HospitalInspections.org

Based on a review of medical records and staff interview, it was determined the hospital did not receive informed consent from four patients who required transport to another hospital for a higher level of care. This deficient practice poses the risk of patients making uninformed decisions about the risks and reasons for transfer, or family members not being informed in an emergency of the patient transfer or the risks of transport.

Findings include:
Policy titled "Patient Transfer and Transport," revealed: "...In the event the transfer is planned the physician or designee is responsible for obtaining informed consent from the patient or legal representative. Informed consent includes review of risks and benefits of transfer based on the patient ' s medical condition and the mode of transfer. This information must be documented in the patient ' s medical record...Documentation in the patient ' s medical record includes: For a planned transfer or transport, consent by the patient or the patient ' s legal representative or why consent could not be obtained such as an emergency transfer to Emergency Department for evaluation and treatment...."

A review of medical records revealed four out of four patients (Patients #1, #6, #9, and #19) who were transferred to another hospital for a higher level of care did not have consent documented for the transfer in their medical record.

Employee #3 confirmed in an interview conducted on 07/16/2024, the hospital did not get informed consent when patients were transferred to another facility.

Based on a review of hospital records, interview, and observation, it was determined the hospital failed to ensure patient bathrooms were ligature free. This deficient practice poses the risk of a patient who is receiving psychiatric treatment with possible suicidal ideation, the opportunity to create a ligature, which could result in serious injury or death.

Findings include:
Document titled "Patient Handbook," revealed: "...Here at Haven Behavioral Hospital we provide an inviting, secure and safe environment. We have attractively decorated semi-private rooms with large bathrooms...Patient safety, security and comfort are of the upmost importance to us...."

A tour of the facility and patient rooms, conducted on 07/16/2024, revealed in each patient room, and common bathrooms in each of three units, toilets with hinged toilet seats attached to the base of the toilet by a curved bar with an open space that can be used as a tie off point, creating a ligature risk. The hinge mechanism also created a ligature risk by allowing a tie off point between the hinge of the toilet and the toilet seat.

Employees #2, #3, #5, and #12 confirmed in an interview conducted on 07/16/2024, they recognized the ligature risk to patients, and would immediately work on a plan to remove the risk.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients who were restrained by a chemical restraint were documented as a restraint. This deficient practice poses the risk of a patient being chemically restrained unnecessarily, and proper restraint procedures, such as de-escalation, and appropriate monitoring, not being performed.

Findings Include:

Policy titled, "Restraint, Physical" revealed, ..."Mechanical and Chemical restraint is not utilized at this hospital...."

Patient #15 's medical record contained a note titled "Nursing Reassessment," dated 07/12/2024 at 00:56, which revealed: "...(Patient #15) threw a bottle of shampoo and sandwich at patient hitting her in the head ...(Provider #1) notified and ordered Benadryl, Versed and Haldol x1, given ...." Patient #15 was administered 50 mg Benadryl, 5mg Haldol and 5mg Versed intramuscularly on 07/11/2024 at 22:51, 22:52 and 22:53, respectively.
Patient #15 was also administered 50 mg Benadryl, 5mg Haldol and 5mg Versed intramuscularly on 07/14/2024 at 20:28. No chemical restraint orders or documentation was found in Patient #15 ' s medical records for this time.

Patient #8 's medical record contained a note titled "Nursing Reassessment," dated 12/06/2023, at 12:33, which revealed: "...(Patient #8) displays impulsive behaviors such as disrobing and urinating in the hallway. Patient received IM medication for severe agitation with no physical hold required ...." Patient #15 was administered 50 mg Benadryl, 5mg Haldol and 2mg Ativan intramuscularly on 12/06/2023 at 11:42. No chemical restraint orders or documentation were found in Patient #8 ' s medical records for this time.

Patient #16 's medical record contained a note titled "Discharge MAR,", which revealed Patient #16 was administered 50 mg Benadryl, 100mg Thorazine and 5mg Versed Intramuscularly on 07/11/2024 at 21:15. No chemical restraint documentation or orders were found in the Patient ' s medical records for this time.

Employee #6 confirmed in an interview conducted on 07/16/2024, that patients were being administered the combination of intramuscularly injected Benadryl, an antipsychotic medication and an anxiolytic medication without classifying the process as a chemical restraint.