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Based on document review and interviews, the hospital failed to ensure that patients were given accurate information pertaining to their status, in order to make an informed decision regarding their care and treatment process, in one of four patients reviewed (Patient #1). Findings include:

An ambulance report, dated 10/10/11 at 2:51 a.m., indicated that Patient #1 was transported from another hospital to Mayo Clinic Health System - Austin, for inpatient psychiatric admission. The ambulance report indicated that Patient #1 had been placed on a 72-hour hold., due to suicidal ideation. The patient was cooperative and was transported without incident.

The receiving hospital's emergency department (ED) record, dated 10/10/11, indicated that Patient #1 arrived at the hospital at 3:50 a.m., for direct admission to the inpatient psychiatric unit. She was assessed in the ED and reported that she was suicidal with a plan to overdose on Metoprolol (an antihypertensive medication) or shoot herself. She reported that she sought emergency care on her own volition, because of suicidal ideation. She was subsequently admitted to the inpatient psychiatric unit, on a voluntary basis, for treatment of recurrent, major depressive disorder.

The progress notes, dated 10/10/11 at 4:48 a.m., indicated that Patient #1 arrived to the psychiatric unit, was cooperative, answered questions appropriately, had a flat affect, and appeared depressed. She was placed on 15-minute safety checks, based on her suicide plan to either overdose on medications or shoot herself. Documentation indicated that although Patient #1 was not on a 72-hour hold, she was holdable, based on suicidal ideation.

The history and physical (H&P) completed on 10/10/11 indicated that Patient #1's plan of care would include psychological testing, occupational therapy assessment and treatment, group therapy, psychopharmacologic intervention, and appropriate lab tests, as indicated. The patient's estimated length of stay was 7 days. The H&P indicated that a discharge planning meeting was scheduled for 10/12/11.

The progress notes, dated 10/10/11 at 9:58 p.m., indicated that Patient #1 was cooperative, pleasant, and attended her planned group sessions.

The progress notes, dated 10/11/11 at 1:41 p.m., indicated that Patient #1 had been withdrawn to her bedroom, between groups. Documentation reflected that Patient #1 felt "out of place" on the unit and interacted only minimally with peers. She expressed that she preferred 1:1 counseling versus group therapy. Staff observed Patient #1 as having depressed affect with little insight into thought processes or emotional well-being. The patient was medication-compliant and cooperative.

The progress notes, dated 10/11/11 at 10:58 p.m., indicated that Patient #1 had expressed that she would like to take an active role in developing her care plan. The patient also expressed that she would like to be discharged before 10/17/11. The patient was cooperative and not expressing ideations of suicide.

The discharge planning meeting notes, dated 10/12/11 at 12:56 p.m., indicated that Patient #1 reported that she felt she had made progress (after medication adjustments) and no longer wanted to harm herself. Patient #1 maintained that the communication about her plan of care was inadequate and that things had not been explained to her about the treatment process. Patient #1 was very upset about the length of her recommended stay on the psychiatric unit, and that staff had told her that she would be placed on a 72-hour hold if she tried to leave. Patient #1 voiced that she really did not want to stay in the hospital, until her anticipated discharge date of 10/17/11.

Patient #1 remained hospitalized until 10/17/11. The discharge summary, dated 10/17/11, indicated that Patient #1 progressed with individual, group, and milieu therapy. Her medications were adjusted, her condition was stabilized, and arrangements were made for her to be followed on an outpatient basis. Her discharge diagnosis was Anxiety disorder (with elements of posttraumatic stress disorder).

Patient #1 was interviewed on 03/15/12 at 1:05 p.m. She stated that she recognized her need for mental health help on 10/10/11, when she voluntarily sought assistance from the hospital. She was admitted to the psychiatric unit on a voluntary basis. The admitting nurse gave her a packet of information, which contained literature about patient rights, grievances, and the unit rules. The admitting nurse handed her the packet but did not review any of the material with her. On 10/11/12, she asked the staff what her plan of care was. She also asked to see her plan of care. A nurse showed Patient #1 her plan of care, which was generic, and had her discharge date as being 10/17/11. The nurse asked Patient #1 to sign the plan of care, which Patient #1 declined. Patient #1 expressed concern that she did not think she needed to be hospitalized beyond 72 hours, as she was no longer suicidal. None of the staff provided any information to Patient #1 regarding the treatment process or answered her questions about an individualized plan of care. The following day on 10/12/11, she again asked staff about an earlier discharge date than the designated 10/17/11 date. She was told that if she tried to leave earlier than 10/17/11, she would be placed on a 72-hour hold. She attended the 10/12/11 discharge planning meeting, which was held by the treatment team. Again, she expressed that she wanted to be discharged sooner than 10/17/11 and agreed to continue her mental health treatment on an outpatient basis. She was told that a 5 -7 day stay was recommended for everyone. Patient #1 expressed concern that her plan of care was not individualized and she felt she would benefit more from one-to-one therapy on an outpatient basis. None of the treatment team members answered her direct questions about whether or not she was holdable or on a 72-hour hold. Patient #1 told the treatment team that she felt much better with the medication adjustments that had been made and she was no longer harboring thoughts of suicide. Patient #1 did not get any straight answers from the staff regarding what her status was (whether she was considered a voluntary admission or if she was on a 72-hour hold). Patient #1 repeatedly asked the staff, day after day, about an earlier discharge date. On 10/15/11, staff told Patient #1 that all patients who are not on a 72-hour hold are assigned a 7-day discharge date (from the time of admission) in order to get insurance to cover the services. Patient #1 had not had suicidal ideation since 10/11/11. Patient #1 felt the group sessions and generic approach to mental health care was an unproductive use of her time. Patient #1 was not discharged until 10/17/11.

