HospitalInspections.org

Based on policy and procedure review, medical record review, review of personnel records, and staff interviews, the facility staff failed to ensure an accurate medical record by documenting active group notes in a discharged patient's medical record on 1 of 7 discharged charts reviewed (Patient #6); and failed to ensure correct documentation authenticity to progress notes for 2 of 11 medical records reviewed. (Patients #1 and #8)

The findings include:

A. Review of policy titled "Active and Individualized Treatment--Acute" with approval date of 04/28/2022, revealed "Definition: Active treatment is substantive engagement with the patient in their care through the course of the day. A variety of therapeutic and activity/recreational activities are used as therapeutic interventions in providing active treatment to patients. Active treatment activities include but are not limited to the following: individual, family, group therapies and medication management. Milieu management and structured activities such as goals and wrap up groups, level groups,, and other unit activities that support changes in behavior are considered active treatment. Policy: It is the policy of the (named facility) to provide care and a model of active treatment for all patients hospitalized at the facility... Procedure: 3. Group modalities can be used as interventions for delivering active treatment to patients. Each group leader assigned to conduct a group session identified in the treatment plan is responsible for encouraging all assigned patients to attend the group, maintaining an attendance list of patients who are in the group, and documenting the group per facility policy in each patient's medical record. 4. Progress notes are recorded by the group leader and address: active treatment modalities, assessment, intervention, evaluation of the effectiveness of the intervention and progress towards treatment plan goals...."

Review on 02/08/2023 of the closed medical record for Patient #6 revealed a 14 year-old- female was admitted on 01/19/2023 for thoughts of suicide with general anxiety. Patient #6 was discharged on 01/23/2023 at 0940 in the care of her mother. Review of MHT Group note dated 01/23/2023 revealed documentation of Patient #6 attended Group session titled "Movement" at 1200 and ended at 1215, 2 hours and 35 minutes after Patient #6's discharge. Documentation revealed Patient #6's "Response: Positive Participation, with Plan to encourage participation and engagement." Review revealed "Facilitator signature and title" was signed and dated on 01/23/2023 at 1245 by MHT #24. Review of "MHT Group Note" revealed documentation of Patient #6 attended Group session titled "Community" on 01/23/2023 at 1604 and ended at 1620, 6 hours and 40 minutes after Patient #6's discharge. Documentation revealed Patient #6's "Response: Positive Participation, with Plan to encourage participation and engagement." Review revealed "Facilitator signature and title" was signed and dated on 01/23/2023 at 1645 by MHT #24. Review of the MHT Group note dated 01/23/2023 revealed documentation of Patient #6 attended Group session titled "Self Expression" at 1800 and ended at 1900, 9 hours and 20 minutes after Patient #6's discharge. Documentation revealed Patient #6's "Response: Positive Participation, with Plan to encourage participation and engagement." Review revealed "Facilitator signature and title" was signed and dated on 01/23/2023 at 1935 by MHT #24.

Review on 02/09/2023 of personnel record for MHT #24 revealed a hire date 01/09/2023.

Interview on 02/09/2023 at 1120 with NM #20 revealed MHT #24 documented on the active group notes although the Patient #6 was discharged. Interview revealed the policy was not followed to complete the group notes on the patients attending the group. Interview revealed MHT #24 had been terminated by the facility and no longer worked at facility. Interview revealed MHT #24 was terminated on 02/08/2023 for actions not related to the inaccurate documentation on Patient #6's medical record.

Interview on 02/09/2023 at 1135 with HR #25 revealed MHT #24 is not an employee at the facility. Interview added MHT #24 was terminated on 02/08/2023.



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B. Review of facility policy, "MEDICAL STAFF RULES AND REGULATIONS" last revised "03/2021" revealed " ...5.6 Progress Notes ...5.6.2 A progress note shall be recorded at each visit by the Member/AHP (Allied Health Provider) making the visit and dated, timed and authenticated."

