HospitalInspections.org

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A0117: Failure to ensure ensure a patient or patient's representative received a written copy of their patient rights.

Cross reference A0131: Failure to inform patients that there was not an MD/DO present at the hospital 24/7.

Cross reference A-0144: Failure to ensure a patient bedroom and bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

Cross reference A-0160: Failure to record and monitor as a restraint, the use of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition, and therefore did not follow proper procedures and protocols for a chemical restraint.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on record reviews and staff interviews, it was determined the hospital failed to ensure adequate numbers of qualified professional staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

Cross reference A-1695 - Availability of medical personnel - The facility failed to ensure medical personnel was available to provide medical treatment services.

The effect of this deficient practice resulted in the facility's potential inability to provide necessary medical care and treatment to patients.

Based on review of facility policy and procedure, medical records, and employee interview, the Department determined the administrator failed to ensure consent was completed for a patient in advance of furnishing or discontinuing patient care. This deficient practice poses the potential risk of patients receiving services they did not consent to.

Finding include:

Facility policy titled "Client (Patient) Rights and Responsibilities," Policy #15137047, last revised February 2024, revealed "...C. Client (or Patient) Rights and Responsibilities Form...1. At the time of enrollment, admission and discharge, all clients receive Polara Health's "Client (or Patient) Rights and Responsibilities" Form...A signed copy of this form is placed in (or scanned into) the client's/patient's clinical record...3. To acknowledge their review and understanding of the Client (or Patient) Rights and Responsibilities Form, clients/patients sign on a signature line which reads "I have read the above client rights and responsibilities. A copy of these rights has been made available to me. I understand my rights as stated above, they have been verbally explained to me...."

Facility medical record for Patient #11 revealed a voluntary admission to the hospital on August 2, 2024. A request was made for evidence of Patient #11's signed "Client (or Patient) Rights and Responsibilities" form, None was provided.

Employees #4 and #6 confirmed during joint interviews conducted from December 17, 2024 to December 23, 2024, that the medical record for Patient #11 contained a signed patient rights acknowledgment for "CRU" however the medical record did not contain evidence of a signed "Client (or Patient) Rights and Responsibilities" form, acknowledging review and understanding of patient rights for the hospital admission.

Based on review of hospital policy & procedure, medical records, and interview, it was determined that the hospital failed to ensure that the patient (pt) or his/her representative make informed decisions regarding the patient's care, including being able to request or refuse treatment as evidenced by:

1. Failure to require informed consent by the patient or his/her legal representative for hospital admission per hospital policy for 1 of 20 patients (Patient #11); and

2. Failure to require written informed consent for psychotropic medication per hospital policy for 5 of 20 patients (Patient #4, Patient #16, Patient #17, Patient #18, and Patient #20.); and

3. Failure to inform patients that there was not an MD/DO present at the hospital 24/7 for 20 of 20 patients.

The deficient practice poses a potential risk to patients that may compromise the quality and safety of patient care. This deficient practice poses the risk of patients making uninformed decisions about the risks and reasons for receiving treatment and for patients receiving psychotropic medications without understanding the risks, benefits, and effects the medications may have.

Findings include:

1. Facility policy, "General Care Guidelines and Provision of Services in Polara", revised 12/2024, requires, "...The policy of Polara Health Inpatient Facilities is to provide psychiatric inpatient services within the practice standards of psychiatric medicine, psychiatric nursing, social work standards of care, and applicable regulations, rules, statutes, and binding interpretive statements ..."

Facility policy, "Informed Consent", revised 04/2023, requires, "...Polara Health will inform clients and patients of necessary information pertaining to their treatment or change in treatment including changes in medications. A signed, voluntary consent for treatment form will be obtained and medication consents for all prescribed medications will be obtained ...C. Obtaining Informed Consent: 1. A member of the clinical team will explain the course and purpose of treatment to the client/patient and guardian as appropriate. 2. It shall be the opinion of this member of the clinical team whether the client/patient, and guardian as appropriate, can understand and are able to consent to treatment. The client/patient or guardian signs a "Conditions of Admission and Consent for Treatment" form; staff witness the signature: and clients/patients are provided a copy to take with them. 3. If it is determined that informed consent can be achieved, the clinical staff member shall obtain necessary consents and place them in the client's/patient's clinical record. a. A Clinic or Hospital staff member will read or give oral explanation in a language the client understands. b. The client/patient and guardian as appropriate shall be given an adequate opportunity to read the Clinic/Hospital consent to treatment form before signing. c. Clients/patients will receive verbal instructions of the following: i. The specific treatment being proposed; ii. The intended outcome, nature and procedures of the proposed treatment; iii. Any risks, side-effects and complications of the proposed treatment, including any risks of not proceeding with the
proposed treatment; iv. The alternatives to the proposed treatment, and; v. That informed consent is voluntary and may be withheld or withdrawn at any time..."