The hospital's policy, Admission to Mental Health Facility (Voluntary - Involuntary), dated 08/2011, indicated "After physician and/or mental health professional's examination and consultation, if it is decided that the patient needs to be admitted to a mental health facility, the physician/ and/or mental health professional will inform the patient and family. If the patient is agreeable to this and will go voluntarily to a mental health facility, arrangements are made with the receiving facility to accept the patient...If it is decided that the patient needs to be admitted to a mental health facility because he is a danger to himself or others, and the patient will not go voluntarily, then a 72-hour hold form needs to be filled out...If the patient is being held at the Austin Medical Center under a 72-hour hold, the form 'Notice to Patients of Rights under Emergency Hospitalization' is to be read to the patient and needs to be documented on the patient's chart that this was done."

The hospital's policy, 12-Hour Discharge Policy, dated 02/06/07, indicated "We encourage each person to explore the causes of their distress, consider alternative ways of responding to life's conditions, and come to an agreed upon date of discharge with the staff. In the event a person wishes to leave before that time, we need to know, by written request, 12 hours in advance, to permit review of ones' experiences on the Unit, and consideration of discharge plans."

Employee (D)/RN Manager was interviewed on 03/05/12 at 8:40 a.m. She stated that nursing staff informs patients, on admission, that the average length of stay on the psychiatric unit is 5 - 7 days. Nursing staff then assigns the patient's discharge date seven days out from the date of admission. Patient #1 was admitted on 10/10/11, so her assigned discharge date was 10/17/11. Employee (D) acknowledged that nursing staff provided Patient #1 erroneous information regarding her status, as it pertained to the 12-hour discharge policy. Employee (D) clarified that the 12-hour discharge policy applied only to patients who were voluntary admissions and not to patients who were on a 72-hour hold. Patient #1 was a voluntary admission and once she expressed that she wanted an earlier discharge date (prior to 10/17/11), she should have been told she had the right to execute the 12-hour notice of intent to discharge form. Employee (D) explained that the patient is required to give staff a 12-hour notice of intent to discharge, in order to ensure the patient receives a risk assessment and adequate post-hospitalization continuity of care. Part of the risk assessment includes an evaluation by a physician regarding the patient's safety. If the physician determines that the patient would be unsafe (i.e., due to self harm) with an earlier discharge, the physician effectuates a 72-hour hold. Employee (D) stated that Patient #1 did not want to sign the 12-hour notice of intent to discharge form, when staff misinformed her that signing the form would result in a 72-hour hold. Employee (D) clarified that a 72-hour hold represents only one of two possible outcomes (after a patient signs the 12-hour notice of intent to discharge form), the other being an earlier discharge if the risk assessment is favorable. Patient #1 was not provided with sufficient information to make an informed decision. Employee (D) stated that psychiatric staff have been re-educated about the 12-hour notice, so a consistent message is delivered to patients by all staff. Employee (D) also stated that nurses admitting patients to the psychiatric unit are required to review the entire admission packet with the patient and answer any questions the patient might have. Both of these areas are part of the psychiatric unit's performance improvement measures.

Physician (E)/Psychiatrist was interviewed on 03/05/12 at 1:20 p.m. He stated that Patient #1 was distraught on admission and had expressed ideations of suicide. Suicidal ideation constitutes a safety concern and the patient's need for inpatient psychiatric care, which is facilitated by a 72-hour hold if the patient does not agree to voluntary inpatient care. By virtue of Patient #1's ideations of suicide, at the time of admission, she was holdable. However, Patient #1 did not require a 72-hour hold because she sought help voluntarily and agreed to inpatient admission. Physician (E) felt that Patient #1's care on the psychiatric unit was comprehensive and addressed her needs for outpatient success. Physician (E) acknowledged that Patient #1 did not express ideations of suicide or harming herself, after hospital admission.

