HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that thorough physician assessments/patient encounters were documented by the physician performing and completing Certificate of Medical Examinations (CME) to obtain an Order of Protective Custody (OPC) on 4/5 patients reviewed (Patient ID #1, 12, 26 and 28).

Findings included:
Observation of Camera footage with Director of Risk Staff ID #A on 11/13/2024 at 1:15 pm. Camera footage of security cameras labeled 2 West and 2 South was reviewed for date 11/12/2024 with Staff ID #A. She confirmed there was no evidence of Physician Staff ID #K on the Womens Connections unit where patient ID #12 was bedded on 11/12/2024.

Record Review of Medical Staff Rules and Regulations, last revised 10/24, stated "5.3 Member Responsibility for Medical Record. 5.3.1 Attending members are responsible for ensuring that the medical contains all such information as may be necessary to prevent harm to patients in the Hospital or to others. 5.3.2 Attending Members are responsible for ensuring that the following are dated, timed, documented legibly, and in chronological order in each patient's medical record: admission information, orders for consultations, medications ...." It further stated "5.6 Progress Notes 5.6.2 Progress notes involving subjective interpretation of the patient's progress should be supplemented with a description of the actual of actual behavioral observed. 5.6.3 A progress note shall be recorded at each visit by the Member making the visit and dated."

Record Review of Electronic Medical Record performed:
Patient ID #1 Certificate of Medical Examination completed by Staff MD # K on 09/25/24. No progress note or assessment located for Staff MD #K in the medical record for Patient ID #1's medical record.

Patient ID #12 Certificate of Medical Examination completed by Staff MD # K on 11/12/24. No progress note or assessment located for Staff MD #K in the medical record for Patient ID #12's medical record.

Patient ID #26 Certificate of Medical Examination completed by Staff MD #K on 10/30/2024. No progress note or assessment located for Staff MD #K in Patient ID #26's medical record.

Patient ID #28 Certificate of Medical Examination completed by Staff MD #K on 11/3/2024. No progress note or assessment located for Staff MD #K in Patient ID #27's medical record.

These findings were confirmed by Director of Risk Staff ID #A with record review on 11/13/2024.

Record Review of Human Resource Badge Fob for Staff Physician #K demonstrated he did not utilize his badge fob to enter or exit the Women's Pathways unit, where Patient ID #12 was bedded on 11/12/2024, the date he completed Certificate of Medical Examination form for Patient ID #12.

Interview with Court Liaison Staff ID #M on 11/12/24 at 11:35 pm. She stated that the paperwork for order for protective custody must be obtained early in the day in order to facilitate getting it to the courts before they close. She stated the process is she asks attending psychiatrists who round early in the day to assist with completing the process. She stated that the physician completing the certificate of medical examination may not be the patient's attending physician. She stated that since the intake psychiatry consult/assessment is performed via telemedicine, that she needs an on-site physician to sign the paperwork.

Telephone Interview with Attending Psychiatrist Staff ID #K on 11/12/24 at 1:35 pm. He confirmed that he performed patient assessment for purposes of certificate of medical examination for Patient ID #12. He confirmed that he does not document his assessments or patient engagements related to signing for order of protective custody, if the patient is not assigned to him as the attending of record. He stated that the process is that the facility's court liaison Staff ID # M will call or text him to assist with obtaining order of protective custody paperwork certificate of medical examinations because he "rounds early."