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BEHAVIORAL HOSPITAL OF BELLAIRE 5314 DASHWOOD, SUITE 200 HOUSTON, TX Aug. 29, 2018
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documentation, observation and staff interview, the hospital failed to ensure each patient had the right to make informed decisions regarding his or her own care, as:

1) Each voluntarily admitted individual who informed a staff person of his or her desire to leave, was not either discharged from the facility or a physician pursued court-ordered mental health services according to facility policy, for 3 of 10 patients [#2, 7-8]. This deficient practice potentially resulted in voluntarily admitted patients being detained at the facility against their wishes.

2) Patients were not provided information on specific psychoactive medication prescribed and administered to them for 10 of 10 patients [Patients #1-10]. They were only provided information about the medications according to medication class. This resulted in patients receiving non-specific information regarding medication side effects and possible benefits. Thus, they were not supplied the information which would enable them to provide true informed consent.

Findings were:

1) Facility policy entitled "Request For AMA Discharge," last reviewed 1/15/16, included the following:
"Procedure: ...
2. The patient or guardian will be informed that the request should be in writing signed timed [sic] and dated by the patient or guardian, if necessary and as soon as possible, assist the patient/guardian in creating a written request for discharge and present it to the patient for the patient's/guardian's signature (Request for Release from Voluntary Admission.) Patient or guardian will be advised that physician may (1) agree to discharge patient, (2) discharge patient AMA, (3) hold patient for 24 hours to evaluate for court commitment or (4) begin court commitment process ...
8. The attending physician or the physician designee will be notified immediately by the Unit RN. Within four hours the attending physician or designee will make a decision on the patient or guardian's request for discharge and advise the hospital of that decision. If the physician who is notified does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician shall discharge the patient. The discharge maybe [sic] against medical advice at the physician's discretion.
9. If the physician notified has reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention. [sic] The physician shall order that the patient remain in the hospital so that the patient may be examined as soon as possible within 24 hours after the request for discharge is made known to the hospital and physician.
10. If the physician conducting the examination determines that the patient does not meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician shall discharge the patient upon the completion of the examination. The discharge may be against medical advice at the physician's discretion.
11. If the physician conducting the examination determines that the patient meets the criteria for court-ordered inpatient mental health services or emergency detention and [sic] application for court-ordered inpatient mental health services or emergency detention will be filed by 4:00 p.m. on the next business day ..."

Facility policy entitled "Patient Rights," last reviewed 3/27/15, included the following:
"Policy:
It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form ..."

Basic Rights for All Patients include:
"Voluntary Patients - Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave, the staff person must write it down for you.
2. You have the right to be discharged from the hospital within four hours of requesting discharge. There are only three reasons why you would not be allowed to go:
" First, if you change your mind and want to stay at the hospital, you can sign a paper that says you do not wish to leave, or you can tell a staff member that you don't want to leave, and the staff member has to write it down for you ...
" Second, if you are under [AGE] years old ...
" Third, you may be detained longer than four hours if your doctor has reason to believe that you might meet the criteria for court-ordered services or emergency detention because:
You are likely to cause serious harm to yourself;
You are likely to cause serious harm to others; or
Your condition will continue to deteriorate and you are unable to make an informed decision as to whether or not to stay for treatment.
If your doctor thinks you may meet the criteria for court-ordered services or emergency detention, he or she must examine you in person within 24 hours of your filing the discharge request. You must be allowed to leave the hospital upon completion of the in-person examination unless your doctor confirms that you meet the criteria for court-ordered services and files an application for court-ordered services ..."

Patient #2 was admitted voluntarily to Behavioral Hospital of Bellaire on 4/18/17 at approximately 12:30 p.m. She reported upon intake that she was the caretaker of her disabled mother. A review of her medical record revealed she did not wish to be admitted and had signed a request for discharge on 4/18/17 at 4:45 p.m. Patient #2 reported she had been threatened with a more intense level of care if she did not revoke the request for discharge. The request was revoked by her on 4/19/17 at an undocumented time.

Further review of the Patient #2's record included the following:

A physician note dictated on 4/20/17 at 12:48 p.m. included the following:
"CHIEF COMPLAINT: "I'm not having withdrawal symptoms. I'm feeling great." ...
On exam today, she gets very upset. She is tearful. She is labile. Says that we are holding her against her will. She wants to leave as she does not need to be in hospital. She did come voluntarily with friends while she was intoxicated ... We discussed the options of her doing another program and needing to be detoxed first. She wants to go to The Right Step, but stating she cannot spend the night there. At this point, she is quite labile and impulsive and very anxious and appears unstable. She is very tearful and is argumentative. She is minimizing her current situation ...Patient is very irrational and has unrealistic expectations and appears quite labile at this time. She denies cravings or wanting to use. She states she just wants to go home and spend the weekend with her mom ..."

