The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 July 25, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of each patient in the facility. The facility's noncompliance has placed the health and safety of patients in its care at risk for serious injury, serious harm, serious impairment, or death. This failure resulted in:

A. Thirty-one (31) bathroom doors in the bedrooms of patients on the Psychiatric Intensive Care Unit and the Intermediate Care Unit with observable ligature risks. There was a tie-off point on the top edge of the doors near the hinge. In addition, nine (9) patients had been placed on suicide precautions and placed in bedrooms with these bathroom doors. These ligature points could be used to attach material for the purpose of hanging or strangulation. Such actions have the likelihood to cause serious injury, impairment, or death.

B. Three (3) seclusion rooms had blind spots. The positioning of the bed created a blind spot on the furthest side of the room for staff monitoring the patient from outside the seclusion room door. Staff would not be able to observe a patient positioned on the floor between the bed and the wall.

Cross reference CFR 482.13(c)(2) A0144 - Patient Rights: Care in Safe Setting


C. A housekeeper left her unlocked housekeeping cart unattended in the hallway of a patient care area. This gave patients access to toxic chemicals, cleaning equipment (mop, broom, dust pan) that could be use as weapons to harm self or others, and rubber gloves that could be used for self-strangulation or suffocation.

Cross reference CFR 482.13(c)(3) A0145 - Patient Rights: Free from Abuse/Harassment


D. Nine patients did not have a 1-hour face-to-face by a qualified RN documented in the medical following the administration of medications that were used as a restriction to manage a patient's behavior.

Cross reference CFR 482.13(e)(16)(i) A0184 - Patient Rights: Restraint or Seclusion
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, review of medical records, and staff interviews, the facility failed to ensure that patients received psychiatric care in a safe setting.

A. This failure resulted in 31 of 31 rooms on the Psychiatric Intensive Care Unit and the Intermediate Care Unit with observable ligature risks. This was evidenced by the bathroom doors with an observable tie-off point on the top edge of the doors near the hinge. In addition, 9 of 9 patients (Patient #37, #38, #39, #49, #56, #58, #66, and #67) had been placed on suicide precautions and placed in bedrooms with these bathroom doors.

B. This failure resulted in 3 of 3 seclusion rooms with blind spots behind the bed. The positioning of the bed created a blind spot on the furthest side of the room for staff monitoring the patient from outside the seclusion room door. Staff would not be able to observe a patient positioned on the floor between the bed and the wall.

C. This failure resulted in 1 of 2 housekeepers left unlocked housekeeping cart unattended in the hallway of a patient care area. This gave patients access to toxic chemicals that could have been ingested, cleaning equipment (mop, broom, dust pan) that could have been used as weapons to harm self or others, and rubber gloves that could be used for self-strangulation or suffocation.


Findings:

A. Bathroom doors.

Observation of the Behavioral Health Department on 7/25/2016 9:00 AM - 10:00 AM revealed two patient care areas: 3rd floor - Psychiatric Intensive Care Unit and 4th floor - Intermediate Care Unit.

The Psychiatric Intensive Care Unit had 20 bedrooms - 4 private rooms and 16 semiprivate rooms. The capacity was 36 patients.

The Intermediate Care Unit had 19 bedrooms - 4 private rooms and 15 semiprivate rooms. The capacity was 34 patients.

The top edge of the bathroom door in room 3012 had been cut at an angle beginning at the top of the continuous hinge.

Staff OO (MHT) tied a knot in the corner of a sheet and secured it to the top edge of the hinged side of the bathroom door in room 3012, a patient's bedroom. Staff OO (MHT) applied his weight to the sheet. The sheet held his weight. Staff I and Staff X (RN) witnessed this demonstration.

In interviews with Staff I, Staff X (RN), and Staff OO (MHT) on 7/25/2016 at 9:15 AM, they stated that a patient could hang self by tying a knot in the corner of a sheet and securing it to the top edge of the hinged side of the bathroom door. They also stated that the top of the bathroom doors in all 31 bedrooms had been cut at an angle beginning at the top of the continuous hinge. They stated the doors posed a ligature risk.

