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.

REGIONAL MENTAL HEALTH CENTER 8555 TAFT ST MERRILLVILLE, IN March 18, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review and staff interview, the facility failed to inform each patient, or patient's representative of the patient's rights in advance of furnishing patient care for 1 of 1 (Adult Inpatient Unit [AIU]) area.

Findings:

1. Review of the Plan for Professional Services and Staff Composition on 3/18/15 at approximately 1040 hours, indicated on pg. 14, under Inpatient Program Admission Criteria section, point 2., "The client is willing to voluntarily consent to treatment or is eligible for admission on an involuntary basis."

2. Staff #5 (R.N., Charge Nurse for AIU) was interviewed on 3/18/15 at approximately 1355 hours and confirmed patients are sometimes brought up to the AIU by staff from the RAU (Residential Addictions Unit) downstairs to get a shot or TB (tuberculosis) test. Medical records for the patients being brought up to the AIU from the RAU who received medical treatment and/or medications do not have a medical record maintained on the AIU.

3. Staff #6 (R.N., Staff Nurse for AIU) was interviewed on 3/18/15 at approximately 1415 hours and confirmed sometimes the patients are brought up to the AIU, especially if they get a Phenergan shot.

4. Due to the lack of medical records, patient's rights were not furnished in advance of rendering patient care and consent to treatment was not documented.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review and staff interview the facility failed to ensure informed consent for patients in advance of furnishing patient care for 1 of 1 (Adult Inpatient Unit [AIU]) area toured.

Findings:

1. Review of the Plan for Professional Services and Staff Composition on 3/18/15 at approximately 1040 hours, indicated on pg. 14, under Inpatient Program Admission Criteria section, point 2., "The client is willing to voluntarily consent to treatment or is eligible for admission on an involuntary basis."

2. Staff #5 (R.N., Charge Nurse for AIU) was interviewed on 3/18/15 at approximately 1355 hours and confirmed patients are sometimes brought up to the AIU by staff from the RAU (Residential Addictions Unit) downstairs to get a shot or TB (tuberculosis) test. Medical records for the patients being brought up to the AIU from the RAU who received medical treatment and/or medications do not have a medical record maintained on the AIU.

3. Staff #6 (R.N., Staff Nurse for AIU) was interviewed on 3/18/15 at approximately 1415 hours and confirmed sometimes the patients are brought up to the AIU, especially if they get a Phenergan shot.

4. Due to the lack of medical records, informed consent to treatment was not documented and patient's rights were not furnished in advance of rendering patient care.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on policy and procedure review, document review, and staff interview the facility failed to provide adequate numbers of personnel to ensure the availability of a registered nurse for bedside care of any patient on 1 of 1 (Adult Inpatient Unit) area toured.

Findings:

1. Policy titled, "Clinical Staffing Plan Inpatient Unit - Procedure" revised/reapproved 10/28/10 was reviewed on 3/18/15 at approximately 1055 hours and confirmed staffing for the AIU is 3 MHTs (Mental Health Technicians) on the Day and Evening shifts, unless patient census is 9 and below.

2. Nursing staffing pattern, acuity, and census for the AIU for 2/1/15 through 2/28/15, was reviewed on 3/18/15 at 1130 hours and facility did not meet its guidelines. On 2-4-15, 2-6-15, 2-10-15, 2-19-15, 2-20-15, and 2-23-15 there were only 2 MHTs working on the AIU on the day shift (1st), except for 2-10-15 which was on the evening shift (2nd); patient census for these days was 10, 10, 10, 15, 11, and 10, respectively. There should have been 3 MHTs on the day and evening shifts as required by facility policy and procedure.

3. Staff #4 (R.N., Nursing Supervisor for AIU) and staff #3 (Director of Acute Intensive Services & Substance Abuse Units, including Residential Addictions Unit [RAU]) were interviewed simultaneously and confirmed:
A. the AIU is staffed on the 1st and 2nd shifts with 1 Charge RN and 1 Staff RN, with 3 Mental Health Techs (MHTs) on each shift. The 3rd shift is staffed by 1 RN and 2 MHTs.
B. on 2-4-15, 2-6-15, 2-10-15, 2-19-15, 2-20-15, and 2-23-15 there were only 2 MHTs working on the AIU on the day shift (1st), except for 2-10-15 which was on the evening shift (2nd); patient census for these days was 10, 10, 10, 15, 11, and 10, respectively. There should have been 3 MHTs on the day and evening shifts as required by facility policy and procedure.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on policy and procedure review and staff interview the facility failed to maintain a medical record for each patient on 1 of 1 (Adult Inpatient Unit [AIU]) area toured.

Findings:

1. Policy titled, "Inpatient Medication Administration -Procedure" revised/reapproved 5/10/11 was reviewed on 3/18/15 at approximately 1100 hours and confirmed on pg. 3, point 12, "Medications are to be charted at the time the medication is administered."

2. Staff #5 (R.N., Charge Nurse for AIU) was interviewed on 3/18/15 at approximately 1355 hours and confirmed patients are sometimes brought up to the AIU by staff from the RAU (Residential Addictions Unit) downstairs to get a shot or TB (tuberculosis) test. Medical records for the patients being brought up to the AIU from the RAU who received medical treatment and/or medications do not have a medical record maintained on the AIU.

3. Staff #6 (R.N., Staff Nurse for AIU) was interviewed on 3/18/15 at approximately 1415 hours and confirmed sometimes the patients are brought up to the AIU, especially if they get a Phenergan shot.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on document review and staff interview the facility failed to ensure properly executed informed consent forms for procedures and treatments in advance of furnishing patient care for 1 of 1 (Adult Inpatient Unit [AIU]) area toured.

Findings:

1. Review of the Plan for Professional Services and Staff Composition on 3/18/15 at approximately 1040 hours, indicated on pg. 14, under Inpatient Program Admission Criteria section, point 2., "The client is willing to voluntarily consent to treatment or is eligible for admission on an involuntary basis."

2. Staff #5 (R.N., Charge Nurse for AIU) was interviewed on 3/18/15 at approximately 1355 hours and confirmed patients are sometimes brought up to the AIU by staff from the RAU (Residential Addictions Unit) downstairs to get a shot or TB (tuberculosis) test. Medical records for the patients being brought up to the AIU from the RAU who received medical treatment and/or medications do not have a medical record maintained on the AIU.

3. Staff #6 (R.N., Staff Nurse for AIU) was interviewed on 3/18/15 at approximately 1415 hours and confirmed sometimes the patients are brought up to the AIU, especially if they get a Phenergan shot.

4. Due to the lack of medical records, patient's consent to treatment was not documented in advance of rendering patient care.