HospitalInspections.org

Based on interview, and review of 10 open and one closed patient record, is revealed that 3 of 4, open records for patients #1, #7, and #11 eligible patients did not receive an Important Message notification.

Interview with the Patient Access Director on 11/13/14 at approximately 3:30 pm reveals in part that the Important Message (IM) is supposed to be given when patients are admitted through the emergency department or via direct admit to the unit. The Director revealed that Patient Access staff works with nursing on the behavioral health unit when needed to provide these notifications. Further, the Director indicated that if a patient is unable due to their illness to understand the information of the Important Message, a patient representative would be contacted.
Patient #1 is an above-65-year-old female admitted involuntarily to the behavioral health unit in late July 2014. No IM is noted in her record.
Patient #7 is a disabled middle-aged Medicare recipient who was admitted to the behavioral health unit in August 2014. No IM is found in the record.
Patient #11 is an above-65-year-old female who admitted to the behavioral health unit on 11/5/2014. No IM is noted in her record at the time of survey, eight days later.

Based on a review of 10 open and 1 closed patient record and the hospital Universal Consent (UC), it is revealed that the UC form has a check-box stating "Lacks decision-making capacity" which was checked by the Access Clerk for patients #1 and #9, and which was not based on any physician clinical evaluation of capacity.

Interview with the Director of Patient Access on 11/13/14 at approximately 3:30 pm reveals that the check-box for "Lacks decision-making capacity" is not intended to reflect actual patient incapacity, but is used to indicated when a patient is perceived by access staff as being unable to understand the UC.

Patient #1 is an elder female admitted involuntarily to the behavioral health unit in late July 2014. On admission, a UC reveals the statement, "Unable to sign pt is confuse (sic) " Additionally, is a check-box with a check inside which states "Lacks decision-making capacity." On further review of the record, no substantiating physician capacity statements are found.

Patient #9 was admitted on 11/4/2014 and, on admission, did not sign the UC. A typed message on the UC timed "7:08 PM" states "Pt unable to sign AMS (altered mental status) No family pres (present)." However an "x" was placed in the box labeled "Lacks decision-making capacity." No substantiating capacity statements are found in the record.

Information as to how long this form has been in use was not available. However, based on review of the form, the UC asks the Access Clerk to make a clinical judgment regarding a patient's mental status and capacity for decision making which has no clinical basis and is beyond the scope of the clerk to make