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HAVEN BEHAVIORAL HOSPITAL OF PHOENIX 1201 SOUTH 7TH AVENUE, SUITE 200 PHOENIX, AZ 85007 March 29, 2013
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of hospital policies/procedures, medical record and interview, it was determined that the hospital failed to require that the patient or her representative make informed decisions regarding her care for 1 of 1 patient (Pt # 3) who received psychotropic medication without documented consent of the patient or her representative as required by hospital policy.

Findings include:

Review of hospital policy titled Consent, Psychotropic Medication revealed: "...It shall be the attending/covering practitioner's responsibility to obtain informed consent from the patient and/or legal representative when a psychotropic medication is included in the treatment regimen...Practitioners may document informed medication consent on the Order Form, Progress Notes or Medication Consent Form...The nurse will verify evidence of informed medication consent prior to giving the patient a newly prescribed psychotropic medication...."

Review of Pt #3's medical record revealed:

The medical record contained a form titled Informed Consent for Psychotropic Medication. Physician # 2 signed the form and documented consent obtained from the patient's daughter (HCPOA) for three psychotropic medications: Seroquel, Remeron and Ativan.

Review of the Medication Administration Record revealed:

An RN administered Geodon intramuscularly (IM) to the patient 8/9/12 at 1015, for patient refusal of oral medication without the documented consent of the patient or patient's representative and administered Geodon (IM) for patient agitation on 8/15/12 at 1035, without documented consent of the patient or patient's representative.

An RN administered Risperdal orally for agitation/psychosis 8/14/12 through 9/4/12 without documented consent of the patient or patient's representative.

An RN administered Depakote orally, used for behavioral disturbance on 8/27/13, and 8/29/12 through 9/4/12 without documented consent of the patient or patient's representative.

Physician #2 confirmed during an interview conducted on 3/28/13, that he only documents medication consent on the Informed Consent for Psychotropic Medication form and that he had not updated the consents for pt #3.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, medical record and interview, it was determined that the hospital failed to comply with a patient's advance directive and hospital policy when the patient was admitted and treated via consent of her Health Care Power of Attorney without documentation that the patient lacked decisional capacity.

Findings include:

Review of hospital policy/procedure titled Advanced Directives revealed: "...Policy:...The Hospital respects the right of patients to actively participate in health care decisions including the right to accept or reject medical treatment...Pursuant to Arizona law, patients may execute a...durable power of attorney, which will take effect, at such time as patients are unable to make healthcare decisions themselves...Definitions...Durable Power of Attorney for Health Care...An advance directive in which an individual names someone else...to make health care decisions in the event the individual becomes unable to make them himself/herself...This instrument is only valid when the patient is incapacitated...the patient may revoke an advance directive at any time and in any manner regardless of the patient's mental state or competency...."

Review of hospital policy titled Consent for admission-MHPOA (Mental Health Power of Attorney) or Guardian revealed: "...The attending physician will document in the patient's medical record if he/she has assessed the patient to not have decisional capacity, and decisions for treatment will be coordinated with the MHPOA...."

Review of Pt # 3's medical record revealed:

The patient was admitted to the facility on [DATE]. The medical record contained a document titled Health Care Power of Attorney and Living Will which contained documentation that Pt #3 had designated two individuals as co-agents to make health care decisions, including to consent to inpatient psychiatric or mental health treatment and administration of psychotropic medications. The agents specified were directed to make health care decisions when the patient was unable to make or communicate her own health care decisions. Her inability to make decisions was to be determined and documented by her attending physician, in consultation with other physicians if necessary. In assessing the patient's capacity to make health care decisions, the physician was to attempt to discuss with the patient the specifics of any proposed course of treatment.

A physician documented Psychiatric Evaluation on 8/1/2012: "...Chief complaint: 'My daughter wants me to be here'...At the present...the patient denies any suicidal thoughts, no feelings of hopelessness, worthlessness, or guilt. Good sleep. Good appetite. No problems with memory, concentration or attention. Energy at baseline. No anxiety...Objectively, the patient has active paranoid and disorganized delusions during interview...The patient is an unreliable and poor historian...."

The physician documented a Discharge Summary: "...Date of Discharge: 09/04/2012...Mental Status Exam on Admission: The patient is cooperative; however, somewhat agitated and irritable. She maintains good eye contact. There is some mild psychomotor agitation. Her mood is dysphoric and her affect is restricted. Thought process indicates no evidence of hallucinations; however, the patient has disorganized delusions and some paranoid delusions. Her abstract thinking is within normal limits. The patient is alert and oriented times three. Memory, concentration, and attention are mildly impaired. Judgment and insight are poor...."

One of the agents named in the patient's Health Care Power of Attorney (HCPOA) gave both telephone and written consent for the patient's admission.

A Social Worker documented on 8/10/12 at 1400: "...dtr (daughter) is pt's MHPOA (Mental Health Power of Attorney), but she is concerned that the pt will attempt to revoke this. She spoke to the attorney who drafted the...he stated that a psychiatrist could write a letter stating pt unable to make decisions...."

Pt # 3's medical record did not contain documentation by the attending physician/psychiatrist that the patient lacked decision making capacity.

The attending physician documented telephone HCPOA consent for the patient to receive three psychotropic medications. The patient received three additional psychotropic medications without documented informed consent. One of those medications was administered intramuscularly when the patient refused oral medication.

Physician # 2 confirmed during interview conducted on 3/28/13, that he had not documented in the patient's medical record that she did not have decision making capacity. He also confirmed that he did not update the consent for medications.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to ensure patients' right to privacy for 1 of 1 patient who required Line of Sight observation (Pt #7).

Findings include:

Review of hospital policy/procedure titled Patient Rights revealed: "...EACH PATIENT HAS THE RIGHT TO:...privacy in treatment...."

Review of Pt #7's medical record revealed:

An RN documented on 3/27/13 at 2130: "...Pt states she hears voices that tell her to 'kill herself (with) a knife'...Pt is on nursing line of sight (with) bed in hallway. continue to monitor pt...."

Employees #7 and 9 confirmed during interviews conducted on 3/28/13, and employees # 8 and 12 confirmed during interviews conducted on 3/29/13, that patients are placed in their beds in the hallway in front of the nurses' station during the late evening shift and during the night shift in order to maintain the patients on Line of Sight and provide for their safety. The patients sleep in front of the nurses' station. Employee # 12 also confirmed that s/he has observed a patient placed on a mattress in front of the nurses' station.