Facility policy, "Client (Patient) Rights and Responsibilities", revised 02/2024, requires, "...A. Client/Patient Rights 1. Client/patient rights shall include that a client/patient is free from abuse, neglect, manipulation or harassment from staff, other clients/patients, or visitors that result in physical harm, pain, or mental anguish, including: l. A pattern of failure to provide Clinic, Hospital, or Crisis Stabilization Unit services without the informed consent of the client/patient or the client's/patient's representative that results or may result in risk to the health and safety of the client/patient ..."

Facility policy, "Clinical Documentation", revised 12/2024, requires, "...G. Hospital Record Documentation 1. All records must document the following, as appropriate: f. Properly executed informed consent forms specified by the medical staff, or by Federal or State law ..."

Review of patient medical records revealed no documentation of informed consent by the patient or his/her legal representative for hospital admission for Patient #11.

Employee #4 and Employee #5 confirmed during an interview conducted on December 18, 2024, that Patient #11 does not have documentation of informed consent (a general consent to treat) documented in their medical record.

2. Facility policy, "Informed Consent", revised 04/2023, requires, "...Polara Health will inform clients and patients of necessary information pertaining to their treatment or change in treatment including changes in medications. A signed, voluntary consent for treatment form will be obtained and medication consents for all prescribed medications will be obtained ...D. Informed consent for medications..1. Polara Health will require that clients and patients are informed about prescribed medications by the medical staff. The medical staff member and client/patient date, sign and initial when education is given about a medication. This education will be documented using medication consent forms kept in the medical record. 2. The following items will be a part of the discussion: a. The specific problem, symptom or behavior; b. The name of the medication; c. The purpose of the medication; d. The effects and potential side effects including potential for addiction; e. The benefits and risks of taking, or not taking, the medication; f. The prescribed dosage, range, route and frequency ..."

Facility policy, "Client (Patient) Rights and Responsibilities", revised 02/2024, requires, "...A pattern of failure to provide Clinic, Hospital, or Crisis Stabilization Unit services without the informed consent of the client/patient or the client's/patient's representative that results or may result in risk to the health and safety of the client/patient ..."

Facility policy, "Clinical Documentation", revised 12/2024, requires, "...G. Hospital Record Documentation 1. All records must document the following, as appropriate: f. Properly executed informed consent forms specified by the medical staff, or by Federal or State law ..."

Review of patient medical records revealed no documentation of informed consent for psychotropic medication for Patient #4, Patient #16, Patient #17, Patient #18, and Patient #20.

A review of Patient #4 ' s medical record dated 05/10/2024 through 05/16/2024, revealed s/he received ATIVAN (LORAZEPAM) for "...Reason: Anxiety ...," CLOZARIL (CLOZAPINE) for "...Reason: Psychosis ...," KLONOPIN (CLONAZEPAM) for "...Reason: Anxiety ...," SEROQUEL (QUETIAPINE FUMARATE) for "...Reason: Insomnia ...," ZYPREXA (OLANZAPINE) for "...Reason: Psychosis ...," CLONIDINE HCL for "...Reason: Hypertension ...," DEPAKOTE (DIVALPROEX SODIUM) for "...Reason: Seizures ..." Patient #4's medical record did not contain an informed consent form for psychotropic medications. Patient #4 was a voluntary patient and the administration of these psychotropic medications was not an emergency.

