HospitalInspections.org

Based on review of the hospital's Medical Staff Bylaws and Rules and Regulations, review of medical record and interview, it was determined that Family Nurse Practioner (FNP) # 11 failed to comply with the Rules and Regulations, related to the History and Physical Examination, for 1 of 1 "Legally Blind" patient (Pt # 33), posing a risk that the patient's medical condition would be overlooked.

Findings include:

Review of the hospital Medical Staff Bylaws revealed: "...Membership on the Medical Staff or the exercise of Temporary Privileges is a privilege that shall be granted to and continued with only professionally qualified and currently competent Members who:...comply with the provisions of these Bylaws, the Rules and Regulations, and the Facility's policies and procedures...."

Review of the hospital Rules and Regulations of the Medical Staff revealed: "...The History and Physical Examination must be performed by a practitioner with Clinical Privileges to perform such task. The complete History and Physical examination in all cases will be completed and recorded in the chart within 24 hours after admission of the patient...The following shall be included in the H&P:...Review of systems...."

Review of Pt # 33's medical record revealed:

Pt # 33 was admitted on 5/7/16 and his/her medical record contained documentation that s/he was "Legally Blind". Review of FNP # 11's documentation of Pt # 33's History and Physical Examination revealed a Review of Systems. FNP # 11 marked the box designated for " Constitutional: WNL" (Within Normal Limits), for "Vision changes". FNP # 11 also marked the box "WNL" for "Eyes" in the documentation of Pt. # 33's History and Physical Examination.

MD # 10 confirmed, during interview conducted on 5/11/16, that the documentation of the History and Physical Examination of Pt # 33, by FNP # 11 was "unacceptable" and incomplete.

Based on review of hospital policies/procedures, hospital documents, job descriptions, personnel files, medical records and interviews, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with implementation of hospital policies, individualized assignment and supervision of patient care and correct administration and documentation of administration of medication for each patient as evidenced by:

(A395) failure to ensure that a Registered Nurse supervised and evaluated the nursing care of patients, posing a risk to the health and safety of patients as evidenced by:

1. failing to complete and document an RN assessment and discharge note for 1 of 1 patient who left the facility against medical advice (AMA) (Pt # 13) as per facility policy;

2. failing to complete and document an RN reassessment, as required by hospital policy/procedure, for 1 of 1 patient who was transferred to an acute medical center (Pt # 25) and 1 of 1 patient on Title 36 Court Ordered Treatment (Pt # 26); and

3. failing to report to designated authorities the allegation made, by 1 of 1 minor patient, of sexual abuse by adults at his/her school (Pt # 27); and

4. failing to evaluate the nursing care provided for 1 of 1 patients who presented to the Intake and Referral Department (Emergency) as a "Walk-In" who had reportedly not taken medications for a month, and had an elevated blood pressure; the patient returned the next day and had a blood pressure that was trending upward (Patient #22);

(A397) failure to ensure that a Registered Nurse assigned the nursing care of each patient in accordance with the individual patient's needs, posing a risk to patient health and safety; and

(A405) failure to administer and document administration of medications according to accepted standards of practice, hospital policy/procedure and/or physician orders, posing a risk to patient health and safety as evidenced by:

1. RN staff documenting administration of medication prior to actual administration, and failing to observe that patients swallowed their medication, for 2 of 2 adolescent patients (Pt #s 23 and 24). The potential risk is that medications documented as given prior to actually being given could be inadvertently assumed to be administered by another nurse, therefore not given; a patient could "cheek" and save medications for later ingestion if not observed to have swallowed the medication;

2. RN staff failing to document administration of medication ordered for alcohol withdrawal for 1 of 1 patient with a history of withdrawal seizures who required transfer to an acute medical center (Pt # 25), posing a risk of overmedication of the patient; and