In an interview with Staff I on 7/25/2019 at 2:00 PM, he stated that maintenance had altered a bathroom door in an effort to eliminate the tie off point at the top edge of the hinged side of the door. He further stated that maintenance had been unsuccessful in eliminating the ligature risk.

In an email with Staff F, Staff X, and Staff I on 7/30/2019 at 5:11 PM, they provided the names of 9 patients (Patient #37, #38, #39, #49, #56, #58, #66, and #67) that had been on suicide precautions during the tour of the Psychiatric Intensive Care Unit and the Intermediate Care Unit on 7/25/2019 (9:00 AM - 10:00 AM).


Record review of the Current Census - Detail dated 7/25/2019 at 11:05 AM showed the following:

Psychiatric Intensive Care Unit
Patient #29 - room 3015 B
Patient #37 - room 3021 A
Patient #38 - room 3021 B
Patient #39 - room 3022 A
Patient #49 - room 3037 B
Patient #66 - room 3014 A
Patient #67 - room 3030 A

Intermediate Care Unit
Patient #56 - room 4019 B
Patient #58 - room 4021 B


Patient #29.
Record review of the Information Sheet showed Patient #29 was admitted into Adult Psychiatry on 7/8/2019 at 11:50 AM with psychosis. This emergency admission was through the court system. Staff FF was the attending physician.

Record review of the Physician Order Sheet showed that Staff RR (MD) ordered suicide precautions for Patient #29 on 7/8/2019 at 12:00 PM.


Patient #37.
Record review of the Information Sheet showed Patient #37 was admitted into Adult Psychiatry as a voluntary admission on 7/24/2019 at 5:15 PM with psychosis. Staff QQ was the attending physician.

Record review of the Physician Order Sheet showed that Staff SS (PA) ordered suicide precautions for Patient #37 on 7/24/2019 at 5:39 PM.


Patient #38.
Record review of the Information Sheet showed Patient #38 was admitted into Adult Psychiatry as a voluntary admission on 7/21/2019 at 12:51 PM with schizophrenia. Staff EE was the attending physician.

Record review of the Physician Order Sheet showed that Staff RR (MD) ordered suicide precautions for Patient #38 on 7/21/2019 at 12:56 PM.


Patient #39.
Record review of the Information Sheet showed Patient #39 was admitted into Adult Psychiatry as a voluntary admission on 7/16/2019 at 12:33 PM. Staff GG was the attending physician.

Record review of the Physician Order Sheet showed that Staff TT (PA) ordered suicide precautions for Patient #39 on 7/16/2019 at 12:36 PM.


Patient #49.
Record review of the Information Sheet showed Patient #49 was admitted into Adult Psychiatry as a voluntary admission on 7/13/2019 at 4:39 PM with psychosis. Staff EE was the attending physician.

Record review of the Physician Order Sheet showed that Staff RR (MD) ordered suicide precautions for Patient #49 on 7/13/2019 at 4:53 PM.


Patient #56.
Record review of the Information Sheet showed Patient #56 was admitted into Adult Psychiatry as a voluntary admission on 5/15/2019 at 9:01 PM with psychosis. Staff QQ was the attending physician.

Record review of the Physician Order Sheet showed that Staff UU (FNP) ordered suicide precautions for Patient #56 on 5/15/2019 at 9:12 PM.


Patient #58.
Record review of the Information Sheet showed Patient #58 was admitted into Adult Psychiatry as a voluntary admission on 7/16/2019 at 11:17 PM. Staff GG was the attending physician.

Record review of the Physician Order Sheet showed that Staff RR (MD) ordered suicide precautions for Patient #58 on 7/17/2019 at 12:00 AM.


Patient #66.
Record review of the Information Sheet showed Patient #66 was admitted into Adult Psychiatry as a voluntary admission on 7/18/2019 at 3:41 PM. Staff GG was the attending physician.

Record review of the Physician Order Sheet showed that Staff SS (PA) ordered suicide precautions for Patient #66 on 7/18/2019 at 4:40 PM.


Patient #67.
Record review of the Information Sheet showed Patient #67 was admitted into Adult Psychiatry as a voluntary admission on 7/16/2019 at 4:40 PM with suicidal ideation. Staff QQ was the attending physician.

