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Based on record review, observation, and staff interview, the facility failed to inform each patient, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible (A117). The facility failed to ensure care in a safe environment (A144). The facility failed to follow their written policy and procedure for visitor restrictions (A215).

Based on record review and staff interview, the facility failed to inform each patient, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for one of ten medical records reviewed (Patient #1). The active patient census on the behavioral health units was 37.

Findings include:

An interview was conducted simultaneously with Staff C and Staff D on 11/29/21 at 1:00 PM with review of an internal complaint investigation. It was reported Patient #1 was elderly, disabled with an above the knee amputation, and failed outpatient therapy. An outpatient psychiatrist recommended inpatient electroconvulsive therapy (ECT) in which the family agreed. The patient was admitted to the behavioral unit through the emergency department on a voluntary basis and was determined to have mental capacity to make her own medical decisions. The facility received an email from the daughter with concerns of ECT being conducted against wishes, needing testing for a urinary tract infection, desire to be discharged, and the facility not recognizing the medical power of attorney, and threats of a legal consult.

Review of the medical record revealed Patient #1 resided in an assisted living facility and arrived by ambulance to the emergency department 10/12/21 at 9:04 AM with a chief complaint of depression. Review of the emergency department physician documentation revealed the patient had a complex past medical history with reported increased depression symptoms causing alterations in eating and sleeping patterns. She was seen by the outpatient psychiatrist the prior day and reported severe depressive symptoms as well as somatic delusional thoughts that included the belief she had urinated her depends without any evidence of this. The patient had a history of a psychiatric admission in August 2021 and was recommended ECT which she had ultimately declined. After discussion, the patient and her daughter agreed it would be best to initiate psychiatric hospitalization for stabilization by proceeding to the emergency department. The physician assessment noted she was alert to person, place, and time.

Review of the Social Worker emergency room assessment on 10/12/21 at 2:43 PM revealed admission is being recommended by patient's outpatient psychiatrist due to increased depression and related somatic delusions of wetting her depends, and limiting liquids as a result even though multiple checks reveal dryness. The patient deferred to her daughter's decision on her health care and provided limited information herself. Per the documentation ECT will be accepted upon admission as recommended in August 2021. The patient was admitted to behavioral health unit for further stabilization.

Further review of the medical record revealed the patient reported having a medical power of attorney on 10/12/21 at 8:00 PM. Review of the uploaded/scanned documents revealed on 10/14/21 a medical power of attorney was uploaded into the secure on-line medical record that could be accessed externally by the patient or patient's representative. Review of the uploaded document revealed eight pages of twelve were missing and that it failed to include the named medical health care power of attorney. Further review revealed a durable power of attorney (financial) was scanned into the medical record on 11/17/21 at 11:05 AM.

An interview was conducted with Staff F on 12/01/21 at 11:57 AM who reported that during visitation the family would bring documentation which included evidence of the medical health care power of attorney.

An interview was conducted with Staff A on 12/01/21 at 4:07 PM who reported the patient's daughter brought Family and Medical Leave Act (FMLA) paperwork to be completed and the medical health care power of attorney was later found in the stack of paperwork. The patient was discharged on 11/15/21 and the document was not scanned into the medical record until 11/17/21 at 11:05 AM.

Review of a Release of Information form revealed it was signed by the patient on 10/19/21 at 7:16 PM authorizing the hospital to release personal health information for family updates and release the complete medical record to her daughter. There was no documentation in the patient's record that the patient ever withdrew the Release of Information. There was no documentation the facility attempted to secure a copy of the patient's medical health care power of attorney when they were made aware by the patient that one existed.

This deficiency substantiates Substantial Allegation OH00127219.

Based on observation and staff interview, the facility failed to ensure a safe environment for care for three of six patient rooms utilizing moveable hospital beds. This had the potential to affect all patients admitted to the behavioral health units. The active census on the behavioral health units was 37.

Findings include:

A tour of the behavioral health units was conducted on 11/29/21 at 2:49 PM. The units had a combined total of forty-one beds with the majority of the beds bolted to the floor. During the tour it was identified the facility was utilizing six moveable hospital beds on the units. The hospital beds in rooms 9254, 9252, and 9219 were identified as having a long electrical cord from the bed to the electrical outlet in the wall.

