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A. Based on document review and interview it was determined that for 1 of 5 (Pt #1) clinical records reviewed for weekly update Treatment Plan Review, the Hospital failed to ensure the patient signed the update or documented refusal, as required, to indicate the patient was involved in the care planning process.

Findings include:

1. Hospital policy entitled, Weekly Review of Master Treatment Plan," (last reviewed 2/16) required, "Procedure:...4. Each patient is encouraged to participate in the formulation of the Master Treatment Plan and process his/her progress in the program when reviewing the Treatment Staffing Review form weekly. The signature of the patient will be requested following this, though the patient reserves the right to refuse to sign."

2. The Hospital's patient Bill of Rights, (undated) required, "...You have the right to actively participate in the development of your treatment plan which will be implemented by the clinical staff and reviewed periodically."

3. The clinical record of Pt #1 was reviewed on 6/2/16. Pt #1 was a 13 year old female admitted to the Hospital's Partial Hospitalization Program 4/14/16 with a diagnosis of major depressive disorder. Pt #1's clinical record contained an Interdisciplinary Master Treatment Plan dated 4/14/16. Pt #1's clinical record contained Interdisciplinary Treatment Plan Review Worksheets dated 4/20 and 4/26/16. The Worksheets did not include Pt #1's signature or refusal documentation indicating her review of the goals.

4. The Director of Clinical Services (E #1) was interviewed on 6/2/16 at approximately 1:30 PM. E #1 stated, Treatment plans are developed after reviewing the patient's psychosocial and physician's evaluations. The documentation does not indicate if the patient had been involved as required."

B. Based on document review and interview, it was determined that for 1 of 5 (Pt #1) clinical records reviewed for informed consents, the Hospital failed to ensure the registered nurse(RN) had verbal consents witnessed by a second individual as required.

Findings include:

1. Hospital policy entitled, "Informed Consent," (last review 2/16) required, "...Exception to Informed Consent for Medication...Phone approvals obtained by nursing staff should be witnessed and both staff and witness sign the consent..."

2. The clinical record of Pt #1 was reviewed on 6/2/16. Pt #1 was a 13 year old female admitted to the Hospital's Partial Hospitalization Program 4/14/16 with a diagnosis of major depressive disorder. Pt #1's Interdisciplinary After Care Plan dated 5/4/16 included "Discharge education provided to patient and family ...The Aftercare Plan was reviewed with ..." The document, which required the signature of the patient if over 12 years of age was not signed by the patient (age 13) and only a phone consent was received from the mother. The phone consent was not witnessed by a second individual as required.

3. The Director of Risk Management and Performance Improvement stated during an interview on 6/2/16 at approximately 1:00 PM that the phone consent was not witnessed by a second person as required and the only policy the Hospital has regarding the witnessing of a phone consent is the "Exception to Medications".

A. Based on document review and interview, it was determined that in 1 of 1 (Pt #1) clinical record reviewed of a patient that sustained an injury during an altercation, the Hospital failed to ensure the patient's care was provided in a safe environment.

Findings include:

1. The Hospital's "Patient Bill of Rights," (undated) required, "...19. You have the right to be not mentally or physically abused or neglected."

2. The clinical record of Pt #1 was reviewed on 6/2/16. Pt #1 was a 13 year old female admitted to the Hospital's Partial Hospitalization Program on 4/14/16 with a diagnosis of major depressive disorder. Pt #1's clinical record contained a Program Therapist Progress Summary dated 5/4/16 that included, "Pt being disruptive ...Pt calling peer names. Pt got out of seat and went over to pt and start pulling at her hair and hitting her with a closed fist to the face. Staff was able to stop peer from hitting pt by removing her from the room to the hallway. Nurse called in while staff remained with peer in the hallway ..."

Pt #1's clinical record contained a Multidisciplinary Progress Note dated 5/4/16 that included, "...the client was sitting in a chair hands over mouth and nose while bleeding. ...Gave the client gauze and saline to clean up and stop the bleeding. Then called mother ...Explained what happened and the client told mom to 'pick me up, I don't want to be here, a girl attacked me.' Pt taken to intake assessment area to wait for mom ..."

3. The incident report for Pt #1 regarding the altercation dated 5/4/16 was reviewed on 6/2/16. The report indicated Pt #1 was in a physical confrontation with another patient and received a bruised and bloody nose while in the PHP, and non physician first aide was rendered. The patient's mother was notified at 10:45 AM with documentation of being angry. The report indicated Pt #1 was "cooperative" at the time of the incident.

