HospitalInspections.org

Based on review of records and interview, the hospital failed to notify patients (or patient representative when appropriate) of their rights for 4 patients (Patient #'s 5, 11, 13, and 14) out of 6 patients reviewed (Patient #'s 5, 10, 11, 12, 13, and 14).

Findings include:

· Review of Patient #5's chart revealed the patient was a 33 year old female, admitted on 5-5-2015 on a court order. Patient #5 had a court-appointed guardian. On 5-13-2016 the court-appointed guardian signed the voluntary admission paperwork for the patient. Patient #5 was discharged on 5-26-2016

On 5-5-2016, the patient was allowed to sign a form acknowledging the number of days the patient had available to use under the Medicare program. This letter also states that the patient understands their rights pertaining to the use of Lifetime Psych Days and Lifetime Reserve Days.

Patient #5 was allowed to sign a 7 page document. The only page that was in the chart is identified as page 2 of 7. The top part of the form had the name and address of a patient's rights organization, Advocacy Incorporated. The form goes on to explain patient rights for involuntary admissions. The bottom part of the form was a "Statement that you have received this pamphlet and that it has been explained to you." The bottom portion was signed by the patient and witnessed by a staff member on 5-5-2016.

The following forms did not contain signatures of patient, patient guardian, or staff:
1. Consent for Assessment and/or Emergency Treatment/Registration - form annotated "Pt unable to complete".
2. Form titled "Consents" and identified as page 1 of 2. Page 2 of 2 not found in chart.
3. Form titled "Medicare MSP Form". Form annotated "Pt unable".

The following forms were signed by a staff member on 5-5-2016 but did not contain a patient or patient guardian signature.
1. Acknowledgement of Information on Advance Directives & Organ Donations - form annotated "Pt unable"
2. Form titled, "Acknowledgements" - form annotated, "Pt unable".
3. Acknowledgement: Notice of Privacy Practices - form annotated, "Pt unable on POEC"

The "HIV Consent Form" was not signed by patient or guardian. The form was signed by a staff member, undated, and annotated, "Pt unable".

The "Consent for Follow-up Survey", giving consent for post discharge phone calls, was signed by the patient and a staff member, was dated 5-26-2016, and was annotated "unable to complete".

The form, "An Important Message from Medicare about Your Rights", was not signed by patient or guardian at admission or discharge.


· Review of Patient #11's chart revealed the patient was a 20 year old female admitted on 3-25-2016. The patient was cooperative during the majority of the admission process. Documents indicated the patient became uncooperative at the end of the process and refused the following forms:
1. "Acknowledgement of Information on Advance Directives & Organ Donation. The form was annotated, "Pt. did not complete due to mental issues. Pt. refused to cooperate. HS".
2. Form titled, "Acknowledgements"

· Review of Patient #13's chart revealed the patient was a 22 year old female admitted on 4-19-2016 under order of the court. Upon admission the following forms were left blank. They contained no patient/guardian signature, staff signature, or evidence that attempts were made at a later time to present this material to the patient/guardian.
1. "HIV Consent Form"
2. "Acknowledgements"
3. "Acknowledgement of Information on Advance Directives & Organ Donation"
4. "Acknowledgement: Notice of Privacy Practices"
5. "Consents"

· Review of Patient #14's chart revealed the patient was a 48 year old female admitted on 5-8-2016. Upon admission, the following forms were left blank. They contained no patient/guardian signature, staff signature, or evidence that attempts were made at a later time to present this material to the patient/guardian.
1. "HIV Consent Form"
2. "Acknowledgements"
3. "Acknowledgement of Information on Advance Directives & Organ Donation"
4. "Acknowledgement: Notice of Privacy Practices"
The form titled "Consents" had two staff signatures, but no patient/guardian signature or evidence that an attempt was made at a later time to present the consent information.

An interview was conducted with Staff #4. Staff #4 confirmed that there was not a consistent process followed for providing patient rights information to the patient/guardian when the patient was not able to sign consents and acknowledgements upon admission.

Based on review of record, observation, and interview, the hospital failed to ensure an identified patient hazard was removed from the patient lobby.

On 6-16-16 a review of incident reports was completed. Patient #10 made a suicidal gesture after waiting to be screened for admission. She removed the receiver and cord from the phone in the lobby. She walked to the receptionist window. She wrapped the phone cord around her neck and smiled at the staff behind the window.

A tour of the patient lobby was made. The phone in question was still in the lobby with the removable phone cord. Patient's families were in the lobby. The phone was not in use.

An interview was conducted with Staff #1. Staff #1 explained that patient lobby was the main lobby of the building. This was where families come and wait for visitation with their family members. On the day in question, Patient #10 had to wait a long time due to the volume of admissions and was tired of waiting.

After the gesture, the phone had been removed from the lobby. Because families sometimes need to use the phone, the phone had been put back in place as needed. The phone was supposed to be removed again when families were finished using it. Staff #1 stated he was not aware that it was being left there regularly.

Based on review of documents and interview, the facility failed to include criteria for identifying patient stays as extended stay and the process for reviewing extended stays.

A review of the Utilization Review Plan for 2016 was conducted on 6-16-16. The plan did not include the criteria and process for an extended stay review.

An interview with Staff #10 was conducted on 6-16-16 in the conference room. Staff #10 was not able to verbalize a clear definition of an extended stay case or procedures for identifying extended stay cases. Staff #10 was able to verbalize a process for reviewing extended stay cases. The process described was not in the Utilization Review Plan for 2016.