Failure to Inform Resident and Obtain Consent for Involuntary Psychiatric Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed of and able to choose her treatment when she was transferred to a psychiatric facility against her will. The resident had diagnoses of bipolar disorder, anxiety disorder, and mild cognitive impairment, and a recent MDS assessment documented that she was cognitively intact, independent with all ADLs, and had no behaviors or rejection of care during the assessment period. An Emergency Detention Order (EDO) was completed stating that the resident had a psychiatric condition impairing her judgment, was unwilling to accept treatment voluntarily in the facility, and had demonstrated impaired judgment and the physical capacity to cause grave harm to herself and others, including verbal aggression, threats, and spraying chemicals. The order directed law enforcement to take her into custody and transport her to a psychiatric facility. A care management note documented that the resident was taken to a psychiatric hospital under a court order after she refused to go, and that she was escorted by police. On readmission, an NP note recorded that the resident was irritable and stated she intended to sue the facility for sending her to another facility without her permission. At the psychiatric facility, a progress note indicated the sending facility had reported that over the prior 72 hours the resident had been physically and verbally aggressive, cursing and yelling at her roommate, refusing to remove her belongings from the roommate’s side of the room, and spraying a staff member in the face with chemicals to cover a bowel movement odor. The psychiatric facility note also documented that the resident reported she was unclear why she had been sent there and that the reason for the transfer had never been explained to her. Interviews with facility staff showed discrepancies and lack of documentation supporting the behaviors and refusals cited in the EDO. The DON stated the resident had become manic, was pacing the halls, and refusing medications, and that she initially agreed to go to the hospital but refused when she learned it was a psychiatric hospital; the DON also stated the resident had not displayed aggressive behaviors and that documentation of refused medications and manic behaviors was only in the court order. Review of the MAR and progress notes revealed no nursing documentation of medication refusals, with refusals only noted by the SSD. The SSD reported she verbally relayed behavior information, including the alleged spraying incident, to the psychiatric facility based on staff reports that were not specifically documented in the clinical record and could not identify who was sprayed. The NP stated she completed the EDO using information provided by the SSD and that certain wording was needed to qualify for emergency detention; she acknowledged her own clinical notes did not support the description of the resident as verbally abusive to others and that she was not personally aware of specific behavior incidents. The DON later indicated she was unsure why the resident had been sent to a psychiatric hospital and had not been fully informed of the resident’s behaviors, underscoring that the resident’s transfer occurred without clear documentation and without the resident understanding or consenting to the psychiatric transfer.
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