Record review of the Physician Order Sheet showed that Staff SS (PA) ordered suicide precautions for Patient #67 on 7/16/2019 at 4:48 PM.


B. Blind spots in seclusion rooms.

Observation of the seclusion rooms on the Psychiatric Intensive Care Unit on 9/25/2019 at 9:50 AM revealed a bed bolted to the floor. The door to the seclusion room had a dome-shaped observation window. The position of the bed created a blind spot at floor level on the side of the bed furthest from the door.

Record review of the policy PCTS2016.005, "Restraint and Seclusion Policy and Guidelines," final approval date 10/22/2018, showed:

"7. Assessment and Monitoring of Restraint/Seclusion ...

"Monitoring: Restrained or secluded patients shall be subject to monitoring by individuals trained to do so. Restrained/secluded patients shall be continuously monitored every 15 minutes for the physiological and psychological effect of the restraint/seclusion on the patient ..."

In an interview with Staff I on 9/25/2019 at 9:50 AM, he stated that there is a total of three seclusion rooms for the Psychiatric Intensive Care Unit and the Intermediate Care Unit. He further stated that a staff member would be assigned to observe a patient in the seclusion room through a dome-shaped observation window in the seclusion room door. He stated that there was a blind spot in the seclusion room at floor level on the side of the bed furthest from the door. He concluded by saying that a convex mirror in the corner of the room would provide a means for staff to observe the patient, thus alleviating the blind spot.



C. Housekeeping carts unattended.

Observation on the Psychiatric Care Unit on 9/27/2019 at 9:15 AM revealed an unattended housekeeping cart in the hallway. There was no housekeeping staff in sight. The hood on top of the cart was not locked. Chemicals inside the hooded storage area included Oxycide Daily Disinfectant Cleaner [harmful if swallowed; causes skin burns and eye damage; toxic if inhaled] and a toilet bowl cleaner. On the top of the cart was an open box of rubber gloves. At one end of the cart was a dust pan and broom with handles about three feet in length. There was also a mop with a handle about five feet in length. Staff V (housekeeper) came out of the patient bedroom adjacent to the cart. She had been in a patient bedroom, behind the closed door.

In an interview with Staff V (housekeeper) on 7/25/2019 at 9:20 AM, she stated that 7/25/2019 was her first time to work on a psychiatric unit. She also stated she was not trained to keep the housekeeping cart within sight.

In an interview with Staff X (Nurse Manager for Behavioral Health) on 7/25/2019 at 9:25 AM, she stated that Staff V (housekeeper) had never worked on the Psychiatric Intensive Care Unit, adding that Staff V (housekeeper) was a contracted employee. Staff X also stated that orientation for the housekeepers included training to keep the housekeeping cart within sight.

Record review of the Human Resources personnel file for Staff V (housekeeper) showed a five question quiz titled, "Suicide Risk Assessment and Prevention Quiz." The quiz and the accompanying Attestation were dated 6/5/2019 and signed by Staff V. One of the correct answers for question 5 read: "Never leave equipment or supplies where you cannot see it all [sic] times." The five page "Initial Department Skills Competency EVS Technician" checklist was dated 4/29/2019 and signed by Staff V. The checklist did not cover any behavioral health procedures or safety practices.

In an interview with Staff I and Staff X on 7/25/2019 at 9:20 AM, they both stated that training was needed for housekeepers working the behavioral health area.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview with administrative nursing staff and medical record review, the facility failed to ensure that a 1-hour face-to-face was documented in the patient's medical record by a qualified RN following the administration of medications that were used to manage a patient's behavior. This failure resulted in 9 of 9 instances in which a 1-hour face-to-face was not documented in the medical record for Patient #2, #20, #21. #22, #23, #24, #25, #26, and #27.

Findings:

In an interview with Staff X and Staff I on 7/25/2019 at 9:00 AM, they stated that a 1-hour face-to-face medical and behavioral evaluation is not completed on patients that receive emergency medications resulting from behavior that is a danger to self or others. Staff X further stated that the 1-hour face-to-face medical and behavioral evaluation is performed only when there is a physical restraint concurrent with the emergency medications.

