HospitalInspections.org

Based on interview, record review, and hospital policy, the hospital violated patients' rights by failing to discharge one voluntary patient, (Patient #49), of 3 patients surveyed after the patient requested to be discharged and by failing to discharge one involuntary patient, (Patient #48), of 3 patients surveyed after 72 hours of being held under a Baker Act when no longer meeting Baker Act criteria.

The hospital failed to ensure an expressed and informed consent was completed prior to preforming Electroshock Therapy on 3 of 3 Patients surveyed (Patient #42, Patient #46, and Patient #45). The hospital failed to ensure that resident rights were honored by not obtaining consents and involving the designated representative in the participation of the patient's care plan for 1 Patient (Patient #33) of 4 records reviewed. The hospital also failed to ensure patient rights were upheld for 1 Patient (Patient #6) by not obtaining a complete face to face second opinion when identified through the grievance process the second opinion was not completed.

These deficiencies are of such character as to substantially limit the hospitals' capacity to furnish adequate care which adversely affect the health and safety of patients and results in the condition for participation for patient rights in noncompliance.

Based on interview, record review, and hospital policy review, the hospital violated patients' rights by failing to discharge one voluntary patient, (Patient #49), of 3 surveyed, after the patient requested to be discharged. Also, by failing to discharge one involuntary patient, (Patient #48), of 3 surveyed, after 72 hours of being held under a Baker Act no longer meeting Baker Act criteria.

The hospital failed to ensure an expressed and informed consent was completed prior to preforming Electroshock Therapy on 3 of 3 Patients surveyed (Patient #42, Patient #46, and Patient #45). The hospital also failed to ensure patient rights were upheld for 1 Patient (Patient #6) by not obtaining a complete face-to-face second opinion. The hospital identified through the grievance submitted by Patient #6 the second opinion was not completed as required. The hospital did not complete the required second opinion for a Baker Act patient after the hospital identified the deficiency.

The findings included:

Patient #49 is a 75-year-old female who was admitted to the facility on 9/20/23 by Baker Act. Patient #49 was deemed by the psychiatric physicians to be able to make her own decisions. On 9/26/24 Patient #49 signed paperwork to be voluntarily admitted to the facility.

According to the "Psychiatric Progress Note" dated 9/27/23 at 2:46 p.m. the physician wrote, "Pt [Patient] lives on her own with her cats and her daughter is concerned about her long history of depression and ETOH [alcohol] ...Pt is minimizing her hx [history] with ETOH and is seeking to be discharged soon...Pt does not believe she has a problem".
On 9/28/23 at 3:45 p.m. the physician documented, "Pt was brought into treatment team this morning and is seeking discharge ..."

On 9/29/23 at 3:11 p.m. the physician wrote, "Pt continues to seek discharge ...".

On 9/30/23 at 10:38 a.m. the physician wrote, "Pt continues to seek discharge ...Pt has been cooperative with staff and compliant with medications ...Possibly looking at discharge early next week".

According to the hospital policy, "Right To Release" BA1008 origination date 1/1/2012, last reviewed 1/30/24, last revised 2/26/18 Voluntary patients, their guardian, representative, or attorney, in accordance with patient rights and State Law, may request to be discharge in writing or verbally at any time following admission.
1. Upon admission, patients will be provided with information about the facility and informed of their rights and consents. If at any time they wish to be discharged and do not agree with Physician, then a written request for release will be submitted to a member of the team/Charge Nurse for transmittal to the Administrator and physician.
2. If the patient on the unit, or another on his behalf (which may include relative, friend, or attorney), makes an oral of written request for release, such request will immediately be entered in the patient's clinical record by the Charge Nurse. The physician and the Administrator should be notified.
3. Within 48 hours of a written or oral request for release to the Administrator, the patient must either be discharged or involuntarily proceedings must be initiated, or the request rescinded ..."

According to the "Patient Handbook", provided by the hospital on admission, a voluntary patient can request discharge by "filling out a form provided by staff". The Patient Handbook does not inform voluntary patients of their right to orally request to be discharged from the facility.

On 10/29/24 at approximately 10:00 a.m., after reviewing the documentation in the physician's progress notes regarding Patient #49 requesting to be discharged from the facility, The Chief Nursing Officer said Patient #49 was required to fill out a form to request to be discharged from the facility.

On 10/30/24 at approximately 1:00 p.m. the Psychiatric Physician verified he had written the progress notes documenting Patient #49 was seeking to be discharged. The Physician said he did not feel the patient was ready to be discharged because the patient's daughter was concerned about her drinking and the patient was not accepting she had a problem with alcohol. The Physician said he did not know how to interpret seeking to be discharged. He said it could have meant the patient was seeking to be discharged as soon as possible. The physician said this should have been verified and documented in the patient's clinical record.

Patient #48 is a 63-year-old female who was admitted on 9/5/23 under a Baker Act after she texted a car dealership that she wants to die every day.

On 9/5/23 upon admission Patient #48 denied any suicidal Ideations.

The Psychiatric Evaluation dated 9/6/24 at 7:57 p.m., showed Patient #48 denied suicidal Ideations. Her diagnosis was documented as Major Depressive Disorder, and the physician estimated her stay at the facility to be 6 days.

