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Based on review of medical records, hospital documents and staff interview it was determined the medical staff failed to ensure bylaws and rules and regulations of the medical staff are enforced related to recording changes in discharge planning, the writing of discharge orders prior to discharge, timely completion of medical records and timing of all entries in the medical record. This failure impacted five (5) of five (5) closed records reviewed (pt #1, 2, 3, 4 and 5). This failure creates the potential for an adverse impact on the care and condition of all patients. Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted 8/4/14 and discharged 8/13/14. At the time of discharge the father informed staff and patient that the discharge plan changed and the patient was being taken to the mother's home to stay. Review of the record revealed no order for discharge. Review of the 8/13/14 Discharge Instructions, completed and signed by the physician, revealed the physician entry was untimed. These instructions noted the patient was going to the father's home. Review of the Discharge Summary revealed it was dictated 9/15/14, thirty-three (33) days after discharge.

2. Review of the medical record for patient #2 revealed the patient was admitted 8/4/14 and discharged 8/9/14. Review of the 8/9/14 Discharge Instructions, completed and signed by the physician, revealed the physician entry was untimed.

3. Review of the medical record for patient #3 revealed the patient was admitted 8/6/14 and discharged 8/12/14. Review of the 8/12/14 Discharge Instructions, completed and signed by the physician, revealed the physician entry was untimed. Review of the 8/11/14 Discharge Summary revealed it was unsigned. At the time of review it was thirty-six (36) days post discharge. Review of the 8/6/14 Informed Consent for Medications order revealed it was not signed by the physician. Review of the 8/6/14 Medication Reconciliation Telephone Order revealed it was not signed by the physician. Review of the 8/6/14 telephone Admission Order revealed it was unsigned. These orders were written forty-two (42) days prior to review.

4. Review of the medical record for patient #4 revealed the patient was admitted 8/6/14 and discharged 8/12/14. Review of the 8/12/14 Discharge Instructions, completed and signed by the physician, revealed the physician entry was untimed. Review of the record on 9/17/14, thirty-six (36) days post discharge, revealed no discharge summary. Review of physician's orders revealed an 8/7/14 telephone order for medications which was not signed by the physician, forty-one (41) days after the order was given.

5. Review of the medical record for patient #5 revealed the patient was admitted 8/6/14 and discharged 8/12/14. Review of the 8/12/14 Discharge Instructions, completed and signed by the physician, revealed the physician entry was untimed.

These records were reviewed and discussed with the Medical Records Technician at 1350 on 9/17/14 and she agreed with these findings.

The Rules and Regulations of the Medical Staff, last revised 9/3/14, were provided for review. They state in part:

6.4 Updates and changes in discharge criteria and discharge planning should be recorded as appropriate.
7.6 All entries in the medical record must be legibly written, dated, timed and authenticated.
7.8 All orders for medication and/or treatment for patients admitted to Hospital shall be in writing...An order shall be considered to be written if dictated by telephone to a licensed nurse or a licensed pharmacist, and signed within forty-eight (48) hours...
7.12 Patients shall be discharged only on a written order of the Attending Practitioner...The record of each discharged patient must have a discharge summary.
7.13 All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge.

Based on medical record review and staff interview it was determined the nurse failed to supervise and evaluate the care for a patient whose condition changed prior to discharge. The nurse failed to contact the physician for one of one patient's reviewed who threatened suicide and refused to contract for safety prior to discharge (pt #1). This failure puts all patients who experience a change in condition at risk. Findings are:

1. Review of the medical record for patient #1 revealed a Family Therapy/Discharge Meeting was held at 1400 on 8/13/14 and the patient was discharged at 1555. Review of an untimed 8/13/14 Treatment Plan Review note and the 1400 Family Therapy note made by Therapist #1 revealed it was documented the patient threatened suicide and refused to contract for safety when she found out the discharge plan was changed.

Review of the medical record revealed prior to the Family Therapy Meeting staff documented the patient denied suicidal ideation and contracts for safety. There was no documentation to reflect the registered nurse made the physician aware of the changes in the patient's condition.

This record was reviewed and discussed with the Nurse Manager for the Children's and Adolescent Units at 1130 on 9/17/14. She agreed with this finding.

Based on medical record review and staff interview it was determined the hospital failed to ensure the discharge plan was reassessed for one of one records reviewed for a patient whose discharge plan changed on the day of discharge (pt #1). This failure creates the potential for an adverse impact on the post hospital care and treatment of all patients who experience changes in the discharge plan. Findings are:


1. Review of medical record for patient #1 reveals the patient was admitted on 8/4/14 and discharged on 8/13/14. Review of Treatment Plan documentation and Therapy notes throughout the hospitalization of the patient reveals the plan was to discharge patient to fathers home.

Review of 8/13/14 Family Therapy meeting note revealed the patient's father arrived for the 1400 meeting and informed staff and patient the plan was changed and the patient would now go to the mother's home. Therapist #1 documented the patient became upset, threatened suicide and refused to commit to safety.

The medical record lacks documentation to reflect the plan was reassessed by the care team prior to the 1555 discharge of the patient.

This record was reviewed and discussed with Children's Program Director at 0945 on 9/16/14. She indicated the hospital staff were not aware of the change until the family meeting occurred and acknowledged she was summoned to join the meeting due to the patient becoming very upset with the change in plan. She confirmed the record lacked documentation to reflect the care team, including the physician, reassessed the change in the discharge plan and the patient's response to the change prior to discharging the patient.