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.

COTTONWOOD SPRINGS LLC 13351 S ARAPAHO DRIVE OLATHE, KS 66062 Oct. 3, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on interview, document review and policy review the psychiatric hospital failed to ensure patients received notice of all patient rights for seven of seven patients reviewed (Patient 1, 2, 3, 4, 5, 6, and 7). The hospital's failure to ensure all patient rights are provided has the potential for patients to be unclear concerning their rights about being treated with dignity and respect, receiving appropriate treatments/medications, receiving care in a safe setting free from abuse, neglect and exploitation, and achieving positive health care outcomes and continuity of care.

Findings Include:

Document review of the hospital's booklet titled, "Patient Handbook Inpatient Services," dated 2017, showed ...any person who become either voluntarily or involuntarily involved with the mental health treatment system in Kansas had certain legal rights. The sources of those rights may be state or federal laws or regulations, decisions by state or federal courts, or accreditation requirements...federal law, regulations or court cases establish other rights, such as the right to refuse treatment. This booklet is a discussion of Kansas law only. The handbook failed to include all of the federal hospital patient rights.

During an interview on 10/02/19 at 10:24 AM, Patient 5, was sitting all alone is a chair in the television area, and he stated that he is not sure why he is at the psychiatric hospital and he verbalized he did not receive his patient rights upon admission, but he knows he has patient rights.

During an interview on 10/02/19 at 10:44 AM, Patient 7 sat at a small table and chairs for the following conversation, and he stated that he has been at the facility four days and he did not remember going over any patient rights upon admission or since he has been at the facility.

During an interview on 09/30/19 at 3:28 PM, Staff B, Risk and Quality Director verified the patient handbook failed to include the federal regulations for patient rights, they only have the Kansas regulations listed for patient rights.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, interview, document review and policy review the hospital failed to ensure their policy was followed to include informing each patient whom to contact to file a complaint with the state for seven of seven patients reviewed (Patient 1, 2, 3, 4, 5, 6, and 7). The hospital's failure to ensure they inform each patient whom to contact to file a complaint with the state has the potential for patients to fail to receive a prompt and reasonable response to their complaint or grievance.

Findings Include:

Document review of the hospital's booklet titled, "Patient Handbook Inpatient Services," dated 2017, failed to include the State of Kansas Department of Health and Environment (KDHE) complaint address and hot-line phone number.

Document review of the hospital's policy titled, "Patient Bill of Rights," dated 08/2019, failed to include the KDHE complaint address and hot-line number.

Document review of the hospital's policy titled, "Restriction of Patient Rights," dated 08/2019, failed to include the KDHE complaint address and hot-line number.

During an interview on 09/30/19 at 3:28 PM, Staff B, Risk and Quality Director verified the patient handbook and policy for patient bill of rights failed to include the KDHE address and hot-line number for filing a complaint. Staff B stated that the information to file a complaint with KDHE is posted on the refrigerators in each unit activity room.

Observation on 10/02/19 at 2:01 PM showed the Sunrise, Cedar and Meadows units failed to have the KDHE hot line number posted in the activity rooms anywhere.

During an interview on 10/03/19 at 1:53 PM, Staff B, Risk and Quality Director stated that she was not aware the KDHE address and hot-line number for complaints were not posted on the refrigerators in each activity room for all three units.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, document review, and policy review the psychiatric hospital failed to meet all patient rights requirements as evidenced by placing telephone restrictions on one of seven patients reviewed (Patient 2) without renewing the order for restriction every 24 hours. Failure of the psychiatric hospital's staff to ensure telephone restrictions did not impede patient rights has the potential for the patient to fail to have support from family, friends, and organizations concerning their physical, spiritual and emotional needs.

Findings Include:

Review of the hospital's policy titled, "Restriction of Patient Rights," dated 08/2019, showed..."a patient's rights will only be restricted or limited by the attending physician, and only to the extent that the restriction is necessary to maintain the patient's physical and/or emotional well-being or to protect another person...any restriction of the patient's rights as set forth by the Patient Bill of rights must be pursuant to a physician's order and clinically justified for reasons of physical and/or emotional well-being, safety, or security...any restriction of the patient's rights shall be incorporated into the patient's treatment plan...the physician shall provide patient a clear explanation of the clinical rational of any restriction of rights ...the physician shall document by physician's order and in progress notes of the patient's medical record; the reason for the restriction, the explanation to the patient, and the duration of the restriction ...any order for restriction must be reviewed at least every 24 hours. If not renewed at that time; the physician's order for the restriction will expire automatically. If renewed, it may not be renewed for intervals for more than 24 hours."

Review of Patient 2's discharged medical record showed the patient was admitted on [DATE] with a diagnosis of psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality).

Patient 2's medical record showed Staff FF, Physician placed an order on 07/20/19 at 10:33 AM that placed telephone restrictions to three calls/shift starting at 11:00 AM on 07/20/19. The order did not include a stop time.

Patient 2's "Close Observation Sheets", showed her phone calls were documented from admission to discharge. Documentation showed calls were kept to three per shift during her hospitalization starting 11/20/19 except for one night shift on 07/22/19 when she made four phone calls. Documentation showed Patient 2 remained on phone restriction from 07/20/19 through her discharge on 07/29/19.

Patient 2's medical record lacked any further physician orders written from 07/21/19 through discharge on 07/29/19 to continue the phone restrictions. Therefore, the phone restriction should have expired on [DATE] at 11:00 AM.

During an interview on 10/01/19 at 7:34 AM, Staff B, Risk and Quality Director stated that the hospital does not have a policy or protocol related to patient phone use, but a protocol to obtain a physician's order is available and there is a policy for restriction of patient rights.