On 9/7/23 at 3:57 p.m., a second opinion psychiatric evaluation showed Patient #48 was denying suicidal ideations.

On 9/8/23 both day shift and night shift nurses documented Patient #48 denied any suicidal ideations.

On 9/9/23 at 2:00 p.m., the Mental Health Nurse Practitioner documented, "Today patient reports that she is doing good. She reports sleeping an average of 6 hours. She denies any depression. She denies any anxiety. Patient is attending groups. No irritability or agitation evident, Patient denies appetite concerns ...She denies any suicidal ideations plans or intent."

On 10/30/24 at 11:30 a.m., both the Chief Nursing Officer and the Director of Clinical Services reviewed Patient #48's medical record and could not find any documentation for the facility to petition the court for continued involuntary stay after 72 hours of being admitted to the facility. There was no documentation Patient #48 was suicidal after being admitted to the facility.

On 10/30/24 at 1:20 p.m., the Psychiatrist who provided the second opinion evaluation for Patient #48's Baker Act verified there was no documentation in the chart that Patient #48 was a suicidal risk during the time she was at the hospital. The physician said he thought the reason the patient was kept longer than 72 hours was she became unstable on day 3. The MD verified at that time there was no documentation in the chart the Patient was unstable. He said the facility should be documenting on day three why patients are being kept on a Baker Act.

Review of the hospital policy #BA1013 "Right to Express and Informed Consent" last reviewed on 1/29/24 and effective 12/1/2018 reads, "prior to giving written and express and informed consent, the following information is disclosed to the client, guardian advocate, or proxy:

1. Purpose of the treatment provided.
2. Common side effects of medications.
3. Alternative appropriate treatment modalities ..."

Review of the "Consent to Electroconvulsive Therapy" for Patient #42 dated 10/18/24 lists the condition for which the procedure is being provided as "MDD". The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment is blank and uncompleted on the form. The Prognosis if the treatment is rejected is blank and uncompleted on the form.

On 10/29/24 at 2:20 p.m., Patient #42 said he was never told what MDD meant by the staff at the hospital prior to the procedure. Patient #42 verified he was never informed of the likelihood of the success of the treatment and was never told of any alternatives to the treatment.
Review of the "Consent to Electroconvulsive Therapy" for Patient #46 dated 10/23/24 lists no condition for which the procedure is being provided. The area on the form where the diagnosis should be listed is covered with the patient's information sticker. The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment was listed as "None At This Time".

On 10/29/24 at 2:27 p.m., Patient #45 verified she had not been informed of the diagnosis she had electroconvulsive therapy for prior to the procedure. Patient #45 verified the area on the form had been covered prior to her signing the form. Patient #45 verified she had not been informed of any treatment alternatives prior to receiving the procedure.
Review of the "Consent to Electroconvulsive Therapy" for Patient #46 dated 9/23/24 lists no diagnosis for performing the procedure. The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment is blank and uncompleted on the form. The Prognosis if the treatment is rejected is blank and uncompleted on the form. The check box that Patient #46 read and understood the statements on the form was left blank on the form.

On 10/29/24 at 3:00 p.m. the ECT Nurse verified she had obtained patient consents for Patients #42, #45, and #46. The nurse verified the three consents had not been completed appropriately as per hospital policy prior to the procedures.

Clinical records reviewed for Patient #6, a 50-year-old female, admitted to the hospital under a Baker Act on 8/26/23 and discharged 9/7/23. The clinical records documented an initial psychiatric evaluation completed on 8/26/23 at 3:00p.m. Documented a second psychiatric opinion completed on 8/27/23 at 9:00 a.m.

Patient #6 completed and submitted a grievance form to the hospital on 8/28/23 stating, "I was seen by the doctor on Saturday morning, my first official day at Park Royal (8/26/23). I was expecting to see a second psychiatrist yesterday, 8/27/23 but did not. However, upon speaking with our service provider it was discovered that in my file a second doctor had written notes about a visit that did not take place. That is my grievance. I have only been seen by one doctor and am due a second by today."

Review of the grievance investigation documents the hospital substantiated the second opinion was not conducted face to face as required and a letter was sent to Patient #6 dated 9/8/23 after discharge.

On 10/30/24 at 2:00 p.m., during an interview, the Risk Manager (RM), confirmed the grievance investigation showed the psychiatrist did not complete the second opinion as required. Stating, "He did not see her in person, he reviewed records. In the nursing station." The RM said the physician involved was addressed by the Chief Medical Officer (CMO) and the Chief Executive Officer (CEO) and that the hospital adjusted the billing. She had nothing further to do about the incident.

On 10/30/24 at 3:40 p.m., during an interview the Director of Clinical Services confirmed the invalid second opinion was used for the Baker Act court filings submitted on 8/28/23. "The staff filing the court papers would not know about the grievance and the grievance investigation findings." Confirmed the grievance was filed on 8/28/23 and the court filings were filed on 8/28/23. The Director of Clinical Services said that the second opinion should have been repeated when it was identified that it was not done face to face as required.