Review of PROFESSIONAL SERVICE AGREEMENT revealed a signed contract between facility and CCNC (Carolina Coastal Neuropsychiatric Center) revealed, " ...1.4 Professional Standards. Contractor shall perform all duties under this Agreement strict compliance with federal, state and local laws, rules and regulations, ...policies, procedures, rules and regulations of the Hospital, ..."

1. Review of Patient #8's opened medical record on 02/09/2023 revealed, a 13-year-old male Patient admitted via IVC (Involuntary Commitment) on 12/30/2022 with a chief complaint of Disruptive Mood Dysregulation Disorder and a history of SI (Suicidal Ideation/ self-harm/ sexual aggression) and elopement risk.

Review of " ...Physician Progress Note" dated " ...01/18/2023 at 08:12 PM ..." by PA #8 for Patient #8 revealed the following bold note: "Provider assistant contacted patient's mother, (name), on 01/17/2023. Mother reports, '"I keep calling Morehead City, NC, but I'm being told we have to have an authorization from Tricare to have his hand looked at ... Provider assistant relayed mother's concerns to the medical provider on 01/17/2023. Mother reported no further questions or concerns for the medical provider at this time of call." Review revealed bold entry into the progress note was not authenticated as to the author's name, date or time.

Review of " ...Physician Progress Note" dated " ...02/08/2023 01:29 PM ..." for Patient #8 revealed the following bold note "Provider assistant contacted patient's mother, (name), on 02/03/2023. Mother reported no questions or concerns for the medical provider at this time of call ....Addendum: ...02/08/2023 PM ..." PISA #30 name " ...> Follow up collateral: Provider assistant contacted Patient's mother, (name), on 02/08/2023. Mother is requesting to speak directly to patient's clinician regarding, '"Norfolk, VA"' at the earliest availability; provider assistant relayed mother's request to patient's clinician via mailbox on 02/08/2023. Mother reported no questions or concerns for the medical provider at the time of call." Review revealed bold entry into the progress note was not authenticated as to the author's name, date or time.

2. Closed medical record review of Patient #1 revealed a 15-year-old male admitted via involuntary commitment on 01/06/2023 for suicidal ideations, harm to self and others, attention deficit hyperactivity disorder and bipolar disorder. Review of a "Physician
Progress Note" dated " ...01/18/2023 at 02:22 PM ..." by PA # 8 for Patient #1 revealed the following bold note "Provider assistant contacted patient's mother, (name), on 01/17/2023. Mother reported, '"I know he got some news in court today that he didn't like; I'm worried about him trying to act out, or hurt himself. They may want to keep a close eye on him ..."' Review revealed at time of review Patient #1 was discharged and the bold entry into the progress note was not authenticated as to the author's name, date or time.

Interview on 02/10/2023 at 0900 with MD #27 via telephone revealed, MD #27 is the owner of staff with the title Psychiatric Assistants. MD #27 revealed the staff works in the CCNC office as assistance to the physician. MD #27 revealed the office received numerous complaints because patient's parents were not receiving calls from the office/providers. MD #27 revealed MD #27 would spend hours on the telephone trying to reach patient's parents. The staff called parents, gathered information and entered information into the progress notes if the progress notes were not locked.

Interview on 02/10/2023 at 1200 with staff HIS #29 revealed HIS #29 (Health Information Management -Medical Records) assembled and filed patient's charts after discharge. HIS #29 revealed the charts are assembled with the notes from the unit. HIS #29 revealed the charts are partially electronic which include physicians progress notes, orders and MAR. HIS #29 revealed the assistants from CCNC will bring a discharge summary and doctor's notes for court to the facility medical record area. HIS #29 revealed the assistants from CCNC provided the H&P (History and Physical), doctor's progress note, patient's psychiatric evaluation and discharge summary. The assistance worked on site at the facility in an office provided by the facility but not in medical records area. HIS #29 revealed there were several PISAs from CCNC but the main two were PISA #30 and PISA #31. HIS #29 reviewed "Physician Progress Note" dated " ...01/18/2023 at 08:12 PM ..." for Patient #1 and revealed the bold text was not documented by the provider but by one of the PISAs from CCNC. HIS #29 was not sure if the bold information in the patient's charts are entered via CCNC office electronic medical record system or the facility's electronic medical record system.

