to have his GPS ankle monitor removed. Documentation described the GPS ankle monitor as clinically justified, but did not mention alternative options such as losing privileges afforded by the ankle monitor. There was no documentation to reflect if Patient #6 still agreed with his treatment plan. On 12/14/20, the GPS ankle monitor was removed due to direction from the Office of Behavioral Health.

ii. Patient #9's medical record was reviewed. Patient #9 made multiple requests to have his GPS ankle monitor removed. On 5/26/20, Patient #9 told staff he did not understand why he had an ankle monitor. On 7/29/20, Patient #9 questioned the placement of his ankle monitor and expressed he wanted the monitor removed. On 9/3/2020, Patient #9 stated he wanted the GPS ankle monitor removed as it was causing him significant stress. There was no documented response from the facility concerning these complaints. On 4/12/21, a short term goal in the treatment plan for Patient #9 read, Patient #9 would demonstrate compliance and report any concerns regarding the GPS ankle monitor. Patient had the same short-term goal listed in his treatment plan since 2019.

c. Interviews with staff revealed inconsistent interpretations of court-ordered instructions which granted temporary physical removal from secured unit either on facility grounds with less supervision, or off facility grounds). There was no clear process for placement or removal of GPS ankle monitors.

i.On 4/21/21 at 4:35 p.m., an interview was conducted with Psychiatrist #4. Psychiatrist #4 stated he was on a committee which determined whether patients were assigned a GPS ankle monitor. Psychiatrist #4 stated GPS ankle monitors were used to allow patients to have privileges or be on a lower security unit if they were still considered a risk for escape. Psychiatrist #4 stated the facility could not place or keep a GPS ankle monitor on a patient without the patient's consent. Psychiatrist #4 stated the court's role on GPS ankle monitors was in the context of granting privileges rather than a mandate to order the patient wear a GPS ankle monitor regardless of patient preferences.

ii. On 4/22/21 at 8:30 a.m., an interview was conducted with Chief of Psychiatry (COP) #5. COP #5 stated when patients requested to have GPS ankle monitors removed patients should be educated regarding the court order and privileges granted due to the court order. When asked if patients could be forced to wear GPS ankle monitors, COP #5 stated the facility could not force medications unless there was a court order, but the facility had not thought about GPS ankle monitors in the same way. He stated the concept of GPS ankle monitors being voluntary was a new concept. COP #5 stated the facility staff should have a consistent understanding of how GPS ankle monitors should be implemented and staff needed to be educated regarding GPS ankle monitors. COP #5 stated it was standard practice to educate patients regarding the GPS by the team coordinator.

iii. On 4/22/21 at 1:14 p.m., an interview was conducted with Health Care Professional (HCP) #6, a team coordinator. HCP #6 stated the team coordinator was responsible for the overall review and the long term and short term goals for the patient. HCP #6 stated GPS ankle monitors should be on the patient's treatment plan. HCP #6 stated in cases where patients wanted the GPS ankle monitor removed, staff should try to determine why the patient wanted the monitor removed. Staff should then educate the patient and document events and outcome. HCP #6 stated if the patient insisted the facility remove the GPS ankle monitor, the patient was told the ankle monitor was a court order and the patient had to continue to wear it.

HCP #6 viewed Patient #9's record and read documentation of him requesting the monitor be removed on 5/26/20, 7/30/20 and 9/3/20. HCP #6 could not recall any requests for the removal of the GPS ankle monitor mentioned during the Patient #9's treatment. HCP #6 could not identify in Patient #9's medical record any documentation of whether the facility addressed Patient #9's requests for the removal of his GPS ankle monitor.

iv. On 4/21/21 at 12:30 p.m., an interview was conducted with Chief Clinical Officer (CCO) #1. CCO #1 stated GPS monitoring was not a specific court order but was part of the integration plan. CCO #1 stated patients could have their GPS ankle bracelet off, but then could not leave the facility grounds. CCO # 1 stated a court order specifically for GPS monitoring would be self-defeating because the court only agreed to GPS monitoring to grant privileges.

On 4/21/21 at 3:02 p.m., a second interview was conducted with CCO #1. CCO #1 stated the policy did not speak to GPS monitoring being forced and it was counterproductive to force patients to wear GPS monitoring devices. CCO #1 stated patients needed to know the pros and cons of GPS monitoring to make a competent decision. CCO #1 stated patients who refused to wear GPS monitors should be regressed to a unit with higher security. CCO #1 stated the policy should clarify the process of GPS monitor removal and moving patients to a unit with higher security upon patient request. CCO #1 stated it was unacceptable to force a patient to wear a GPS monitoring device.

v. On 4/21/21 at 2:15 p.m., an interview was conducted with Nurse Practitioner (NP) #2. NP #2 stated GPS ankle monitors were intended for patients with a high risk of leaving the facility to have additional privileges granted. NP #2 stated the facility made the decision regarding GPS monitoring and the court could deem it a requirement. NP #2 stated the policy granted the facility the authority to place GPS ankle monitors on patients regardless of patients' objections in the interest of progressing treatment. This was in contrast to Psychiatrist #4 and CCO #1's interview.

vi. On 4/21/21 at 3:49 p.m. an interview was conducted with Director of Quality (DOQ) #3. DOQ #3 stated GPS ankle monitors were choice-based and if a patient did not agree to wear an ankle monitor, then privileges may not be granted. When asked if Patient #6 was forced to wear a GPS ankle monitor, DOQ #3 stated Patient #6 wanted his privileges. When asked if the facility explained to Patient # 6 the removal of the GPS ankle monitor would result in a loss of privileges, DOQ #3 stated the facility did not want to coerce patients to wear GPS ankle monitors.