3. RN staff administering medication for anxiety, without an order, for 2 of 2 patients who were receiving treatment for alcohol withdrawal (Pt #s 28 and 29), posing a risk to patient health and safety if the wrong dosage of medication was given.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of the Registered Nurse (RN) job description, policy and procedure, medical record and interview, it was determined that a Registered Nurse (RN) failed to supervise and evaluate the nursing care of patients, posing a risk to the health and safety of patients, as evidenced by:

1. failing to complete and document an RN assessment and discharge note for 1 of 1 patient who left the facility against medical advice (AMA) (Pt # 13) as per facility policy;

2. failing to complete and document an RN reassessment, as required by hospital policy/procedure, for 1 of 1 patient who was transferred to an acute medical center (Pt # 25) and 1 of 1 patient on Title 36 Court Ordered Treatment (Pt # 26); and

3. failing to report to designated authorities the allegation made, by 1 of 1 minor patient, of sexual abuse by adults at his/her school (Pt # 27); and

4. failing to evaluate the nursing care provided for 1 of 1 patients who presented to the Intake and Referral Department (Emergency) as a "Walk-In" who had reportedly not taken medications for a month, and had an elevated blood pressure; the patient returned the next day and had a blood pressure that was trending upward (Patient #22).

Findings include:

Review of hospital job description Job Title "Registered Nurse" revealed: "...Conducts patient assessments and provides nursing interventions to patients as assigned...Complete nursing reassessments as assigned, and any time a change in status is observed or reported by team members...Oversee all aspects of patient care and complete assignments as assigned by the Charge Nurse...Ensure patients are discharged with all personal medication, belongings, prescriptions, discharge and referral information...Document as required including assessments, nursing notes...discharge planning...."

Review of hospital policy/procedure titled Re-assessment of Patient Needs revealed: "...The Registered Nurse will complete a full re-assessment of the patient every 24-hours and document this in the daily notes...will address issues of pain management, symptoms changes and reductions, response to medications, changes in behavior demonstrated on the unit, and any physical changes that might effect treatment and treatment outcome...."

1. Review of Pt # 13's medical record revealed:

Patient # 13 was admitted to the facility on April 19, 2016 with a diagnosis of Heroin detoxification. Patient requested to leave against medical advice (AMA) on April 22, 2016. MD # 4 progress note dated April 22, 2016 revealed that patient #13 was stable and had no delusions or hallucinations, not a danger to others or self.

Pt # 13's medical record did not contain documentation of an RN assessment or any RN progress note for April 22, 2016. The last nursing assessment and nursing progress note was completed on April 21, 2016 at 1800.

The Assistant Director of Nursing confirmed, during interview conducted on May 5, 2016, that an RN did not complete the required assessment and documentation for Patient # 13 for April 22, 2016.

2. Review of hospital policy/procedure titled Nursing Staff Allocation, Date: 1/2012, revealed: "...Registered Nurse prescribes, delegates and coordinates care of all patients to assure the following mechanisms are in place:...Assessment of patients takes place prior to assignment of staff...."

Review of hospital policy/procedure titled Re-assessment of Patient Needs, Revised 3/14/13, revealed: "...Re-Assessment and notes completed at least every 24 hours by the Registered Nurse will include only one nurse assessment and one note per 24 hour period as follows: Day Shift Nurse-Even numbered rooms on Monday, Wednesday, Friday and Sunday; Odd-numbered rooms on Tuesday, Thursday and Saturday...Evening Shift Nurse-odd numbered rooms on Monday, Wednesday, Friday and Sunday; Even-numbered rooms on Tuesday, Thursday and Saturday...Night Shift Nurse-24-hour chart check and assessments/notes by exception only...."

The Acting Director of Nursing confirmed, during interview conducted on 5/4/16, that nursing currently is scheduled on 12-hour shifts. The day shift is scheduled from 0700-1930 and the night shift is scheduled from 1900-0730. S/he confirmed, on 5/5/16 that reassessments should be completed every shift for patients who require acute hospitalization such as that provided by Sonora.

