HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the hospital nursing staff failed to perform an assessment for 8 of 11 patients (#s 2, 3, 6, 7, 8, 9, 10, and 11) within one hour of discharge per policy.

The findings include:

1. Review on 12/15/2016 of the hospital's policy titled, "Discharge of Patients, D-50-ED-39", revised 09/2016, revealed "POLICY: ...Prior to discharge, completed documentation to include vital signs within 60 minutes of discharge time, reassessment if change in condition, abnormal vitals [sic] signs are to be reported to the provider ..."

Review on 12/15/2016 of the hospital's policy titled, "Discharge Planning", revised 12/2016, revealed "...Nursing Discharge Assessment...j. All hospital discharges must include vital signs documented in the EMR (emergency medical record) within 1 hour of discharge. K. Pain Assessment within numerical pain scale documented in EMR within 1 hour of discharge ..."

a. Medical record review on 12/16/2016 for Patient #2 revealed a 65 year old was
admitted on 11/28/2016 for a planned left knee arthroplasty (replacement) secondary to "severe osteoarthritis". Review revealed the patient was discharged on 12/01/2016 at 1110. Continued record review revealed at 0800 on 12/01/2016, the patient's Blood Pressure (BP) was 124/76, Heart Rate (HR) 95, Temperature (Temp) 98.0, Respirations (Resp) 18, and SPO2 95% (oxygenation) on 2 L/min supplemental oxygen (3 hours, 10 minutes prior to discharge). Review failed to reveal the patient's vital signs (VS) were assessed within one hour of discharge per policy.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

b. Medical record review on 12/16/2016 for Patient #6 revealed a 54 year old presented to the Emergency Department (ED) on 12/08/2016 with a history of Alzheimer's Dementia and medication non-compliance after threatening a family member with a knife and physical altercation with a resident in a nursing home. Review revealed the patient was placed in the ED #3 (psychiatric outpatient) for stabilization and treatment where she remained until discharge on 12/14/2016 at 0940. Continued review of the record revealed at 0713 on 12/14/2016 the patient's BP was 131/86, HR 76, Temp. 97.9, Resp. 20, and SPO2 98% on room air (2 hours, 27 minutes prior to discharge). Review failed to reveal the patient's VS were assessed within one hour of discharge per policy.

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of vital signs one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

Interview on 12/15/2016 at 1205 with RN #1 (primary nurse assigned day of discharge) revealed vital signs should have been taken within one hour of discharge according to hospital policy. RN #1 stated" failure to obtain the patient's VS was an oversight and that hospital policy was not followed."

c. Closed medical record review on 12/13/2016 for Patient #7 revealed a 56 year old presented to the ED on 07/10/2016 with a history of chronic schizophrenia (mental illness) exacerbated by medication non-compliance, suicidal thoughts, and verbal aggression. Review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until discharge on 10/12/2016 at 1700. Continued review of the record revealed at 2100 on 10/11/2016 the patient's BP was 127/81, HR 96, and Resp. 18 (20 hours prior to discharge). No documented temperature or SPO2 were noted or of patient's refusal to allow assessment of same. Review failed to reveal the patient's VS were assessed within one hour of discharge per policy and revealed that the last set of VS did not include a temperature or SPO2.

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of VS one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

Interview on 12/14/2016 at 1155 with RN #2 (primary nurse assigned to patient at time of discharge) revealed VS should be taken within one hour of discharge according to hospital policy. RN #1 stated, "I have no idea why those were not documented. I'm kinda speechless and don't know what happened or how to explain." The interview revealed the hospital's policy was not followed.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

d. Closed medical record review on 12/15/2016 for Patient #8 revealed a 50 year old presented to the ED on 12/04/2016 with worsening depression, suicidal thoughts, and opiate withdrawal. Review revealed the patient was placed in ED #3 for stabilization and treatment where she remained until discharge on 12/09/2016 at 1645. Continued review of the medical record revealed at 0900 on 12/09/2016 the patient's BP was 154/93, HR 80, Temp. 98.1 and Resp. 16 (7 hours, 45 minutes prior to discharge). No documented SPO2 documentation was noted. Review failed to reveal the patient's VS were assessed within one hour of discharge per policy and that the last set of VS did not include SPO2.

Interview on 12/13/2016 at 1230 with RN #3 (primary nurse assigned day of discharge) revealed vital signs should have been taken within one hour of discharge according to hospital policy. RN #3 stated "failure to obtain the patient's VS was an oversight and that hospital policy was not followed."

