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ST JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 Feb. 22, 2019
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on Review of Policy and Procedure, Medical Records, and Interviews the hospital failed to follow Policy and Procedure to obtain an Order of Protective Custody (OPC) in 1 out of 10 patient charts.

Findings:

Review of the Policy and Procedure for a Involuntary admission revealed the following information:

Policy and procedure TITLE: Involuntary Admissions NUMBER: CBH .11
When a patient is brought into the hospital with a warrant/legal document, the nurse documents the warrant on the chart and forwards the document to the appropriate personnel.
7.A physician must examine and evaluate the patient within 24 hours and sign the first Certificate of Medical Examination. This document allows the processing of an Order of Protective Custody, which allows legal holding of the patient for 14 days.
8. Upon signing the first certificate, the attending physician will designate a consulting physician to sign the second Certificate of Medical Examination before the patient ' s final hearing.
9.A probable cause hearing will be held within 72 hours of the Order of Protective Custody, a final hearing will occur within 5 days.


Medical Record Review of patient #1 revealed: that the patient did not have a notarized Order for Protective Custody (OPC) while a patient at the hospital. Patient #1, spent 11 days out of a 14 day admission with out an OPC.
Patient was admitted on a Emergency Detention Warrent on 1/16/2019

Medical record review of the patient's Discharge Summary dated 2/2/2019 revealed the following information about Patient #1.
admitted : 1/16/2019
discharge date : 2/01/2019
Admitting Diagnosis: Psychosis

Interview with employee #3 on 2/22/2019 at 09:30 revealed the following:
Our doctor told us he filled out the request and it was taken to the court.

The court has set up a meeting for our staff, they are going to go over how to obtain an OPC with our staff.

Interview with a representative from Harris County Probate Court on 2/26/2019 at 10:30 revealed that the policy for OPC's is as follows:
1. Bring completed patient paper work for order.
2. Bring Doctor affidavit
3. Bring f-25 completed and signed.
4. Give to clerk in file room.

When asked if there is proof of delivery the representative responded, "well when courier services drop paperwork off they get a delivery signature, but usually everyone else just drops them off because they know who we are". The Representative was asked could regular Hospital staff get a signature too. "Well, yes, there is no reason why the clerks would not sign off on receiving the forms".

Interview with employee #2 on 2/26/2019 at 10:00 revealed that she was aware that the patient did not have an OPC as was in the process of obtaining one, but she was discharged .