On 10/31/24 at 8:30 a.m., during an interview the Psychiatrist who documented the second opinion on 8/28/23 said he did not recall Patient #6. The Psychiatrist said, "I remember (CMO) speaking to me about a patient saying they had not seen me. I know I wasn't feeling well and took off some time around that time. I might have missed that one patient." The physician confirmed that all assessments must be completed face to face. "If it wasn't face to face it is incomplete." The psychiatrist looked through the clinical records and confirmed the second opinion was not repeated. "Yes, it should have been repeated but I was not working then so I don't know what was done."

On 10/31/24 at 10:30 a.m., during an interview the CEO reviewed grievance filed by Patient #6 and the grievance investigation. Based on emails and a phone conversation with the RM the CEO confirmed the allegation was substantiated on 8/30/23. The CEO said, "They should have repeated the second opinion. I could not tell you why the providers did not repeat it." The CEO confirmed the hospital is responsible for ensuring Baker Act regulations are followed saying, "the hospital is responsible we are responsible." The CEO did not provide any evidence of staff education or practice change to ensure this would not occur again. The CEO confirmed that Patient #6 patient rights were not upheld saying, "No, not with that situation."

Based on record review and interview, the facility failed to ensure that resident rights were honored by not obtaining consents and involving the designated representative in the participation of the patient's care plan for 1 (Patient #33) of 4 records reviewed.

The findings included:

Review of Park Royal Behavioral Health Services Discharge Planning Policy; policy origination date 1/1/2012, stated, "A discharge plan will be created based on information obtained from the patient, family, physician, medical record, and other information available and reassessed throughout hospital stay." Furthermore, the policy stated, "The patient/family will be given discharge instructions upon discharge by nursing staff, which includes, but is not limited to: medication reconciliation, follow-up appointments within seven days of discharge, and discharge referral information."

Review of Patient #33's health record showed an admission date of 12/2/23 and the patient was deemed incompetent; unable or refused to sign consents for treatment at the facility.

Review of Patient #33's health record showed documentation of an Agreed Order Expanding Authority of Guardian Advocate for the person and property of Patient #33, a developmentally disabled person, in the duty and responsibility to consent to medical treatment ordered on 7/9/2007, and a faxed confirmation of this documentation was received by the facility on 12/8/23.

Review of Patient #33's health record showed no documentation of attempt to obtain consents from legal guardian, and no documentation of collaboration of care in the development and implementation of the patient's plan of care, including discharge planning.

During an interview with the Chief Executive Officer (CEO) on 12/31/24 at 12:05 p.m., she said that the process for when the facility becomes aware of a guardian is that they should make an attempt to get consent from that guardian, and that the only two places she would look to see that documentation would be in provider notes or nursing notes. She then confirmed that she did not see documentation of consents obtained in Patient #33's health record.

Based on interview, record review, and hospital policy, the hospital failed to ensure an express and informed consent was completed prior to preforming Electroshock Therapy on 3 of 3 Patients surveyed (Patient #42, Patient #46, and Patient #45).

The findings included:

Review of the hospital policy #BA1013 "Right to Express and Informed Consent" last reviewed on 1/29/24 and effective 12/1/2018 reads, "prior to giving written and express and informed consent, the following information is disclosed to the client, guardian advocate, or proxy:

1. Purpose of the treatment provided.
2. Common side effects of medications.
3. Alternative appropriate treatment modalities ..."

Review of the "Consent to Electroconvulsive Therapy" for Patient #42 dated 10/18/24 lists the condition for which the procedure is being provided as "MDD". The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment is blank and uncompleted on the form. The Prognosis if the treatment is rejected is blank and uncompleted on the form.

On 10/29/24 at 2:20 p.m., Patient #42 said he was never told what MDD meant by the staff at the hospital prior to the procedure. Patient #42 verified he was never informed of the likelihood of success of the treatment and was never told of any alternatives to the treatment.
Review of the "Consent to Electroconvulsive Therapy" for Patient #46 dated 10/23/24 lists no condition for which the procedure is being provided. The area on the form where the diagnosis should be listed is covered with the patient's information sticker. The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment was listed as "None At This Time".

On 10/29/24 at 2:27 p.m., Patient #45 verified she had not been informed of the diagnosis she had electroconvulsive therapy for prior to the procedure. Patient #45 verified the area on the form had been covered prior to her signing the form. Patient #45 verified she had not been informed of any treatment alternatives prior to receiving the procedure.

Review of the "Consent to Electroconvulsive Therapy" for Patient #46 dated 9/23/24 lists no diagnosis for performing the procedure. The form lists the "LIKELIHOOD OF SUCCESS" the boxes provided as Good, Fair, Poor, and Unknown remains unchecked on the form. The Alternatives to Treatment is blank and uncompleted on the form. The Prognosis if the treatment is rejected is blank and uncompleted on the form. The check box that Patient #46 read and understood the statements on the form was left blank on the form.

On 10/29/24 at 3:00 p.m. the ECT (Electroconvulsive Therapy) Nurse verified she had obtained patient consents for Patients #42, #45, and #46. The nurse verified the three consents had not been completed appropriately as per hospital policy prior to the procedures.