Review of hospital policy/procedure titled Initial Assessment/Admission Process, Date Effective: 03/01/2014, revealed: "...Nursing Assessment...Nursing Assessments are provided by the registered nurse upon admission to the inpatient hospital and observation services...The Nursing Assessment and the Intake Assessment provide the core documents which drive the initial assessment and treatment planning processes for these programs until the comprehensive treatment plan is completed...Each patient is completely reassessed at least every shift and more often if needed related to the patient's course of treatment; to determine the patient's response to treatment; when a significant change occurs in the patient's condition; and when a significant change occurs in the patient's diagnosis...."

Patient # 25

Review of Pt # 25's medical record revealed:

Pt # 25 was admitted on 4/29/16, with a diagnosis of "Opioid use disorder, severe; Alcohol use disorder, severe; and Unspecified Depressive Disorder." On 5/5/16, Pt # 25 was transferred to an acute medical center "...for admission to higher level of care for continued alcohol detox...."

Nursing documented:

Reassessment on 4/29/16, at 0400 with Progress Notes at 0500 and 0530;

Reassessment on 4/29/16, at 1510, with Progress Notes at 1510, 1700 and 1730;

Reassessment on 4/30/16, at 1025, with Progress Notes at 0300 and 1025;

Reassessment on 5/1/16, at 1230, with Progress Notes at 1250;

Reassessment on 5/2/16, at 1045, with Progress Notes at 0700, 1000, 1030, 1100 and 1900;

No Reassessment on 5/3/16 and no Progress Note on 5/3/16;

Reassessment on 5/4/16, at 1800, with Progress Notes at 1800 and on 5/5/16, at 0530;

Reassessment on 5/5/16, at 1200, with Progress Notes at 0800, 1000, 1100, 1140, 1200 and 1220. Patient # 25 was transferred to an acute medical center on 5/5/16, at 1220.

Pt # 25's medical record did not contain a Nursing Reassessment or Nursing Progress Note on 5/3/16. An RN did not document a reassessment from 5/2/16 at 1045 until 5/4/16 at 1800.
Nursing did not reassess Pt # 25 every shift.

RN # 30 and the Acting Director of Nursing confirmed, during interview conducted on 5/5/16,
that nursing failed to reassess Pt # 25, as required on 5/3/16.

RN # 30 confirmed that reassessments were not documented every shift.

Patient # 26

Review of Pt # 26's medical record revealed:

Pt # 26 was admitted on 12/14/16, and documentation included that Pt # 26 was
on Title 36 Court Ordered Treatment.

Review of Nursing Reassessments and Nursing Progress Notes between 4/25/16 and 5/6/16, revealed:

Nursing Reassessment for 4/26/16 was blank with a Progress Note at 1745;

Reassessment on 4/27/16, at 1000, with Progress Note at 2020;

Reassessment on 4/28/16, at 1200, with Progress Note at 1100;

Reassessment on 4/29/16, at 0831, with Progress Note at 1930;

No Reassessment or Progress Note on 4/30/16;

Reassessment on 5/1/16, at 1730, with Progress Note at 1730;

Reassessment on 5/2/16, at 1520, with Progress Note at 1520;

Reassessment on 5/3/16, at 1730, with Progress Note at 1745;

Reassessment on 5/4/16, at 0850, with Progress Note at 1800;

Reassessment on 5/5/16, at 1355, with Progress Note at 1355; and

Reassessment on 5/6/16, at 0910, with Progress Not at 1440.

Pt # 26's medical record did not contain a Nursing Reassessment on 4/26/16. It did not contain a Nursing Reassessment or Progress Note for 4/30/16. An RN did not document a reassessment from 4/29/16 at 0831 until 5/1/16 at 1730.
Pt # 26 was not reassessed by an RN every shift.

RN # 25 confirmed, during interview conducted on 5/10/16, that nursing had not documented the reassessment of Pt # 16 as required by hospital policy/procedure.