Record review of the policy PCTS2016.005, "Restraint and Seclusion Policy and Guidelines," approval date 10/22/2018, showed:

"Restraint or seclusion is used only to ensure the immediate physical safety of the patient, a staff member, or others ...
"d. Chemical restraint is the use of a medication used to restrict the patient's freedom of movement that is not a standard treatment for the patient's new or continuing medical or behavioral condition.

"e. Emergency psychoactive medication administration is the use of a psychoactive medication to treat the signs and symptoms of mental illness in a psychiatric emergency when other interventions are ineffective or inappropriate ...

"3. RESTRAINT/SECLUSION USE:

"a. Use of Antipsychotic Medications to Manage Violent Behavior: Antipsychotic medications shall be used ... to protect the patient or others ... Such use is considered an 'Emergency Psychoactive Medication Administration' and therefore must be used only when other interventions are ineffective or inappropriate. This medication will be ordered as a single, immediate administration for a psychiatric emergency. The use of non-standard medications or doses for this purpose is considered a 'Chemical Restraint' and is prohibited.

"Monitoring of vital signs as appropriate for the potential sedating effect of the medication and dose, and physiological and psychological impact upon the patient ..."

"7. Assessment and Monitoring of Restraint/Seclusion

"a. Restraint used for the management of violent behavior:

"One-hour Face-to-face Assessment: A responsible licensed independent practitioner, qualified registered nurse or physician's assistant shall perform a face-to-face assessment within 1 hour of the initiation of restraint or seclusion. The assessment should take into account the patient's immediate situation, the patient's reaction to the intervention, the patient's medical or behavioral condition ..."


Patient #2.

Record review of the Psychiatric Evaluation by Staff EE (MD), dated 3/12/2019 at 4:45 PM, for Patient #2 showed a [AGE]-year-old male, probably schizophrenic, off medications for several months. He was delusional, paranoid, and experiencing auditory hallucinations. He believed others were out to kill him. He lunged at staff. As a result of his danger to others, he was given medication.

Record review of the Medication Administration Record, dated 2/22/2019 at 9:35 AM, for Patient #2, showed Haldol 5 mg, diphenhydramine 50 mg, and lorazepam 2mg intramuscular were ordered by Staff EE (MD).

Record review of the medical record of Patient #2 for 2/22/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Haldol 5 mg, diphenhydramine 50 mg, and lorazepam 2mg intramuscular on 2/22/2019 at 9:35 AM.


Patient #20.

Record review of the Emergency Medication Use Tracking Log, dated 5/29/2019 at 9:22 AM, for Patient #20 showed a [AGE]-year-old female patient with physical aggression; highly erratic, unpredictable behavior; and psychosis. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg were administered intramuscular by Staff II (RN).

Record review of the medical record of Patient #20 for 5/29/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg intramuscular on 5/29/2019 at 9:22 AM.


Patient #21.

Record review of the Emergency Medication Use Tracking Log, dated 5/30/2019 at 8:00 PM, for Patient #21 showed a [AGE]-year-old female patient with physical aggression; highly erratic, unpredictable behavior; and psychosis. Ativan 2 mg, Haldol 10 mg, and Benadryl 50 mg were administered intramuscular by Staff JJ (RN).

Record review of the medical record of Patient #21 for 5/30/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg, Haldol 10 mg, and Benadryl 50 mg intramuscular on 5/30/2019 at 8:00 PM.


Patient #22.

Record review of the Emergency Medication Use Tracking Log, dated 6/1/2019 at 10:50 AM, for Patient #22 showed a [AGE]-year-old female patient with physical aggression; highly erratic, unpredictable behavior; psychosis; and spitting on staff. Haldol 5 mg, and Benadryl 50 mg were administered intramuscular by Staff KK (RN).

Record review of the medical record of Patient #22 for 6/1/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Haldol 5 mg, and Benadryl 50 mg intramuscular on 6/1/2019 at 10:50 AM.


Patient #23.

Record review of the Emergency Medication Use Tracking Log, dated 6/2/2019 at 2:50 PM, for Patient #23 showed a [AGE]-year-old female patient with physical aggression, highly erratic and unpredictable behavior, psychosis, and aggression in group. Geodon 10 mg and Benadryl 50 mg were administered intramuscular by Staff KK (RN).

