HospitalInspections.org

Based on medical record review, document review and staff interviews, it was determined that the governing body failed to ensure the medical staff was accountable for the quality of care in (1) one out of (10) ten patients, Patient #2. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #2. The patient was involuntarily admitted to the facility on 11/12/23. The record contains an entry titled "Nursing Progress Note (Free Text)" entered on 5/25/24 at 3:32p.m. by Emp #12 which states, "Patient requested to speak with this writer. [Patient #2] stated [Patient #2] wants to switch providers." It should be noted there is no documentation in the medical record that the provider discussed a transfer of care to another hospital provider with the patient.

An email was reviewed dated 5/28/24 at 10:41a.m. sent by Emp #8, this email was sent to Emp #11, Emp # 9 and two other employees. The email states, in part, "Can we re-educate about these types of notes being placed in the chart? This is more of a direct conversation or an email etc. [Patient #2] was absolutely fine talking with us this morning. This is just one example- but these chart messages from staff or patients to us makes our chart look terrible and that we are not communicating which is not the case." The email contains a segment from Patient #2 ' s chart indicating [Patient #2 ' ] wanting to change providers.

A document was reviewed titled "Employee Acknowledgement Form" [EAF] which states, "I acknowledge and have been made aware of notifying the attending when a patient wants a new doctor, via email. DO NOT put a note in the patients ' chart stating the patient wants a new doctor. Failure to comply may result in progressive discipline. I have read and understand these terms." May it be noted that this document has a Name, Signature and Date lines. The document itself is not dated.

A document was reviewed titled "Mildred Mitchell-Bateman Hospital Governing Body Bylaws" signed 10/21/21. A section of this document titled "Glossary" states, in part, "Chief Executive Officer (CEO): The hospital ' s Chief Executive Officer who is qualified by education and experience, who is hired by the Secretary of the Department of Health and Human Resources and represents the Governing Body, acting as its agent in the overall, daily administrative operations and management of Mildred Mitchell-Bateman Hospital." The document contains a section titled "Section VI.02 Authority and Duties" which states, in part, "(a) The Corporation shall empower the Chief Executive Officer to be responsible for the Hospital ' s management. The specific authority and duties of the Chief Executive Officer shall be the following ...(xiv) To cooperate with the Medical Staff and with those concerned with rendering professional services, to the end that quality care will be rendered to the patients."

A document was reviewed titled "Medical Staff Bylaws, Rules, and Regulations" adopted and approved 4/25/23. This document has a section titled "Article II Medical Records" which states, in part, "2.1 Preparation/Completion of Medical Records. The Patient's Provider shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current ...The record shall also contain a written plan of care, treatment and services appropriate to the patient's needs, identifying the patient's needs, goals, timeframes, settings, and services required to meet the patient's needs."

An interview was conducted with Emp #1 on 6/26/24 at 4:20p.m. Emp #1 was shown an email authored by Emp #8 on 5/28/24 at 10:41a.m. and the EAF. Emp #1 stated, "This is the first time I 've seen these." Emp #1 was asked about the EAF and Emp #1 stated, "This has to be changed. It needs a few more sentences." Emp #1 was asked why they were not included in the email from Emp #8. Emp #1 stated, "I'll need to talk to [Emp #8] about that."