3. Review of hospital policy/procedure titled Abuse, Exploitation or Neglect Reporting-Child or Vulnerable Adult revealed: "...Appropriate reporting occurs when suspicion arises that a patient may have been or is at risk for abuse, exploitation or neglect...Documentation is completed by the reporting party for all reports made to comply with ARS 46-454. Staff is to immediately report suspected or alleged abuse, neglect, and exploitation to the CEO/designee...Reports will be called in to Child Protective Services and Pima County Sheriff's Department as mandated by law...The Medical Record shall include documentation of examinations, treatment given, any referrals made to other care providers and to community agencies and any required reporting to the proper authorities...."

Patient # 27

Review of Pt # 27's medical record revealed:

On 4/21/16, RN # 26 documented, on the Nursing Assessment for Child/Adolescents: "...talking about sexual abuse 'I was sexually abused by adults at my school and nobody believes me'...."

On 4/21/16, at 2355, RN # 26 documented: "...when asked regarding sexual/physical abuse stating 'adults @ my school sexually abused me and nobody believes me'...."

Pt # 27's medical record did not contain documentation of any follow-up by nursing regarding Pt # 27's allegation.

The Interim Assistant Director of Nursing confirmed, during interview conducted on 5/4/16, that she was unable to find documentation that a report was made to proper authorities, as required by hospital policy/procedure, or that any other follow-up took place.

RN # 26 stated, during interview conducted on 5/5/16, that she had verbally reported Pt # 27's allegation of abuse during nursing report, at shift change on 4/22/16. S/he also stated that s/he had reported the allegation to a Social Worker, on 4/22/16. RN # 26 stated that s/he had not notified authorities prior to 5/4/16, (when the surveyors were on-site). S/he stated that she was aware that a report to authorities was required, but s/he thought that the individuals from the oncoming shift would report it. S/he did call the Department of Child Safety on 5/4/16, after a conversation with the Interim Assistant Director of Nursing Services. RN # 26 stated that s/he also called MD # 5, on 5/4/16 and notified him/her of the allegation.

MD # 5 confirmed, during interview conducted on 5/5/16, that s/he had not been informed of the allegation made by Pt # 27 on 4/21/16. S/he confirmed that the allegation required a report to Department of Child Services. S/he also stated that he would follow up with an interview of Pt # 27, since he became aware of the allegation on 5/4/16.

MSW # 31, stated, during interview conducted on 5/5/16, that the usual practice of the hospital is for the individual who heard the allegation firsthand would make the report to authorities.

4. The policy titled "Initial Assessment/Admission Process," dated 03/01/14, revealed: "POLICY: It is the policy of (Hospital) to provide each patient, regardless of referral source or payer, with an assessment that determines the appropriate level of care and identifies individual care needs through the collection of data, analyzing data and determining appropriate care decisions .... "

Patient # 22

Patient #22 presented to the hospital on a voluntary basis on 04-10-16, with a "Chief Complaint" which included "Need Help" and "Need meds." The patient reported that family members had put chips in his back and that he needed the chips out. The patient endorsed "AVH" (Auditory/Visual Hallucinations).

Patient #22 had vital signs which included a blood pressure of 156/80, a pulse of 75, respirations of 16, and a temperature of 97.4 (degrees Fahrenheit). The field for "Pain Rating" was blank.

The patient-reported "Medical History Part I" revealed that the patient had marked an "x" in the field titled "Uncontrolled pain." The patient checked that he had chronic pain, drug dependency, and sleep apnea. The patient did not check that he used "Illicit drugs." The patient also self-reported that s/he had night sweats, and uncontrolled pain. The patient reported that s/he needed an "implant" taken out of her/him.