Interview on 02/10/2023 at 1227 with PISA #30 revealed, PISA #30 worked for and with MD #29 for the last 2-3 years. PISA #30 worked every day and occasionally on weekends onsite at the facility. PISA #30 revealed PISA #30 gathered information prior to rounds, performed collateral rounds with the doctor onsite at the facility. PISA #30 revealed once on the unit PISA located the patients and took patients to see the doctor. PISA #30 revealed in the progress notes PISA #30 is identified as Provider Assistant and the note is bold. PISA #30 revealed the progress notes are generated by the Provider and PISA entered information in the progress notes if the notes were not locked (the notes locked once Provider signed the note). If the notes were locked, the notes entered by a PISA would transpose over into an addendum note. PISA revealed the computer system generated the date, time and name to the addendum note. PISA #30 revealed once a note was entered into the progress note PISA #30 communicated with the Provider via message regarding the note entered. PISA #30 reviewed the "Addendum: ..." for " ...Physician Progress Note" dated " ...02/08/2023 at 01:29 PM ..." for patient #8 and revealed the addendum note was dated " ...02/08/2023 02:33 PM ..." with PISA #30's name. PISA #30 reviewed " ...Physician Progress Note" dated " ...02/08/2023 at 01:29 PM ..." for patient #8 and a bold note "Provider assistant contacted patient's mother, (name), on 02/03/2023. Mother reported no questions or concerns for the medical provider at this time of call." PISA #30 revealed the note was entered by PISA #30 and the note did not have a name, date or time. PISA #30 revealed PISA #30 remembered Patient #1 and spoke to patient's mom. Patient #1's mom revealed to PISA #30 that mom felt Patient #1 would act out and staff needed to keep a close watch on Patient #1. PISA #30 reviewed "Physician Progress Note" dated " ...01/18/2023 at 02:22 PM ..." by PA # 8 for Patient #1 revealed the bold note was entered by PISA #30 and revealed the bold note did not have a name, date or time. PISA stated "I was not trained to put my name or time on the note.

Based on review of hospital policy, Medical Staff Bylaws, Rules and Regulations, medical record review and staff interviews the hospital failed to ensure that orders were authenticated by the ordering physician for 1 of 11 medical records reviewed (Patient #1).

Findings include:

Requested the hospital policy referencing telephone and verbal orders. No policy presented prior to exit.

Review of the hospital's Medical Staff Bylaws, Rules and Regulations, reviewed and approved 03/31/2021, revealed "Medical Staff Rules and Regulations ... 5.4 ... 5.4.2 ... Verbal or telephone orders shall be authenticated by the physician/AHP (Allied Health Professional) within 60 hours of the order. ..."

Closed medical record review of Patient #1 revealed a 15-year-old male admitted via involuntary commitment on 01/06/2023 for suicidal ideations, harm to self and others, attention deficit hyperactivity disorder and bipolar disorder. Record review revealed "Physician's Order Form" dated 01/17/2023 at 2123 signed by a registered nurse as a verbal order. Review of the record on 02/07/2023 and again on 02/10/2023 revealed no documentation of physician authentication of the physician's discharge order dated 01/17/2023 (24 days later).

Interview on 02/10/2023 at 1030 with a Nurse Manager (NM) #1 revealed verbal orders should have been signed by the physician within 60 hours of the verbal order. Interview confirmed the verbal discharge order dated 01/17/2023 for Patient #1 was not authenticated by the physician.



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