During a further interview on 10/02/19 at 2:21 PM, Staff B, Risk and Quality Director discussed the restriction of patient rights policy and she verified the physician must write an order every 24 hours or it will be considered expired and she will have it clarified in the policy. Staff reviewed the medical record and verified it did not show the phone restriction orders were renewed after 07/20/19 for another 24 hours and that the staff continued to keep the restriction for phone calls for the patient.



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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on policy review, the psychiatric hospital failed to publicize all patient rights in documentation provided to patients at admission including physician reevaluation at regularly scheduled times during the use of restraints or seclusion. Failure of the psychiatric hospital to include in the patient rights documents that restraints and/or seclusion are to be provided with regularly scheduled physician assessments places all patients at risk of inappropriate and untimely care provided by the staff.

Findings Include:

Document review of the psychiatric hospital patient handbook provided to all in-patients at admission, includes the document "Basic Rights for All Patients" and includes the statement, "This booklet is a discussion of Kansas law only." The document further stated, "The use of restraints or seclusion should not exceed three hours without medical reevaluation, except that between midnight and 8:00 AM, reevaluation is not mandatory." The handbook failed to include the federal requirement which is more restrictive than the Kansas State Regulation.


During an interview on 09/30/19 at 3:28 PM, Staff B, Risk and Quality Director verified the patient handbook failed to include the federal regulations for patient rights, they only have the Kansas State Regulations listed for patient rights.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the psychiatric hospital failed to ensure on-going reassessment and documentation of patient discharge plans for one of seven patients reviewed (Patient 2). Failure of the psychiatric hospital to ensure on-going reassessment and documentation of discharge plans has the potential to place patients at risk for failure to receive safe, effective, and appropriate care when transitioning from one care setting to another.


Findings Include:


Document review of the hospital's policy titled, "Discharge and Transition Planning," dated 03/2019, showed ...'the facility engages in ongoing transition planning at the start of services throughout the course of treatment and at the time of discharge...using the discharge planning form...the treating therapist will be responsible for competing the form in its entirety...it is very important that all steps of discharge are documented...the chart minimally includes...weekly discharge discussions...discharge discussion within 24 hours of discharge...information on family sessions...information on living arrangements...the referrals and recommendations are in place to ensure continued growth, development and success throughout the patient's road to recovery...staff will obtain a release of information for the referral, pending the patient's consent to release information ...once release is obtained, staff will share appropriate documents with the next care/referring provider to ensure continuity of care ...notify referral source (if authorized to release information)."


Review of Patient 2's discharged medical record showed the patient was admitted on [DATE] and discharged on [DATE]. The documentation in the medical record lacked evidence of any ongoing discharge planning conversations with the patient or her husband, family sessions, weekly discharge discussions, a discharge discussion within 24 hours of discharge and information on living conditions by the therapist. A release of information (ROI) form was signed and dated by Patient 2 at the time of discharge for three locations, and the forms were not faxed to those locations until 08/02/19 (3 days later).


During an interview on 10/01/19 at 3:35 PM, Staff M, Licensed Professional Counselor (LPC), stated that they tried to work with Patient 2, but it was difficult because of her acuity and that they had difficulty getting Patient 2 to talk about discharge plans as she was not mentally able or willing to talk to them. Staff M stated that they can do family sessions over the phone and face time, but because the husband would "ramp up" Patient 2's emotions, he was out of state and Patient 2 did not request it, we did not do them. Staff M stated that Patient 2's husband was being very intrusive, trying to make decision for her and wanted to put her in a nursing home and Patient 2 didn't want to go. Staff M stated that throughout the discharge process they look at completing the release of information (ROI) form and that she remembers faxing the ROI's right after she received a voice mail from Patient 2's husband on 08/02/19.
Staff M reviewed the policy for discharge and transition planning and she verified some of the items that were to be completed were not addressed due to the patient being so difficult and it just did not get completed.


During an interview on 10/02/19 at 9:36 AM, Staff S, LPC, stated that she remembers upon discharge she called Patient 2's husband, reviewed the discharge plan and the husband asked her to have Patient 2 sign a ROI forms for different nursing facilities. Staff S stated that she is not sure if she sent the ROIs or not and that she does not remember if the patient told her where she wanted to go when she filled them out. She stated the ROI's were a request from her husband and not from Patient 2. She stated that it was not clear whether Patient 2 wanted to go to the facilities or not. Patient 2 was confused about the long-term plan for discharge and she was okay with going back to her home.


During an interview on 10/02/19 at 12:08 PM, Staff D, Clinical Director, Psychologist stated that she is responsible to supervise the inpatient therapist and she has a mixture of social workers and LPC's. Staff D shared the therapist should have followed up with the husband and the patient concerning the discharge plans. Staff D explained her expectation would be that if the therapist made a call to the husband she should have documented the call and talked with the supervisor to pass on the information concerning transition of care upon discharge. Staff D was told that the therapist did not document any of conversations with the husband. Staff D stated that at that time they were not auditing the records consistently. Staff D verified the therapist notes failed to show ongoing discussions with the husband, patient, and treatment team concerning discharge preferences and plans.


During a phone interview on 10/03/19 at 7: 52 AM, Staff R, Physician stated that she remembered the patient wanted to go home and there were issues concerning verbal abuse, not physical abuse. Staff R stated that the husband was very demanding and that he wanted the patient placed by where he worked so they could move into the place together. Staff R stated the therapist should have all this documented. It was shared with Staff R that the therapist did not have any of this documented and she responded by stating that we forget to document the details sometimes.