RN #32, the nurse responsible for the patient's care while in the Emergency Unit, documented that the patient had been off his medications "X 1 month Appx (Approximately)." The RN did not assess if the patient's missed medications included blood pressure medications. The RN did not assess if the blood pressure of 156/80 would trend up or down, by re-taking the blood pressure. The RN failed to evaluate the patient's report of sleep apnea, other than to document: "Sleep Prob (Problems) R/T (relate to) Life Issues." RN #32 failed to evaluate the patient's report of night sweats, and failed to assess if the patient's auditory-visual hallucinations were telling him to do anything regarding the chips that he wanted to be removed from his body.

RN #32 documented a telephone consultation with Medical Staff #4, and the patient was instructed to return home and to present the next day for a scheduled appointment.

Patient #22 presented again to the Intake Department for his scheduled appointment for assessment on 04-11-16. Staff #36, an RN, provided the assessment.

On 04-11-16, the patient-reported Medical History Part I, revealed that the patient now acknowledged that he used "Illicit Drugs," and now denied that he had Sleep Apnea.

On the 04-11-16 visit, the patient had a BP of 162/84, a pulse of 78, respirations of 16, and a temperature of 98.2.

There was no documentation that the RN addressed the medical history discrepancies with the patient. There was no acknowledgment by the RN that the blood pressure was trending upward from the 04-10-16 visit. There was no documentation that the physician was made aware that the patient had been off his medications for around one (1) month. The patient was discharged to an outpatient mental health facility.

Based on review of job description, hospital policies/procedures, hospital documents and interviews, it was determined that the hospital failed to require that a registered nurse assign the nursing care of each patient in accordance with the individual patient's needs, posing a risk to patient health and safety that individual patient needs will not be met.

Findings include:

Review of Job Description for Job Title: "Registered Nurse (RN)" revealed: "...Complete Charge Nurse duties when assigned including assignment sheet, verification that staff assignments are completed and providing ongoing supervision as needed to the assigned nursing staff...

Review of hospital policy/procedure titled Nursing Staff Allocation revealed: "...Assessment of patients takes place prior to assignment of staff...Responsibilities-It is the responsibility of the Director of Nursing Services or Nursing Supervisor...to make the nurse/patient shift assignments...Considerations-Patient care responsibilities are assigned to nursing staff based on four general considerations including: patient acuity, environment in which nursing care is provided, staff competency, and supervision required by and available to each nursing staff member assigned responsibility...."

Review of Assignment Sheet-Day/Evening Shift for the Tortolita-AM shift on 5/4/16, revealed that RN # 21 was assigned to patients in consecutive room numbers from 400A through 405A and B. 405B was blocked, to provide a private room for the patient in 405A. RN # 17 was assigned to patients in consecutive room numbers from 406A through 410B.

RN # 21 confirmed, during interview conducted on 5/4/16 that patients were assigned to the nurses by dividing the hall and the corresponding names on the "board". Patients located on the top half of the "board" and the first six rooms down the hall, were assigned to RN # 21. Patients located on the bottom half of the board and the other half of the hall were assigned to RN # 17. RN # 21 confirmed that individual patients were not assigned to the nurses based on the individual patients' needs.

Review of Assignment Sheet-Day/Evening Shift for the Tortolita-AM shift on 5/5/16, revealed that RN # 33 was assigned to patients in consecutive room numbers from 400A through 405A and B. 405 B was blocked. RN # 22 was assigned to patients in consecutive room numbers from 406A through 410B.

RN # 22 confirmed, during interview conducted on 5/4/16 that patients were assigned by room number which is a random process. RN # 22 confirmed that individual patients were not assigned to the nurses based on the individual patients' needs.

Review of Assignment Sheet-Day/Evening Shift for the Rincon-AM shift on 5/10/16 revealed that RN # 25 was assigned to patients in consecutive room numbers from 300A through 305B. RN # 31 was assigned to patients in consecutive room numbers from 306A through 311B.