A review of Patient #16 ' s medical record dated 04/02/2024 through 04/05/2024, revealed s/he received ATIVAN (LORAZEPAM) for "...Reason: ETOH/Drug Abuse ...," SEROQUEL (QUETIAPINE FUMARATE) for "...Reason: Insomnia ...," VALIUM (DIAZEPAM) for "...Reason: ETOH/Drug Abuse ...," VISTARIL (HYDROXYZINE PAMOATE) for "...Anxiety ...," LORAZEPAM for "...Withdrawal Symptoms ..." Patient #16's medical record did not contain an informed consent form for psychotropic medications. Patient #16 was a voluntary patient and the administration of these psychotropic medications was not an emergency.

A review of Patient #17 ' s medical record dated 10/01/2024 through 10/03/2024, revealed s/he received ABILIFY (ARIPIPRAZOLE) for " ...Reason: Mood ...," ATIVAN (LORAZEPAM) for "...Reason: Alcohol Dependency ...," VALIUM (DIAZEPAM) for " ...Reason: ETOH/Drug Abuse ...," VISTARIL (HYDROXYZINE PAMOATE) for " ...Reason: Anxiety ...," BACLOFEN for " ...Reason: Muscle Tension/Spasm ...," LORAZEPAM for " ...Reason: Withdrawal Symptoms ..." Patient #17's medical record did not contain an informed consent form for psychotropic medications. Patient #17 was a voluntary patient and the administration of these psychotropic medications was not an emergency.

A review of Patient #18 ' s medical record dated 03/30/2024 through 04/05/2024, revealed s/he received ABILIFY (ARIPIPRAZOLE) for " ...Reason: Mood ...," EFFEXOR XR (VENLAFAXINE HYDROCHLORIDE) for "...Reason: Depression/Mood ...," KLONOPIN (CLONAZEPAM) for " ...Reason: Anxiety ...," SEROQUEL (QUETIAPINE FUMARATE) for " ...Reason: Mood ...," VISTARIL (HYDROXYZINE PAMOATE) for " ...Reason: Insomnia ...," BENZTROPINE MESYLATE for " ...Reason: Tremors ...," GABAPENTIN for " ...Reason: Anxiety ..." Patient #18's medical record did not contain an informed consent form for psychotropic medications until 04/05/2024, after the psychotropic medications had been administered. Patient #18 was a voluntary patient and the administration of these psychotropic medications was not an emergency.

A review of Patient #20 ' s medical record dated 03/20/2024 through 04/12/2024, revealed s/he received HALOPERIDOL for " ...Reason: Psychosis ...," GABAPENTIN for " ...Reason: Anxiety ...," LITHIUM CARBONATE for " ...Reason: Mood ..." Patient #20's medical record did not contain an informed consent form for psychotropic medications until 03/23/2024, after the psychotropic medications had been administered. Patient #20 was a voluntary patient and the administration of these psychotropic medications was not an emergency.

Employee #4 and Employee #5 confirmed during an interview conducted on December 18, 2024, that Patient #4, Patient #16, and Patient #17 had been administered psychotropic medications with no documentation of informed consent in their medical record. Employee #4 and Employee #5 confirmed during an interview conducted on December 18, 2024, that Patient #18, and Patient #20 had been administered psychotropic medications prior to obtaining informed consents.

3. Review of patient medical records revealed no documentation of notification of provider coverage for 20 of 20 patients.

Observations on tour conducted on December 16, 2024 included the hospital lobby and intake area. Patient rights were posted in the hospital's intake area. There was no notice informing patients that there was not an MD/DO on-site 24/7.

Employee #4 and Employee #5 confirmed during an interview conducted on December 18, 2024, that the hospital does not have a hospital posting to notify patients that there is no MD/DO present on-site 24/7. Employee #4 and Employee #5 confirmed during an interview conducted on December 18, 2024, the hospital does not provide patients with a written notification that there is no MD/DO present at the hospital 24/7.

Based on hospital policy and procedure, observation during hospital on-site tours conducted from December 16, 2024 to December 23, 2024, and employee interviews, the Department determined the administrator failed to ensure the hospital was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients.

Findings include:

Hospital policy titled "Client (Patient) Rights and Responsibilities," Policy #15137047, Last Revised February 2024, revealed "...A. Client/Patient Rights...1. Client/patient rights shall include that a client/patient is free from abuse, neglect, manipulation or harassment from staff, other clients/patients, or visitors that result in physical harm, pain, or mental anguish, including...b. Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..."

