HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt #1) clinical records of minors who presented to the ED (emergency department) for treatment, the hospital failed to ensure that informed consent regarding care of patient seeking psychiatric care, was obtained as required.

Findings include:

1. The hospital's policy titled, "Informed Consent for Non-Experimental Procedures or Treatments (11/22/2024), was reviewed, and required, " ...Who Must Provide Consent ...Exception Based on Type of Treatment. d. i. A minor sixteen (16) years of age or older may give his or her own consent for voluntary inpatient mental health treatment and execute the application ..."

2. The clinical record for Pt #1 was reviewed on 3/17/2025. Pt #1 presented to the ED (emergency department) on 12/18/2024 at 1:27 PM, via EMS (emergency medical services), for a psychiatric evaluation. Pt #1 was transferred to a psychiatric facility on 12/19/2024.

- Pt #1's Treatment and Consent Agreement was reviewed. The consent was signed on 12/18/2024 at 4:52 PM by the Consumer Access Specialist (E #9). The consent included, "Patient is a minor unable to obtain." The consent was not obtained by Pt #1 [self], as required per policy. The clinical record did not contain any additional consent forms.

-The ED Triage note (dated 12/18/2024 at 1:32 PM), included, "Chief Complaints: Psychiatric Evaluation (Patient with suicidal ideation X (times) 2 days, denies plan or intent at this time ...)"

- An ED Note documented by the A & R (Assessment and Referral) Social Worker/E #4, (dated 12/18/2024 at 3:20 PM), included, "Per school counselor ... pt's [parent] (Z #2) was informed that pt was reporting SI [suicide ideation] and that [Z #2] would need to come to the school, [Z #2] refused and counselor stated pt would be taken in ambulance to ED and [Z #2] 'said go ahead and send [Pt #1]', still refusing to come to ED to meet pt here. Spoke with [Z #2] on phone, [Z #2] provided verbal consent for treatment stating pt does not need anyone with [Pt #1] because this is a mental health issue. This writer and DON [Director of Nursing] informed [Z #2] that pt is a minor, [Pt #1] is not petition-able ...DON informed pt we are here to take care of the pt and that we would see [Z#2] when [Z #2] presents to the ED..."

- An ED note documented by the ED Charge RN (E #3), dated 12/18/2024 at 3:46 PM, included, "This RN received a phone call from the parent of this patient who was very upset. Parent was told there need to be a guardian present to make medical decisions for the patient. Parent then explained that neither their mother or father would not be coming because (Pt. #1) is over 12 years old and can therefore make medical decisions for [self] regarding mental health exam. This RN explained I am not informed of that Law and our policy is we need a guardian to be present or we are to inform DCFS (Department of Children and Family Services)...Parents were ultimately requested to be present ..."

The clinical record lacked an informed consent signed by Pt #1.

3. On 3/17/2025 at 3:07 PM, an interview was conducted with the Consumer Access Specialist (E #9). E #9 acknowledged that E #9 signed Pt #1's Hospital consent and HIPPA (Health Insurance Portability and Accountability Act) form. E #9 stated that E #9 signed Pt #1's consent form since Pt #1 was unable to sign as a minor.

4. On 3/17/2025 at 11:30 AM, an interview was conducted with the ED Manager (E #2). E #2 stated that at the time when Pt #1 presented to the ED, the patient was 16. E #2 stated that the staff would usually get consent for treatment of minors from the parents. E #2 stated that E #2 is now aware that patients16 and over can consent for psychiatric care. E #2 stated that there has not been any formal education on the consent process since the incident with Pt #1.

5. On 3/17/2025 at 1:15 PM, the Regional Director of Accreditation and Regulatory (E #1), confirmed with the ED Educator (E #8) that education has not been provided following Pt #1's ED encounter.

6. On 3/18/2025 at 10:25 AM, an interview was conducted with the A & R Manager (E #12). E #12 stated that a patient that presents to the ED who is 16 years or older seeking psychiatric treatment, can consent on their own. E #12 stated that attempts are still made to contact the family/guardian to keep them informed of the care that the patient is receiving.