The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on a review of facility documents, medical record (MR), and staff interviews (EMP), it was determined that J.C. Blair Memorial Hospital failed to ensure that consultations/second opinion were conducted to ensure effective use of the time of the patient and to avoid the personal discomfort for one of one medical records reviewed. (MR1)

Findings include:

J.C. Blair Memorial Hospital Medical Staff Bylaws, approved January 5, 2017, ... 15.7 Medical Staff Consultations 15.7.1 The role of a practitioner responding to the request for consultation is defined by the attending practioner's written order. 15.7.2 Consult with orders and management, unless the practioner specifies differently 15.7.3 Purpose for consult A patient's condition or anticipated needs are beyond the practitioner's current scope of practice or delineated privileges A second opinion is warranted, required by established policy or is requested by patient/family 15.7.4 Consultant's Responsibilities Conduct consultations in a timely manner Document consultation reports within 36 hours of request Notify ordering practitioner as soon as possible if unable to respond to a consult in a timely manner, or if the requested consult is beyond ability or delineated privilege. ... ."

Title:Administration of Psychotropic Medication to Protesting Patients ... Policy# L-67 ... May 2017. "Policy: The following procedures will be followed whenever a patient is voluntarily admitted under Section 201 or is committed for involuntary treatment under Sections 302, 303, 304 or 305 of the Mental Health Procedures Act and protests the administration of antipsychotic or other psychotropic medications. ... Involuntary Patients: B. During an emergency of any involuntarily committed patient under Sections 302, 303, 304, and 304C of the Act, the treating psychiatrist may order the necessary treatment to protect the health and safety of the individual and others. C. In a non-emergency situation, the treating physician should determine and document whether the medication is necessary in light of the patient's objection and whether there are reasonable alternatives. (If the individual had a valid effective Mental Health Advanced Directive that indicates an objection to the use of medication, the Advanced Directive is to be treated as a contemporaneous objection to the medication). The physician should then do the following: 1. Discuss with the patient the reasons why a specific medication is indicated and any available alternatives. The physician should seek informed consent and document the reasons for the protest and whether or not consent is obtained. 2. If the patient continues to refuse medication, the treating physician shall obtain a second option from a psychiatrist concerning the degree of medical necessity/advisability for the medication. The psychiatrist providing the second opinion may be a colleague of the treatment psychiatrist. However, the second opinion should be based on an independent examination of the patient and an independent review of all medical records or tests. 3. If the consulting psychiatrist concurs that the protested medication is necessary, the medication may be administered. Appropriate respect shall be shown for the patient's feelings and dignity. If the second opinion does not agree with the necessity of the proposed medication, a third psychiatric opinion should be obtained before proceeding. Psychiatrists consulted for a second opinion should consider the risk/benefit value of the medication if administered over protest, the reason (s) for the protest, and alternative treatment approaches available. 4. If protests persist after medication has been tried, an additional second opinion based upon independent review should be obtained every 30 days as to the continuing need for the medication. 5. Treatment Team planning and reviewing sessions should afford the patient and those helping the patient with opportunities to discuss concerns about or protests to any aspect of the proposed treatment. Objection over medication should be documented in the individual treatment plan. ... ."

1. "BHU Progress Note Date: 07/21/2017 ... Subjective: ... the patient has been making some progress, but still very psychotic, delusional, paranoid, threatening. We will be working on getting a second opinion for forced medications because patient does not want to take any medication and is not compliant with medication ... ."

2. "BHU Progress Note Date: 07/26/2017 ... The patient has not been taking medications. We need someone who will do a second opinion on patient. ... We are working on to get [patient]302 and get forced medications after second opinion. ... ."

3. "BHU Progress Note Date: 07/27/2017 ... We need a second opinion to force medications but we don't have a physician here to help us. ... We did try to change medication but [patient] didn't want to take it so we are not changing until we get somebody to do a second opinion for forced medication. ... ."

4. "BHU Progress Note Date: 07/29/2017 ... Patient is not taking antipsychotic, and is not taking Abilify and very oppositional, defiant, angry, irritable, threatening, and writing notes to high officials of County. ... ."

5. "BHU Progress Note Date: 08/02/2017 ... patient says [patient] is only taking meds that [patient] wants to; [patient] is noncompliant with medications ... ."

6. "BHU Progress Note Date: 08/03/2017 ... patient is not taking medication at this time. We are trying to get a second opinion and once we get a second opinion then we will force medications. ... ."

7. "BHU Progress Note Date: 08/05/2017 ... Patient is refusing medication; we are trying to find somebody to do a second opinion so that we can force medication."

8. "BHU Progress Note Date: 08/08/2017 ... Medication Changes, Rational, Side Effects: None, because patient is not taking medications and has been refusing, we need a second opinion. ... ."

9. "BHU Progress Note Date: 08/09/2017 ... The patient has been worsening, has not been taking medications, and we are waiting Dr. ... to do a second opinion for forced medications. ... ."

10."BHU Progress Note Date: 08/10/2017 ... Patient is not taking medications. We are waiting for Dr. ... to do second opinion on the weekend, and then we will force medications. ... ."

11. Facility electronic documentation provided by EMP1, dated December 22, 2017, revealed, "I asked our Chief of Staff about the second opinion being considered as a Consult they responded "yes" that a second opinion is considered a Consult."

Interview with EMP3 on November 15, 2017, at approximately 10:30 AM revealed, " ...
We only have one psychiatrist on staff so we had to wait until they were doing coverage to get the 2nd opinion. We don't set a timeframe to obtain the 2nd opinion to force medications. I couldn't request another psychiatrist to do the evaluation for forced meds because they wouldn't be credentialed here."