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of VS one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

e. Closed medical record review on 12/15/2016 for Patient #9 revealed a 30 year old presented to the ED on 12/04/2016 with complaints of recent depression, multiple stressors, inability sleeping and passing suicidal thoughts. Review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until transfer to another treatment facility on 12/05/2016 at 0559. Continued review of the medical record revealed at 0131 on 12/05/2016 the patients BP was 107/74, HR 107, Temp. 98.5, Resp. 16, and SPO2 98% on room air (4 hours, 28 minutes prior to discharge). Review failed to reveal the patient's VS were assessed within one hour of discharge per policy.

Interview on 12/13/2016 at 1230 with RN #3 (primary nurse assigned day of discharge) revealed vital signs should have been taken within one hour of discharge according to hospital policy. RN #3 stated" failure to obtain the patient's VS was an oversight and that hospital policy was not followed."

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of VS one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

f. Closed medical record review on 12/15/2016 for Patient #10 revealed a 39 year old presented to the ED on 12/04/2016 with a history of schizophrenia, autism, intellectual develop delay, recent increased agitation and assaultive behaviors. Review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until discharge on 12/09/2016 at 1227. Continued review of the medical record revealed at 0832 on 12/09/2016 the patient's BP was 118/82, HR 94, Temp. 97.6, Resp. 18 and SPO2 100% on room air (3 hours, 55 minutes prior to discharge). Review failed to reveal the patient's VS were assessed within one hour of discharge per policy.

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of VS one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

g. Closed medical record review on 12/15/2016 for Patient #11 revealed a 38 year old presented to the ED on 10/24/2016 with a history of bipolar disorder with depression and prior suicide attempt. Review revealed a recent admission to the facility in the Intensive Care Unit (ICU) for attempted overdose and subsequent inpatient stay in the facility's psychiatric unit. Continued review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until discharge on 11/01/2016 at 1710. Continued review of the medical record revealed at 1426 on 11/01/2016 the patient's BP was 142/88, HR 95, Temp. 98.1, Resp. 18 and SPO2 97% on room air (2 hours, 44 minutes prior to discharge). Review failed to reveal the patient's VS were assessed within one hour of discharge per policy.

An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should obtain a set of VS one hour prior to discharge. The interview revealed VS should include BP, HR, Resp., Temp., and SPO2.

During an interview on 12/15/2016 at 1000, the CNO (Chief Nursing Officer) revealed "a complete set of VS should be obtained within one hour of discharge" on all patients. Interview revealed a completed set of vital signs include: BP, HR, Resp., Temp. and SPO2. Interview confirmed nursing staff failed to assess vital signs within one hour of discharge per policy.

2. Review on 12/15/2016 of the hospital's policy titled, "Pain Management", revised 05/2013, revealed "...V. DOCUMENTATION... f. At the time of discharge, the nurse will assess and record the current pain level ... "
a. Closed medical record review on 12/15/2016 for Patient #3 revealed a 57 year old presented to the ED on 12/27/2016 with complaints of recurrent nausea and vomiting. Review revealed Patient #3 was admitted to the medical floor for stabilization and treatment where she remained until discharge on 12/07/2016 at 1650. Continued review of the medical record revealed at 1240 on 12/07/2016 a pain assessment was performed with a reported level of "0" (4 hours, 10 minutes prior to discharge). Review failed to reveal a pain assessment was conducted within one hour of discharge per policy.
During an interview on 12/15/2016 at 1000, the CNO revealed "a pain assessment should be completed within one hour of discharge on all patients." Interview confirmed nursing staff failed to complete a pain assessment within one hour of discharge per policy.
b. Closed medical record review on 12/15/2016 for Patient #9 revealed a 30 year old presented to the ED on 12/04/2016 with complaints of recent depression, multiple stressors, inability sleeping and passing suicidal thoughts. Review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until transfer to another treatment facility on 12/05/2016 at 0559. Continued review of the medical record revealed at 2130 on 12/04/2016 a pain assessment was performed with a report of "None" (8 hours, 29 minutes prior to discharge). Review failed to reveal a pain assessment was conducted within one hour of discharge per policy.
Interview on 12/13/2016 at 1230 with RN #3 (primary nurse assigned day of discharge) revealed a pain assessment should have been taken within one hour of discharge according to hospital policy. RN #3 stated failure to perform a pain assessment was an oversight and that hospital policy was not followed.
An interview on 12/14/2016 at 1015 with the ED Director revealed nursing staff should complete a pain assessment within one hour of discharge. Interview confirmed the ED nursing staff failed to complete a pain assessment within one hour of discharge per policy.

