HospitalInspections.org

42995

Based on record review and interview the facility failed to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care for 4 out of 10 patients admitted (P#5, P#7, P38, and P#10) This deficient practice increases the likelihood of patients not knowing their rights in treatment and consenting to treatment.

The findings are:

A. Patient Rights form for 4 of 10 patient charts reviewed had no signed patient rights and signed consent to treatment on the file at admission:
1. Record review for P#5 date of admission 3/14/2020 revealed no signed consent for treatment or signed patient rights on record at time of admission.
2. Record review for P#7 date of admission 3/04/2020 revealed no signed consent for treatment or signed patient rights on record at time of admission.
3. Record review for P#8 date of admission 3/05/2020 revealed no signed consent for treatment or signed patient rights on record at time of admission.
4. Record review for P#10 date of admission 3/16/2020 revealed no signed consent for treatment or signed patient rights on record at time of admission.

B. Interview with S#1 (Director) on 4/7/2021 at 2:00pm S#2 (Quality Director) confirmed, "Patients should sign the patient rights form and the consent to treatment at admission and it is scanned into their record. There is no explanation for why these records are lacking the forms".

Based on record review and interview the facility failed to provide an admitting diagnosis on every patient at the time of admission, that justifies the need of being admitted under an involuntary status in 10 out of 10 patient charts reviewed. (P#1-P#10). This failed practice increases the likelihood for patients being treated as an involuntary patient without justification and patient being unable to make decisions about their own treatment due to involuntary status.

The findings are:


A. Record review of P#1 - P#10 reveal all 10 patients were admitted with an involuntary admission status without documentation provided to justify an involuntary status:

1. Record review for P#1 date of admission 03/25/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" signed on 03/25/2020 with no justification or reason. "History and Physical - Psych" dated 03/26/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/29/2020 has no mention of "involuntary status change at discharge".

2 .Record review for P#2 date of admission 03/14/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" signed on 03/14/2020 with no justification or reason. "History and Physical - Psych" dated 03/14/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/20/2020 has no mention of "involuntary status change at discharge".

3. Record review for P#3 date of admission 03/26/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/26/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/26/2020 has no mention of "involuntary admission status". Discharge Summary dated 04/02/2020 has no mention of "involuntary status change at discharge".

4 Record review for P#4 date of admission 03/29/2020 reveals a signed Admission Status Update Form showing Status changed to "neither voluntary or involuntary checked" signed on 03/29/2020 with no justification or reason. "History and Physical - Psych" dated 03/31/2020 has no mention of "involuntary admission status". Discharge Summary dated 04/03/2020 has no mention of "involuntary status change at discharge".

5. Record review for P#5 date of admission 03/14/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/14/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/16/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/20/2020 has no mention of "involuntary status change at discharge".

6. Record review for P#6 date of admission 03/04/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/04/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/06/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/09/2020 has no mention of "involuntary status change at discharge".

7. Record review for P#7 date of admission 03/04/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/04/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/05/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/06/2020 has no mention of "involuntary status change at discharge".

8. Record review for P#8 date of admission 03/05/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/05/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/06/2020 has no mention of "involuntary admission status". Discharge Summary dated 04/02/2020 has no mention of "involuntary status change at discharge".

9. Record review for P#9 date of admission 03/03/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/03/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/04/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/07/2020 has no mention of "involuntary status change at discharge".

10. Record review for P#10 date of admission 03/23/2020 reveals a signed Admission Status Update Form showing Status changed to "involuntary" on 03/23/2020 signed with no justification or reason. "History and Physical - Psych" dated 03/23/2020 has no mention of "involuntary admission status". Discharge Summary dated 03/25/2020 has no mention of "involuntary status change at discharge".

B. Record review of Patient Consent to treatment under Patient Rights 151-NPMR-7601HMS dated 4/16, Revised 7/16, pg. 2 under subtopic Consent stated: "You have the right to be fully informed about any suggested treatment or therapy before giving consent. To be fully informed you must have the following information: The problem for which the treatment/therapy is proposed; What treatment/therapy is and how it works; Risks and consequences of treatment/therapy; Likelihood of success; Possible alternatives; and the consequences of not receiving the treatment/therapy".

B. On 04/08/2021 at 1:10 pm during interview, S#2 (Quality Director) confirmed, "the facility does not have a policy in reference to "voluntary/involuntary admission status", it is a directive from the physician." S#2 stated, "Everyone who is being admitted involuntary status should have it noted in the History & Physical at least". "We (facility) need to do education with the doctors, we (facility) will make it happen".