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Based on interview and record review, the facility failed to furnish complete medical records for Patient 1 upon written request. This failure had the potential to cause delay in Patient 1's continuity of care in his effort to provide the necessary health records in a timely manner to his Primary Care Physician for a follow-up care visit .

Findings:

Review of Patient 1's medical record indicated he presented to Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) on 1/1/24 with intermittent chest pain and left arm pain. A series of lab and diagnostic tests were performed at ED such as Complete Blood Count (CBC, blood tests that measure the number and size of the different cells in your blood), Comprehensive Metabolic Panel (CMP, a blood test that measures your blood sugar levels, how your kidneys and liver function, and your electrolyte and fluid levels), D-Dimer (a test that may indicate a blood clot), Electrocardiogram (EKG, a non-invasive medical test that measures the electrical activity of the heart), Chest X-ray (a medical imaging procedure that uses X-rays to create a detailed image of the organs and structures in the chest, including the lungs, heart, and ribs), and Computed Tomography Angiography (CTA, a noninvasive medical test that uses a CT scanner to create images of the blood vessels and tissues in the chest and upper abdomen. A contrast material is injected into the body to make the blood vessels appear brighter in the images). Patient 1 was discharged from ED on same day.

During a concurrent interview and Patient 1's medical record review on 1/21/25 at 11:20 a.m. with the Patient Safety Manager (PSM) and Director of Quality (DOQ) revealed, Patient 1 made two written requests of his medical records on 1/3/24, the first one indicated a request of all images, etc. taken on 1/1/24 in ER. The second one indicated a request of all medical records in ER visit on 1/1/24, CT Scan and X-rays of chest and left arm. The DOQ confirmed that only scan and X-ray results were sent to Patient 1 on 1/3/24. The DOQ acknowledged the complete medical records of ER visit on 1/1/24 should have been provided to Patient 1 upon his written request.

Review of the facility's policy and procedure dated 7/2023 titled, "Privacy-Patient Rights-Access", indicated, A patients have the following rights to access their health information: Inspect or receive a copy of health information within the prescribed frames. Upon receiving a request to access, inspect, or receive a copy of the designated record set, Hospital is responsible to do all the following:..b. To receive copies of health information related to health history, diagnosis, condition of the patient, or treatment provided...within 15 days. c. To provide a copy of patient's health information within 15 days the receipt of payments for copies and and an authorization (written request for records). 2. c The summary shall contain for each injury, illness, or episode, any information included in the record relative to the following: 1) Chief complaint or complaints including pertinent history. 2) Findings from consultations and referrals to other health care providers. 3) Diagnosis where determined. 4) Treatment plan and regimen including medications prescribed. 5) Progress of the treatment. 7) Prognosis including significant continuing problems or conditions. 7) Pertinent reports of diagnostic procedures and tests and all discharge summaries. 8) Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests. 9) The summary shall contain a list of all current medications prescribed, including dosage, and any sensitivities or allergies to medications recorded by the provider.

Based on interview and record review, the facility failed to ensure that a Physician's order was obtained in accordance with their policy and procedures for one of six patients (Patient 7). This failure had the potential not to determine whether the type of restraint used for Patient 7 was approved and confirmed by the Physician for appropriateness.

Findings:

Review of Patient 7's medical record he had a history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs). He was brought in by his mother at Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) for psychiatric crisis (a state where someone experiences a sudden and severe disruption in their mental health, causing significant distress and impairing their ability to function normally, often requiring immediate professional intervention due to symptoms like intense anxiety, suicidal thoughts, self-harm, or extreme behavioral change) on 3/30/24 at 3:05 p.m. During the course of stay in ED, Patient 7 had an episode of aggressiveness and ran out of ED. He reported assaulted one security staff and bit him several times. A violent-rigid type restraint (limb restraints, a physical intervention used to manage a patient's violent or self-destructive behavior when it poses an immediate danger to the patient or others) was applied on both upper and lower limbs for Patient 7 on 3/30/24 at 5:45 p.m.

During a concurrent interview and Patient 7's medical record review on 1/22/25 at 2:22 p.m. with the Patient Safety Manager (PSM) and Director of Quality (DOQ), revealed there was no written Physician's order for violent rigid type restraint that was used for Patient 7 on 3/30/24 at 5:45 p.m.

During an interview with the PSM on 1/23/25 at 10:08 a.m., he confirmed there was no written order by the Physician found in Patient 7's medical record for the use of restraint on 3/30/24 at 5:45 p.m. at ED. He acknowledged the Hospital staff should have followed the policy and procedures in obtaining Physician written order for the use of restraint for Patient 7.

Review of the facility's policy and procedures dated 1/2023 titled, "Use of Restraint And/Or Seclusion: Restraint and/or Seclusion Orders-3. A Violent or Self-Destructive Behavior Restraint and/or Seclusion" indicated, a. A provider order must be obtained for the application of violent /self-destructive behavior restraints and/or seclusion.

Based on interview and record review, the facility failed to evaluate the post hospital care needs and make appropriate recommendations and/or instructions before discharging one of seven patients (Patient 7). This failure had the potential not to address the other health problems occurred during the course of his stay in the Hospital and may affect the continuity of care for Patient 7.

Findings:

Review of Patient 7's medical record indicated he had a history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs). He was brought in by his mother at Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) for psychiatric crisis (a state where someone experiences a sudden and severe disruption in their mental health, causing significant distress and impairing their ability to function normally, often requiring immediate professional intervention due to symptoms like intense anxiety, suicidal thoughts, self-harm, or extreme behavioral change) on 3/30/24. During course of stay at ED, he had an episode of aggressiveness and ran out of ED. He was reported assaulted a security staff and bit security staff several times on same day. Patient 7 sustained tooth and mouth injuries.

Review of Patient 7's medical record dated 4/3/24 indicated, "04/1/24: Per staff earlier in course had bite security (patient has chipped tooth)."

During a concurrent interview and record review with the Patient Safety Manager (PSM) on 1/22/25 at 9:06 a.m. regarding Patient 7's Discharge Summary Instructions dated 4/3/24, he confirmed there was no instructions or recommendations to see or follow-up with the Dentist for the chipped tooth upon discharged for Patient 7.

Review of the facility's policy and procedures dated 6/10/22 titled "Rules & Regulations" indicated, A clinical resume shall concisely summarize the reason for hospitalization, the significant findings, the procedure performed, and treatment rendered, discharge diagnosis, the patient's condition on discharge, and any specific instruction given to the patient or surrogate decision-maker as pertinent, including but not limited to, discharge medications, follow-up care and appointments, diet, and recommended activity.