A Psychosocial Assessment completed on 4/20/17 at 4:45 p.m. included the following:
" ...Clinical Impressions:
Pt is quite irritable about attending MD's decision to postpone her discharge. She is focused on leaving the hospital, returning to work on Monday 4/24/17 and attending SA IOP (substance abuse intensive outpatient program) at the PARC ([local hospital's] prevention and recovery center). Pt emphatically denied SI (suicidal ideation), indicating that what she reported was misconstrued ..." Upon admit, Patient #2 had stated she owned a gun when asked if she owned any weapons.

The medical record of Patient #2 included no documented evidence that the treating physician intended to petition for court-ordered mental health services for Patient #2.

A review of the medical record of Patient #7 revealed he was voluntarily admitted on [DATE]. He signed a Request for Release from Voluntary Admission on 8/11/18 at 10:40 a.m. It was revoked by the patient on 8/12/18 at 9:37 a.m. The record included no documented evidence that the patient was evaluated by a physician for possible discharge within four hours of the request. A nursing progress note on 8/11/18 at 1:05 p.m. read as follows:
" ... Patient requested for Release from voluntary admission form and signed it accordingly. Awaiting for MD's approval..."
The first physician progress note in the record was on 8/12/18 and included the following:
"Pt had signed 4 hr letter yesterday. Retracted this morning ..."

A review of the medical record of Patient #8 revealed he was voluntarily admitted to the facility on [DATE]. He completed and signed a Request from Voluntary Admission on 8/10/18 at 10:00 p.m. It was witnessed by a hospital RN. The request was never revoked by the patient. The record included no documented evidence of the physician pursuing court-ordered mental health services. Patient #8 was discharged from the facility on 8/20/18.

In an interview with Staff #5, treating physician of Patient #2, on the afternoon of 8/28/17 at 2:42 p.m. in the facility conference room she stated, "We wouldn't have just kept her. She had to have been telling me she wanted to be here ...If you're a physician and someone says they don't want to stay, but you need to motivate them to treatment, wouldn't you say anything to keep them in treatment?" When this surveyor stated there was little documentation in the chart to support that the patient was a danger to herself or others other than drinking alcohol, Staff #5 stated, "She was drunk at work. I think her principal brought her in ...She was a teacher ..."

In a subsequent interview with Staff #5 on the morning of 8/29/17 in the facility conference room, she clarified, "I never meant that I'd threaten a patient. I'd never do that ..." She agreed that several physician and nursing notes appeared to support that Patient #2 did not wish to be at the facility and that the patient had been admitted voluntarily. She also agreed that the record contained no documented evidence of the physician having felt the patient met the criteria for court-ordered mental health services.

2) Facility policy entitled "Patient Rights," last reviewed 3/27/15, included the following:
"Policy:
It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form ..."

Basic Rights for All Patients include:
" ...26. You have the right to be told about the care, procedures, and treatment you will be given, the risks side effects, and benefits of all medications and treatment you will receive ...the other treatments that are available, and what my happen if you refuse the treatment ..."

As examples of patients not receiving information regarding specific psychoactive medications they were prescribed and administered:
a) A review of the psychoactive medication consents for Patient #1 included consents only for classes of medications. For example, a consent for "Benzodiazepines" was signed by Patient #1 on 8/7/17 at 6:20 a.m. This consent was used by the facility for patients consenting to receive any of the following medications: Xanax, Dalmane, Ativan, Restoril, Librium, Halcion, Valium, Klonopin and "Other" where the name of another medication could be filled in.

Similarly, Patient #1 signed consents for "Anti-Depressants - SSNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)" for Effexor on 8/9/17 at 6:50 p.m. and "Mood Stabilizers" for Trileptal on 8/10/17 at 6:45 p.m.

A review of the medication administration record revealed Patient #1 was administered these medications.

b) Patient #2 signed psychoactive medication consents for classes of medication, and not for specific medications, on 4/19/17 at 2:15 p.m. These included: "Anti-Depressants - SSRI" for Prozac, "Sleep Medications" for Desyrel (trazodone), and "Benzodiazepines" for Librium.

c) Patient #9 was admitted on [DATE]. He signed consent to be treated with "Sleep Medications" with "Trazodone" circled on 8/10/18 at 9:00 p.m. He signed a consent to be administered "Mood Stabilizers" on 8/10/18 at 9:00 a.m. in order to be treated with Depakote. Likewise, at the same time, he signed a consent for "Antipsychotics" in order to be treated with "Seroquel."

The above findings were confirmed in an interview with the facility Director of Performance Improvement on the afternoon of 8/28/18 in the facility conference room, and in an additional interview with the facility Chief Executive Officer and other administrative staff on the afternoon of 8/29/18 in the facility conference room.