Staff I confirmed in an interview the electrical cords were a ligature risk on 11/29/21 at 3:03 PM.

Based on medical record review, staff interview and policy review, the facility failed to follow their written policy and procedure for visitor restrictions for one of ten patient records reviewed (Patient #1). The active patient cenus on the behavioral health units was 37.

Findings include:

Review of the policy and procedure for Behavioral Health Inpatient: Visiting Privileges, Number: OH.POL.P-110.011 Effective Date 11/19/2019, revealed visitation restrictions can be implemented by the patient's Multidisciplinary Treatment Team. The restrictions imposed must be clinically based. Restrictions and rationale will be discussed with patient/family and documented daily by the physician in the patient's electronic medical record.

An interview was conducted with Staff J on 11/30/21 at 2:32 PM who reported visitation was encouraged on the units but may be restricted if the visitor was interfering with the patient's plan of care. The facility currently had COVID-19 restrictions and allowed one visitor from 6:00 PM to 7:00 PM seven days per week on the behavioral health units. We do have the visitor complete a feedback form with each visit.

Review of the visitor feedback forms noted visitation by Patient #1's daughters on the following dates; 10/15/21, 10/16/21, 10/17/21, 10/19/21, 10/22/21, 10/23/21, 10/24/21, 10/29/21, 10/30/21, and 10/31/21. The medical record revealed no visitation was conducted thereafter.

Review of Patient #1's medical record revealed on 11/01/21 at 11:30 AM the social worker noted no visitors per physician order. Review of the physician documentation dated 11/01/21 at 10:31 AM revealed the daughter was updated on the plan of care however lacked evidence of the discussion of no visitors. Review of the physician orders dated 11/03/21 at 10:29 AM revealed the patient was to not have visitors until further notice. The visitor restriction remained in effect until 11/11/21 at 4:17 PM with no rationale and/or daily documentation as to why vitiation was restricted as per policy.

This deficiency substantiates Substantial Allegation OH00127219.

Based on medical record review and staff interview, the facility failed to evaulate the nursing care for one of ten medical records reviewed (Patient #1). The active patient census on the behavioral health units was 37.

Findings include:

Review of the medical record for Patient #1 revealed a physician order for a urinalysis dated 10/12/21 at 9:24 AM which was not completed until 11/06/21 at 11:08 AM. The results of the urinalysis confirmed positive nitrates, large leukocyte esterase, high white blood count, high red blood count, many bacteria, and high squamous epithelial.

An interview was conducted with Staff J on 11/30/21 at 3:03 PM who reported the patient was incontinent and wore depends which made it difficult to obtain the urine sample. The staff attempted to collect the sample, but was unable to. The staff member agreed the time frame from the order to the specimen collection was not an acceptable hospital practice.

This deficiency substantiates Substantial Allegation OH00127219.

Based on medical record review, review of behavioral health patient rights, and staff interview, the facility failed to ensure the inpatient medical record was accurately written for one of ten medical records reviewed (Patient #1). The active census on the behavioral health units was 37.

Findings include:

Review of the Behavioral Health Inpatient: Statement of Patient Right's Rights and Hospital Responsibilities, Number OH.POL.P.110.004 effective 06/21/19, revealed patients will be asked to sign the notification of patient rights form which acknowledges that he/she was informed of and has received a copy of his/her rights. If the patient was admitted involuntarily, they will be asked to sign the notification of involuntarily patient rights.

Review of the medical record for Patient #1 revealed a voluntary admission signed and dated on 10/12/21. Review of the psychiatrist documentation dated 10/13/21 at 11:23 AM revealed the patient was admitted on a "pink slip" and signed in voluntarily. Further review of the record revealed no evidence of an Application For Emergency Admission. The medical record documentation was conflicting as to whether the patient was admitted voluntarily and/or involuntarily.

An interview was conducted with Staff A on 12/01/21 at 4:07 PM who reported the patient was a voluntary admission and he/she was unclear as to why the patient was documented as being pink slipped.