4. On 6/2/16 at approximately 3:20 PM an interview was conducted with the Mental Health Specialist (E #3) on duty 5/4/16. E #3 stated, "The incident occurred around lunch time and the kids were playing. The second patient (Pt #2) got up and hit the other girl (Pt #1). I got between them within 10 seconds and a code yellow was called. The code yellow is called when additional staff are needed to help calm the kids and redirect them. The second girl (Pt #2) said the first girl (Pt #1) was calling her names. The nurse arrived in the hall took the first girl away."

5. An interview was conducted with the Interim Director of Nursing on 6/3/16 at approximately 12:30 PM. The Director stated staff should have gotten between the patients to try and redirect them and hopefully the altercation should not have happened.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed of a patient with an injury, the Hospital failed to ensure the patient was treated appropriately for the injury.

Findings include:

1. The Hospital's "Patient Bill of Rights," (undated) required, "...You have the right to treatment regardless of...Referrals will be made if Garfield Park Behavioral Hospital does not offer appropriate treatment for your situation."

2. Hospital policy entitled, "HCR/Incident Report Process," (dated 2/16) required, "...Healthcare Facility Staff...2. Patient(s) was examined/received immediate medical attention, sent to ER/Medical Hospital, as needed."

3. The clinical record of Pt #1 was reviewed on 6/2/16. Pt #1 was a 13 year old female admitted to the Hospital's Partial Hospitalization Program 4/14/16 with a diagnosis of major depressive disorder. Pt #1's clinical record contained a Program Therapist Progress Summary dated 5/4/16 that included, "Pt being disruptive ...Pt calling peer names. Pt got out of seat and went over to pt and start pulling at her hair and hitting her with a closed fist to the face. Staff was able to stop peer from hitting pt by removing her from the room to the hallway. Nurse called in while staff remained with peer in the hallway ..."

Pt #1's clinical record contained a Multidisciplinary Progress Note dated 5/4/16 that included, "...the client was sitting in a chair hands over mouth and nose while bleeding. ...Gave the client gauze and saline to clean up and stop the bleeding. Then called mother ...Explained what happened and the client told mom to 'pick me up, I don't want to be here, a girl attacked me.' Pt taken to intake assessment area to wait for mom ..."

4. On 6/2/16 at approximately 3:40 PM the registered nurse (E #4) on duty 5/4/16 was interviewed. E #4 stated, "When I was called and walked into the room, the two girls in the altercation had been separated. The first one (Pt #1) was bleeding. I took her into my office where she said she wanted to call her mother. I got some gauze, saline, and an ice pack and then she called on the speaker phone. When I told her (mother) what had happened she became very upset. I informed her that her daughter had been scheduled for discharge that day. I remember alerting the physician and completing the incident report. I don't remember if I offered to send the patient to the Hospital to be checked out or not."

5. An interview was conducted with the Interim Director of Nursing on 6/3/16 at approximately 12:30 PM. The Director stated staff should have offered to send the patient to the ER and documented what was done. The patient could refuse but that needed to be documented.

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed that included the release of records, the Hospital failed to ensure the patient consented to the release of the records as required.

Findings include:

1. Hospital policy entitled, "Release of Information to Persons, Agencies or Facilities/Handling of Valid Authorizations," (reviewed 3/16) required, "Policy Statement...Patient information, written and verbal can only be disclosed to persons, agencies...with a valid written authorization..."

2. The Hospital's "Patient Bill of Rights," (undated) required, "...13. You have the right to confidential treatment of your personal and medical records. Information from these sources will not be released without your prior consent..."

3. The clinical record of Pt #1 was reviewed on 6/2/16. Pt #1 was a 13 year old female admitted to the Hospital's Partial Hospitalization Program 4/14/16 with a diagnosis of major depressive disorder. Pt #1's clinical record contained two (2) Authorization for Release of Protected Health Information forms. The forms required the release of Pt #1's health information to outpatient community centers. The forms have a patient signature line that included, "Required if patient is at least 12 years old and also included: This authorization must be filled out in its entirety or it will not be valid." The forms indicated that Pt #1's mother had given phone consent for the release of the information, however the patient (age 13) had not signed or given a phone consent for the release her information.

4. The HIM Supervisor stated during an interview on 6/3/16 at approximately 12:30 PM that the consent to release records was not signed by the patient and she only sent the patients After Care Plan to the Facility mentioned and not the whole record.