During an interview on 12/15/2016 at 1000, the CNO revealed "a pain assessment should be completed within one hour of discharge on all patients." Interview confirmed nursing staff failed to complete a pain assessment within one hour of discharge per policy.

Based on policy and procedure review, medical record review, and staff interviews, the hospital staff failed to ensure accuracy of the medical record for 1 of 6 psychiatric patients (#7) treated in the hospital's Emergency Department per policy.
The findings include:
A review on 12/14/2016 of the hospital's policy titled "Health Information Management Department Policies", revised 11/2015, revealed, "...Signatures - Authentication... ·Dictated reports must be electronically signed in the electronic medical record...Recording Entries in the Medical Record...·All entries in the medical record shall be factual; ..."
Closed medical record review on 12/13/2016 for Patient #7 revealed a 56 year old presented to the ED on 07/10/2016 with a history of chronic schizophrenia (mental illness) exacerbated by medication non-compliance, suicidal thoughts, and verbal aggression. Review revealed the patient was placed in ED #3 for stabilization and treatment where he remained until discharge home on 10/12/2016 at 1700. The "Psychiatric Discharge Summary" dated and timed 10/13/2016 at 1442 by Transcriptionist #1 revealed it was not authenticated by MD #1. Continued review of the document revealed, "The patient was admitted to the behavioral health unit here at (hospital name) for crisis stabilization and further diagnostic clarification. He underwent a comprehensive assessment...and engaged in multimodal programming involving group therapy, individual therapist, and medication management. Milieu therapy was also offered. He underwent a comprehensive medication review and medications selected after informed consent obtained...Also underwent appropriate laboratory testing and psychological testing. Informed consent was obtained on all treatments...Consultation with...let [sic] us to the conclusion that unless we wereAwarded [sic] a guardian, we could not proceed with...We believe that he is not able to offer informed consent...Review of the "CONSENT FOR SERVICES AND FINANCIAL RESPONSIBILITY" dated and timed 07/10/2016 at 2250 by Registrars #1 and #2 revealed "Pt. Unable to Sign" noted on the line designated as "Signature of Patient, Legal representative for healthcare Hospital Services if other than the patient". The word "Combative" was documented as the "Reason individual is Unable to Sign, i.e. Minor or Legally Incompetent".
While interviewing MD #1 on 12/13/2016 at approximately 1415, he stated Patient #7's case was difficult. He said the patient suffered from dementia mixed with delirium and at times, dehydration. MD #1 stated that due to the patient's episodes of verbal outbursts, non-compliance, refusal to consent for treatment and number of patients already on the Behavioral Health Unit, he did not qualify for admission to the facility's inpatient psychiatric unit. The interview revealed patient's in ED #3 do not receive any type of group therapy, milieu therapy, or other multimodal therapy due to payment issues. MD #1 stated that he is consulted as needed but there is no "active treatment per say" for patients in ED #3. When asked about the patient's engagement in "multimodal programming involving group therapy, individual therapist, and medication management", "Milieu therapy" being offered, and "informed consent obtained" as outlined in the "Psychiatric Discharge Summary", he stated he "was not sure how that information had got into the discharge summary" and that he "must have gotten him confused with another patient." Interview revealed information contained in the "Psychiatric Discharge Summary" was not accurate.
During an interview on 12/13/2016 at approximately 1445 with the ED Director revealed that Patient #7 remained in ED #3 until discharge on 10/12/2016 at 1700 and that he was not admitted to the Behavioral Health Unit during hospitalization. The interview went on to reveal Patient #7's consent for treatment was not obtained. Continued interview revealed patients in ED #3 do not receive "multimodal programming " , " group therapy", an "individual therapist", or "Milieu therapy" as indicated in the "Patient Discharge Summary" completed my MD #1.
An interview on 12/14/2016 at 1135 with the Chief Medical Officer (CMO) revealed MD #1 did not authenticate the "Patient Discharge Summary" completed 10/23/2016 at 1442 following dictation as required by policy. During the interview, the CMO stated that Patient #7 did not sign consent for treatment and did not receive" multimodal programming, group therapy, an individual therapist, or Milieu therapy as indicated in the "Patient Discharge Summary" completed my MD #1. The CMO stated that it sounded as though they (ED staff) were trying to get a patient cleared for discharge and that perhaps a template of sorts may have been used for the discharge summary. The CMO stated he would "look into it" and follow up. Interview revealed the discharge summary should have been signed by MD #1 and that the contents were not accurate.

NC00121732