Record review of the medical record of Patient #23 for 6/2/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Geodon 10 mg and Benadryl 50 mg intramuscular on 6/2/2019 at 2:50 PM.


Patient #24.

Record review of the Emergency Medication Use Tracking Log, dated 6/11/2019 at 9:00 AM, for Patient #24 showed a [AGE]-year-old male patient with highly erratic and unpredictable behavior, and psychosis. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg were administered intramuscular by Staff HH (RN).

Record review of the medical record of Patient #24 for 6/11/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg intramuscular on 6/11/2019 at 9:00 AM.


Patient #25.

Record review of the Emergency Medication Use Tracking Log, dated 6/11/2019 at 9:12 PM, for Patient #25 showed a [AGE]-year-old male patient with physical aggression, highly erratic and unpredictable behavior, psychosis, and throwing objects. Ativan 2 mg, Haldol 5 mg, and Benadryl 50 mg were administered intramuscular by Staff LL (RN).

Record review of the medical record of Patient #25 for 6/11/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg, Haldol 5 mg, and Benadryl 50 mg intramuscular on 6/11/2019 at 9:12 PM.


Patient #26.

Record review of the Emergency Medication Use Tracking Log, dated 6/13/2019 at 7:30 AM, for Patient #26 showed a [AGE]-year-old male patient with physical aggression and, highly erratic and unpredictable behavior. Ativan 2 mg, Geodon 20 mg, and Benadryl 50 mg were administered intramuscular by Staff MM (RN).

Record review of the medical record of Patient #26 for 6/11/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg, Geodon 20 mg, and Benadryl 50 mg intramuscular on 6/13/2019 at 7:30 AM.


Patient #27.

Record review of the Emergency Medication Use Tracking Log, dated 6/13/2019 at 7:30 AM, for Patient #27 showed a [AGE]-year-old female patient with disruptive, highly erratic, and unpredictable behavior. Ativan 2 mg and Haldol 5 mg were administered intramuscular by Staff NN (RN).

Record review of the medical record of Patient #27 for 6/13/2019 showed that a 1-hour face-to-face medical and behavioral evaluation was not performed following the administration of emergency medications, Ativan 2 mg and Haldol 5 mg intramuscular on 6/13/2019 at 7:30 AM.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, record review of policies, and interview with nursing staff, the director of nursing services and the facility failed to ensure that nursing personnel had the appropriate education and competence to provide nursing care for each patient to meet the individual needs of each patient. Failure to do so resulted in:

A. 1 of 1 post-surgical patient (Patient #6) received nursing care of a Jackson-Pratt drain that did not follow evidence-based practice standards and guidelines, as well as the facility's policies and procedures. This was evidenced by Staff Y failing to use an antiseptic pad to clean the unit's spout and plug after draining the unit.

B. 1 of 1 staff members (Staff Z) was not assessed for competence relative to closed-wound drain removal. In addition, Staff Z failed to obtain a physician's order to discontinue the Jackson-Pratt drain and failed to document the procedure.

C. 1 of 4 patients (Patient #3) that requested discharge was not provided with a Twenty-four Hour Letter, Patient Request for an Early Discharge form to sign. In addition, the Twenty-four Hour Letter, Patient Request for an Early Discharge forms did not have a patient label for 3 of 3 patients (Patient #17, #18, and #19).


Findings:

A. Cleaning of Jackson-Pratt drain spout and plug - Staff Y.

Record review of policy PCTS2016.032, "Nursing Care / Procedure Reference," approved 9/28/2018, showed:

"1. Nursing care is delivered based on evidence-based practice standards and guidelines from the professional nursing organizations, national, state, and local regulatory agencies, and institutional policies and procedures ...

"3. Lippincott Procedures is accepted as the standardized manual to be used as a reference for basic nursing care procedures ..."


Record review of Lippincott Procedures - closed-wound drain management, reviewed 2/15/2019, showed:

"Equipment ... antiseptic pad ...

"Implementation ... Release the vacuum by removing the spout plug on the collection chamber ... Empty the unit's contents ... Use an antiseptic pad to clean the unit's spout and plug ..."