RN # 25 confirmed, during interview conducted on 5/10/16, that RNs are assigned to individual patients based on their room numbers and location on the unit. RN # 25 confirmed that patients are not assigned to RNs in accordance with their individual care needs.

Review of the patients assigned to the Behavioral Health Technicians (BHTs) working on Rincon on the day shift of 5/10/16, revealed that they were assigned to patients in consecutive room numbers.


RN # 25 confirmed, during interview conducted on 5/10/16 that the BHT Educator assigned the BHTs to patients based on the location of the patients' rooms. S/he also assigned the BHTs to specific tasks. S/he stated that the RN reviewed the assignments, but confirmed that the RN did not sign the assignment sheet to indicate agreement with the assignments of the BHTs.

Based on review of the Registered Nurse (RN) job description, hospital policy and procedure, direct observation of a med (medication) pass, medical record and interviews, it was determined that medications were not administered according to accepted standards of practice, hospital policy/procedure and/or physician orders, as evidenced by:

1. RN staff documenting administration of medication prior to actual administration, and failing to observe that patients swallowed their medication, for 2 of 2 adolescent patients (Pt #s 23 and 24). The potential risk is that medications documented as given prior to actually being given could be inadvertently assumed to be administered by another nurse, therefore not given; a patient could "cheek" and save medications for later ingestion if not observed to have swallowed the medication;

2. RN staff failing to document administration of medication ordered for alcohol withdrawal for 1 of 1 patient with a history of withdrawal seizures who required transfer to an acute medical center (Pt # 25), posing a risk of overmedication of the patient; and

3. RN staff administering medication for anxiety, without an order, for 2 of 2 patients who were receiving treatment for alcohol withdrawal (Pt #s 28 and 29), posing a risk to patient health and safety if the wrong dosage of medication was given.

Findings include:

The RN job description revealed: "...Maintains a safe...working and treatment environment...."

The "Medication Administration" policy revealed: "Medications are administered safely and accurately by the professional staff listed below within the specifications of approved job descriptions, licensure, certifications and scope of practice...Registered Nurses...H. Once a patient has taken an oral medication, the administering nurse checks the patient's mouth to assure the medication has been consumed. J. The administering nurse will then document in the patient's MAR (Medication Administration Record) the medication (s) administration or refusal...2. A. Each dose of medicine is recorded on the Patient's Medication Administration Record (MAR) by the person who administers the drug, stating the...time given...."

1. Direct observation of a med pass, conducted on 05-11-16, at 9:00 A.M., on the Child and Adolescent unit, revealed Staff #17, a contracted RN, conducting a medication pass.

Observation revealed medications being passed for Patients # 23, and # 24, both adolescents. Observation of the paper medication record for each patient revealed that the 9:00 A.M. medications had been documented prior to actual administration of the medications.

Observation of the administration of medications to Patient # 23, and # 24, respectively, revealed that the RN failed to observe the adolescents swallow the medications.

Staff #17 acknowledged, during interview conducted on 05-11-16, at 9:30 A.M., that she should not have documented that medications that had not yet been administered had been given, and acknowledged that she should have observed that the medications had been swallowed by the adolescents.

2. Review of Pt # 25's medical record revealed:

On 4/29/16, at 1018, MD # 8 wrote medication orders:
"...Librium 50 mg PO BID (by mouth twice a day) for ETOH WD (alcohol withdrawal), 1st dose now, last dose evening of 4/30/16, X2 days, hold for oversedation...Librium 50 mg PO q AM (every morning) x 2 days for ETOH WD, 1st Dose 5/1/16 AM, last dose 5/2/AM, hold for oversedation...."

Review of the Medication Administration Record for Pt # 25 revealed documentation of 50 mg of Librium on 4/29/16, at 2100 and on 4/30/16, at 0900 and 2100. The "now" dose for 4/29/16, at 1018 was not documented. Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 4/29/16, at 1043.

Review of the Medication Administration Record for Pt # 25 revealed that it did not contain documentation of administration of 50 mg Librium on 5/2/16, as ordered.

Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 5/2/16, at 0803.

RN # 30 and the Acting Director of Nursing confirmed, during interview conducted on 5/5/16, the nursing did not document administration of medication as required by policy/procedure.

3. Patient # 28

Review of Pt # 28's medical record revealed:

On 5/3/16, at 1330, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) and repeat (after) 1 (hr) if medicated SSWD (Signs/Symptoms of Withdrawal)...Ativan 1 mg po/IM Q 4 (hrs) SSWD, BP 150/90 P>100...."

An RN documented, on the Medication Administration Record (MAR), clarification of SSWD from the physician: "Ativan 1 mg po Q 4 hr S/S (Signs/Symptoms) of withdrawl (sic)-diaphorsis (sic) tremors...Prn BP >150/90 P >100".

On 5/3/16, at 1455, an RN documented administration of Ativan 1 mg po for Reason: "Anxiety 10/10" and Response: "Anxiety 5/10" at 1530.

Pt # 28's medical record did not contain an order for Ativan for anxiety.

Patient # 29

Review of Pt # 29's medical record revealed:

On 5/3/16, at 0920, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) VS (Vital Signs) and 1 (hr) (after) each W/D (Withdrawal) medication...Ativan 1 mg po or IM prn (as needed) Q 4 (hrs) if BP (Blood Pressure) above 150/90 P (Pulse) above 100...Ativan 1 mg IM Q (hr) prn SZ (Seizure) for 5 days Q 1 (hr)...."

An RN documented, on the Medication Administration Record (MAR), clarification from the physician: "Ativan 1 mg po Q 4 hr prn S/S (Signs/Symptoms) of W/D symptoms DBP (Diastolic Blood Pressure) >90, SBP (Systolic Blood Pressure >150 T (Temperature) >101 (degrees) & tremors, diaphorsis, visual disturbances"

On 5/3/16, at 2100, an RN documented administration of Ativan "1" for Reason: "Anxiety 6/10" and Response: "2/10" at 2200.

Pt # 29's medical record did not contain an order for Ativan for anxiety.

The Acting Director of Nursing confirmed, during interview conducted on 5/4/16, that Ativan was ordered for Pt # 28 and 29 for elevated vital signs and other S/S due to alcohol withdrawal. S/he confirmed that nursing administered the Ativan for "anxiety" and the medical records of Pt #s 28 and 29 did not contain orders for administration of Ativan for anxiety.

Based on review of hospital policy/procedure, Intake assessment records and interviews, it was determined that the hospital failed to properly file and make accessible, to appropriate staff, a medical record for patients who received an assessment in the Intake Department and referral to an outside hospital and/or agency without being admitted to an inpatient unit of the hospital for 5 of 6 patients (Pt #s 16, 18, 20, 21 and 22) which poses a high potential risk that information obtained during the intake process of the patient will not be readily available for staff accessability if needed.

Findings include:

Review of hospital policy/procedure titled Medical Record Content, revealed: "Policy: the medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The medical record must be complete for the purposes of facilitation of patient care, to serve as a financial and legal record, aid in clinical research, support decision analysis, and guide professional and organizational performance improvement. Purpose:...To provide continuity in the evaluation of the patient's condition...To document communication between the patient care providers...To assist in protecting the legal interest of the patient, facility, and health care providers...To provide data for use in continuing education and research...A medical record is maintained for every individual assessed or treated...The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information:...The record and findings of the patient's assessment and health screen...the diagnosis or diagnostic impression, including a statement on the course of action planned for the patient for this episode of care...the reasons for admission or treatment...evidence of informed consent and patient rights...."

Review of Intake Department patient assessment records revealed:

Pt # 16 was assessed in the Intake Department on 3/23/16 and was assessed as not meeting hospital admission criteria. S/he was transported to another facility.

Pt # 18 was assessed in the Intake Department on 2/1/16 and was referred to an acute medical center.