Observation during hospital on-site tours conducted from December 16, 2024 to December 23, 2024, revealed the following:

Multiple patient bedrooms revealed floor-anchored night stand tables with gaps between the night stand tables and the adjacent walls, creating tie-off points, and floor-anchored beds with gaps between the bed headboards and adjacent walls filled with caulk that was not pick resistant and that displayed evidence of picking, creating a safety hazard.

Multiple patient bedrooms and connected patient bathrooms revealed metal Velcro curtain mounting tracks at windows, bathroom entrances and showers, each containing points where the track metal is hooked, creating tie-off points.

Multiple patient bedroom-connected bathrooms revealed grab bar mounts with gaps between the mounts and the adjacent walls, undersink shrouds with screws loose/missing and with gaps in the connection points between the shrouds and the underneath sides of the sinks, and protruding screws underneath either side of the toilet seats, all creating tie-off points.

Lobby bathroom revealed grab bar mounts, paper towel dispenser and light switch plate with gaps between them and their mounting to the adjacent walls. Lobby bathroom further revealed no anti-ligature door hinge and an automatic door closer swing arm at the top of the door, both creating tie-off points.

Employees #1, #4 and #6 confirmed during on-site hospital tours conducted from December 16, 2024 to December 23, 2024, that:

Multiple patient bedrooms revealed floor-anchored night stand tables with gaps between the night stand tables and the adjacent walls, creating tie-off points, and floor-anchored beds with gaps between the bed headboards and adjacent walls filled with caulk that was not pick resistant and that displayed evidence of picking, creating a safety hazard.

Multiple patient bedrooms and connected patient bathrooms revealed metal Velcro curtain mounting tracks at windows, bathroom entrances and showers, each containing points where the track metal is hooked, creating tie-off points.

Multiple patient bedroom-connected bathrooms revealed grab bar mounts with gaps between the mounts and the adjacent walls, undersink shrouds with screws loose/missing and with gaps in the connection points between the shrouds and the underneath sides of the sinks, and protruding screws underneath either side of the toilet seats, all creating tie-off points.

Lobby bathroom revealed grab bar mounts, paper towel dispenser and light switch plate with gaps between them and their mounting to the adjacent walls. Lobby bathroom further revealed no anti-ligature door hinge and an automatic door closer swing arm at the top of the door, both creating tie-off points.

Based upon hospital policy and procedure, medical records review and request, and employee interview, the Department determined the administrator failed to record and monitor as a restraint, the use of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition, and therefore did not follow proper procedures and protocols for a chemical restraint. This deficient practice poses a risk to patient health and safety including possible death if a patient is not properly monitored after a chemical restraint.

Findings include:

Hospital policy titled "Seclusion and Restraint," Policy #13405853, Last Revised March 2023, revealed "...1. Restraint Types...c. Chemical Restraints...A pharmacological intervention that is not standard treatment or dosage for a condition the patient is being treated for (42CFR482.13(1)(i)(B)) OR a pharmacological agent not standard treatment for a client's medical condition or behavioral health issue and is administered to manage a patient's behavior in such a way as to reduce a safety risk to the patient or others; or to restrict the patient's freedom of movement...B. Procedure...3. An order is issued by a qualified member of the medical staff to execute a seclusion or restraint..."

Hospital medical record for Patient #6 revealed the following:

Document titled "Client Doctor Orders" revealed " ...Order Date/Time...02/02/2024 01:26 PM...Order Description...Admission to The Healing Place...Diagnosis: F25.9 Schizoaffective psychosis... "

Document titled "Client Doctor Orders" revealed "...Order Date/Time...02/09/2024 11:18 AM...Order Description...(Pyxis) Ativan (Lorazepam)...Start Date/Time: 02/09/2024 11:13 AM...Dosage: 2 MG/1 ML Injection Vial...Quantity/Frequency: 1 Milliliter Give now...Discontinue Information...Date/Time: 02/09/2024 11:57 AM...Order Date/Time...02/09/2024 11:18 AM...Order Description...(Pyxis) Diphenhydramine...Start Date/Time: 02/09/2024 11:13 AM...Dosage: 50 MG/1 ML Injection Vial...Quantity/Frequency: 1 Milliliter Give now...Discontinue Information...Date/Time: 02/09/2024 11:57 AM...Order Date/Time...02/09/2024 11:18 AM...Order Description...(Pyxis) Haloperidol...Start Date/Time...02/09/2024 11:16 AM...Dosage: 5 MG/1 ML Intramuscular Solution...Quantity/Frequency: 2 Milliliter Give now...Discontinue Information...02/09/2024 11:57 AM...