Observation on 7/24/2019 at 11:35 AM of Staff #25 providing care to Patient #6 showed six (6) Jackson-Pratt drains. Each drain was numbered. Staff #25 removed the spout plug on the first collection chamber and emptied the unit's contents. She did not use an antiseptic pad to clean the unit's spout and plug.


In an interview with Staff Y on 7/24/2019 at 12:00 PM, she described the procedure for changing dressings and emptying the collection chamber of a Jackson-Pratt drain. Staff Y stated she did not clean the unit's spout and plug with an antiseptic pad when providing care for Patient #6, adding she did not remember orientation or competency training that outlined that procedural step.


In interviews with Staff D and Staff C on 7/24/2019 at 11:50 AM, they stated they did not know that they were to use an antiseptic pad to clean the spout and plug on the Jackson Pratt collection chamber after emptying the chamber of its contents. They both agreed that additional training was indicated.


B. Removal of a Jackson-Pratt drain - Staff Z.

In an interview with Staff A on 7/24/2019 at 9:30 AM, he stated:

a) He had been the attending physician and surgeon for Patient #1;

b) Staff Z was the bariatric nurse that worked closely with him;

c) Staff Z was an employee of the facility; and

d) Staff Z removed the Jackson-Pratt drain from Patient #1 on the day of discharge.


Record review of the medical record for Patient #1 showed that the patient was admitted on [DATE] and discharged [DATE] under the care of Staff A. There was no physician's order to discontinue the Jackson-Pratt drain.


In an interview with Staff Z on 7/24/2019 at 11:00 AM, she stated she is the bariatric coordinator for Staff A. She also stated that in her role as the bariatric coordinator, she removes Jackson-Pratt drains.


In an interview with Staff D on 7/24/2019 at 11:25 AM, she stated that staff nurses provide maintenance care and discharge education on Jackson-Pratt drains, but do not "pull" (remove) the drains. She also stated that Staff Z needs a documented competency to remove a closed-wound drain, as well as any nurse that performs this procedure in the future.

Record review of the HR file for Staff Z showed that there was no competency for closed-wound drain removal.


C. Request for release.

Record review of the policy CBH.02, "Twenty-four Hour Letter, Patient Request for an Early Discharge," final approval date 1/5/2018, showed:

"Patients admitted voluntarily have the right to request discharge from The Center for Behavioral Health against the physician's medical advice. A patient requesting discharge must be released within 4 hours of the request if there is no commitment proceedings initiated wand the physician determines that the patient does not pose a threat to harm self or others ...

"Procedure:

"1. The patient must sign a Request for Release form ("24 Hour Letter) or make a verbal request, which will be documented, in the patient's medical record. If a patient makes a verbal request to leave but refuses to sign the "Request for Release" letter, the staff much write on the "Request for Release" form that the patient requested to leave the hospital but refused to sign the "Request for Release" letter.

"2. The letter must be witnessed by a staff member with the time and date noted. If a patient refuses to sign, then two staff members must witness the letter. The staff must note on the letter that the patient refused to sign."


Record review of the Psychiatric Evaluation by Staff GG, dated 2/20/2019 at 10:17, for Patient #3, showed that she told the physician she wanted to go home.


Record review of a Progress Note by Staff PP, dated 2/20/2019 at 5:06 PM, for Patient #3, showed: "Patient ... requesting to be discharged or be transferred ... Patient was seen by hospitalist and psychiatrist today ..."


Record review of the medical record of Patient #3 dated 2/19/2019 - 3/13/2019 showed there was no Twenty-four Hour Letter, Patient Request for an Early Discharge form signed by the patient.


In an interview with Staff W on 7/25/2019 at 9:40 AM, she stated that when a patient requests release from the hospital, the patient should be offered a "24-hour letter" to sign. She also stated she would immediately notify the physician.


Record review of the Twenty-four Hour Letter, Patient Request for an Early Discharge form for Patient #17, #18, and Patient #19 did not have a patient identification label.


In an interview with Staff X on 7/25/2019 at 1:00 PM, she stated that sometimes staff does not put a label on the Twenty-four Hour Letter, Patient Request for an Early Discharge form prior to scanning into the electronic record. She also stated that the patient should be identified on the form.