Pt # 20 was assessed in the Intake Department on 4/5/16 and was assessed as not meeting hospital admission criteria. S/he was referred to outpatient resources.

Pt # 21 was assessed in the Intake Department on 4/6/16 and was referred for outpatient treatment.

Pt # 22 was assessed in the Intake Department on 4/10/16, was assessed as meeting hospital admission criteria, but since there were no available inpatient beds, s/he was scheduled for a return appoint on 4/11/16.

The Director of Performance Improvement and Risk Management confirmed, during interview conducted on 5/11/16, that the Intake records of Pt #s 16, 18, 20, 21 and 22 were stored in a locked file cabinet in her office. S/he stated that these records and records of other patients who were seen in the Intake Department but not admitted to the hospital, are not maintained in the medical records department/system. They are secure, but are not accessible to other appropriate clinical or administrative staff 24 hours/day, 7 days/week as required for any medical record.

Based on review of hospital policy/procedure, Intake assessment records and interviews, it was determined that the hospital failed to implement a system of coding and indexing the medical records of patients who received an assessment in the Intake Department and referral to an outside hospital and/or agency without being admitted to an inpatient unit of the hospital for 5 of 6 patients (Pt #s 16, 18, 20, 21 and 22).

Findings include:

Review of hospital policy/procedure titled Medical Record Content, revealed: "Policy: the medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The medical record must be complete for the purposes of facilitation of patient care, to serve as a financial and legal record, aid in clinical research, support decision analysis, and guide professional and organizational performance improvement. Purpose:...To provide continuity in the evaluation of the patient's condition...To document communication between the patient care providers...To assist in protecting the legal interest of the patient, facility, and health care providers...To provide data for use in continuing education and research...A medical record is maintained for every individual assessed or treated...The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information:...The record and findings of the patient's assessment and health screen...the diagnosis or diagnostic impression, including a statement on the course of action planned for the patient for this episode of care...the reasons for admission or treatment...evidence of informed consent and patient rights...."

Cross reference Tag 0438 for information regarding the Intake Department assessment records for Pt #s 16, 18, 20, 21 and 22.

The Director of Performance Improvement and Risk Management confirmed, during interview conducted on 5/11/16, that the Intake records of Pt #s 16, 18, 20, 21 and 22 were stored in a locked file cabinet in her office. S/he stated that these records and records of other patients who were seen in the Intake Department but not admitted to the hospital, are not maintained in the medical records department/system. They are not coded and/or indexed by the Medical Records Department as required for other medical records of patients assessed and/or treated in the hospital.

Based on review of the Rules and Regulations of the Medical Staff, record review, and interview, it was determined that all patient records were not authenticated by the person providing the service, when 3 of 3 outpatient records reviewed for authentication, did not have medical staff signatures (Patients #20, 21, and 22). The potential risk is to the health and safety of patients, who may not have been safe for discharge or transfer, without authentication from the medical staff that they were in agreement with the Qualified Medical Person's (QMP's) assessment of the patient.

Findings include:

The Rules and Regulations of the Medical Staff revealed: "...7.13 Completion of Medical Records-All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge...."

Patient # 20

Patient #20 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-05-16. A Medical Screening Examination (MSE) was conducted by a Qualified Medical Person (QMP), and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff
#4, did not sign the telephone consultation.

Patient # 21

Patient #21 presented to the emergency unit on 04-06-16 as a "Scheduled Assessment." A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #15, a Psychiatric Nurse Practitioner (NP). Medical Staff #15, did not sign the telephone consultation.

Patient # 22

Patient #22 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-10-16. A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff # 4, did not sign the telephone consultation.

Medical Staff #15 acknowledged, during interview conducted on 05-10-16 at 12:30 P.M., that the medical staff should sign the telephone consultation, and that within the telephone consultation, the communication between the QMP and the Medical Staff member should be clearly documented.