Document titled "Progress Note: Inpatient Hospital - Nursing" revealed "...Pt is religiously delusional, (he/she) became agitated towards another patient, chased (him/her) and pushed (him/her) while yelling "God is in the building". Pt was re-directed to (his/her) room before the incident escalated further. In (his/her) room, (he/she) continued to voice multiple different religious delusions while yelling and crying. ONE TIME ORDER for IM Ativan 2mg, Benadryl 50mg, and Haldol 10mg given with good results...Mood and behavior labile. Affect congruent to mood...."

Chemical restraint order documentation for Patient #6 for the aforementioned incident was requested, none was provided.

Employee #4 confirmed in interviews conducted from December 17, 2024 to December 23, 2024, that no chemical restraint order documentation for Patient #6 for the aforementioned incident was available for review at the time of the survey.

Based on Hospital Bylaws, personnel credential files and employee interviews, the Department determined the administrator failed to ensure medical staff periodically conduct appraisals of its members. This deficient practice can result in practitioners not being provided oversight resulting in inappropriate patient care and operating outside their scope.

Findings include:

Hospital document titled "Medical Staff Committee (MSC) Bylaws , Rules and Regulations," Revised and Adopted by the Medical Staff Committee on : May 16, 2024, revealed "...Section 2.3 Responsibilities...It is the responsibility of the MEC in collaboration with other Hospital and Clinic Departments (Human Resources, Nursing, Quality Management, etc....) to affect these stated purposes:...E. To participate in Polara Health's Quality by conducting all required and necessary activities for assessing and improving the effectiveness and efficiency of clinical care/services provided. Activities related to this responsibility include:...4. Evaluating individual and institutional performance through valid and reliable measurement systems based on objective, clinically-sound criteria. The Medical Staff shall oversee all activities around Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE) processes to determine medical staff member performance as it relates to ongoing membership, appointment, reappointment, and privileging...Section 4.2 Procedure...2. Reapplication Process...B. The reapplication process follows the same as for new applicants with the following exceptions:...This will include a thorough review of FPPE and OPPE information and data collected in the interim three years...."

Evidence of OPPE for employee #8, completed and signed by peer-level medical staff was requested. None was provided.

Employee #4 confirmed during an interview conducted on December 23, 2024, that no documented evidence of OPPE for Employee #8 was available for review at the time of the survey.

Based on review of Hospital Bylaws, Hospital documents and employee interview, the Department determined the administrator failed to ensure medical staff privileged to provide necessary medical treatment services are available within the Hospital. This deficient practice poses the potential risk of harm to patients who are not able to receive necessary medical treatment in a timely manner.

Findings include:

Hospital document titled "Medical Staff Committee (MSC) Bylaws , Rules and Regulations," Revised and Adopted by the Medical Staff Committee on: May 16, 2024, revealed "...Section 4.1 Qualifications...1. The qualifications any practitioner must demonstrate to receive Clinical Privileges at Polara Health are delineated below. They include application/reapplication processes, categories of privileges available and qualifications required for each...To support the delivery of quality service to all clients, Polara Health developed procedures to privilege eligible staff...A...Polara Health privileges shall be defined as the permission granted to a practitioner to render specific diagnostic, therapeutic, medical, or other services beyond or other than those services specified by the employee job description, and practitioners who by license are authorized to practice independently.... "

Hospital document titled " Provider On-call Schedule August," identified by the Hospital to represent August 2024, revealed Employee #11 scheduled solely on August 5, August 6, August 7, August 12, August 13, August 14, August 19, August 20, August 21, August 26, August 27 and August 28.

Employee #4 confirmed during an interview conducted on December 23, 2024, that Employee #11 is not licensed or privileged to provide dual Family Nurse Practitioner/Psychiatric Mental Health Nurse Practitioner care for the Hospital.