Based on interview and document review, the hospital failed to promote the rights of patients to access information in their medical records in a reasonable amount of time, in one of one patients reviewed (Patient #1). Findings include:

Patient #1's emergency department (ED) record indicated that she arrived at the hospital at 3:50 a.m. on 10/10/11, for direct admission to the inpatient psychiatric unit. Patient #1 reported that she sought emergency care on her own volition, because of suicidal ideation. She was admitted to the inpatient psychiatric unit, on a voluntary basis, for treatment of recurrent, major depressive disorder.

The history and physical (H&P) completed on 10/10/11 indicated that Patient #1's plan of care would include psychological testing, occupational therapy assessment and treatment, group therapy, psychopharmacologic intervention, and appropriate lab tests, as indicated. The patient's estimated length of stay was 7 days.

The progress notes on 10/10, 10/11, and 10/13/11 all characterized Patient #1 as being medication-compliant, cooperative, pleasant, and polite. The progress note, dated 10/13/11 at 2:53 p.m., reflected that Patient #1 indicated a desire to go home because she missed her family. The patient reported that she felt the group therapy was not helping her.

Patient #1 was interviewed on 03/15/12 at 1:05 p.m. She stated that she recognized her need for mental health help on 10/10/11, when she voluntarily sought assistance from the hospital and was admitted to the psychiatric unit, on a voluntary basis. The admitting nurse gave her a packet of information, which contained literature about patient rights, grievances, and the unit rules. The admitting nurse handed her the packet but did not review any of the material with her. Throughout the day and evening of 10/10/11, none of the staff on the psychiatric unit communicated with her about what her treatment plan was, so she asked a nurse if she could see her medical record. The nurse denied her request and told her she would have to sign a form from medical records, but the nurse never offered the form or followed up on her request. The following day on 10/11/11, she asked a nurse what her plan of care was. She also asked to see her plan of care. A nurse showed Patient #1 her plan of care, which was generic, and had her discharge date as being 10/17/11. The nurse asked Patient #1 to sign the plan of care, which Patient #1 declined. Patient #1 expressed concern that she did not think she needed to be hospitalized until 10/17/11 so she asked the nurse if she could see her medical record, as long as she signed a release. The nurse denied her request, did not offer her a release form, and told Patient #1 she would need to discuss the subject with her physician. The next day on 10/12/11, she attended a discharge planning meeting, which was held by the treatment team. Again, she expressed that she wanted to be discharged sooner than 10/17/11 and agreed to continue her mental health treatment on an outpatient basis. She was told that a 5 -7 day stay was recommended for everyone. She asked to see her medical record and was provided with a release form, which she signed. She was again told that it was the physician's decision as to whether she could see her medical record. She remained hospitalized on the psychiatric unit until 10/17/11 (the original discharge date she was given), but was never provided access to her medical record or provided with a reason regarding why she could not see it.

The hospital's policy, Use and Disclosure of Patient Medical Information, dated 12/21/11, indicated "Patients have the right to review information pertinent to their care. It is left to the discretion of the caregiver whether access to patient information can be provided immediately or whether the patient request is referred to the HIS (Health Information Services) Department. Behavioral Health records will be reviewed with a Behavioral Health professional to direct disclosure of information prior to release."

Employee (D)/RN Manager was interviewed on 03/05/12 at 8:40 a.m. She stated that Patient #1 asked to see her care plan on 10/11/11, which was reviewed with her by one of the nurses. Patient #1 expressed concern to the staff that her care plan was generic and not individualized. The patient made her request for the care plan information on her second day of admission. Care plans on the behavioral unit are developed in collaboration with
behavioral health professionals after they have assessed the patient's needs. The care plan is an evolving tool that can change daily, based on the patient's response to treatment. Employee (D) did not recall that Patient #1 requested to review portions of her medical record, other than the care plan.

Physician (E)/Psychiatrist was interviewed on 03/05/12 at 1:20 p.m. He stated that Patient
#1 was distraught on admission with multiple family stressors. She responded well to the treatment team's plan for group therapy, individual therapy (which he conducted), and occupational therapy. Physician (E) acknowledged that Patient #1 was an appropriate candidate to review her clinical record, in the presence of a mental health professional, but he could not recall if Patient #1 had communicated this to him. Physician (E) did acknowledge the possibility of miscommunication between treatment team members. Patient #1's medical record did contain the Authorization for Release of Information form, signed by Patient #1 on 10/12/11. The form indicated that Patient #1 requested copies of her psychiatry and psychology records, the history and physical, and clinic notes for the period 10/09/11 - 10/12/11. There was no evidence that Patient #1's record request was granted or denied. At her time of discharge, Patient #1 also signed a second Authorization for Release of Information form, dated 10/17/11. The form indicated that Patient #1 requested copies of her psychiatry and psychology records, the history and physical, and clinic notes for the period 10/10/11 - 10/17/11. There was no evidence that Patient #1's second record request was granted or denied.