HospitalInspections.org

Based on review of facility policy, medical record review and interview, the facility failed to maintain an accurate, complete medical record for two patients (#1, #2) of five patients reviewed.

The findings included:

Review of facility policy Reference # 4254 titled Mobile Crisis Unit (MCU) Assessments within Hospital Setting most recently reviewed September 6, 2013, revealed, "...MCU is to provide documentation of their assessment & recommendation to the ED (Emergency Department)."

Review of facility policy Reference # 1979 titled Suicide Precautions most recently reviewed January 31, 2013, revealed, "...To provide guidelines for ensuring the safety and integrity of patients who have communicated by act or word a desire to take their own life...may be placed on one of three levels of suicide precautions...Each suicide precaution level requires every 15 minute documentation..."


Patient #1 presented to the facility's Emergency Room (ER) on November 23, 2013.

Medical record review of a history and physical dated November 23, 2013, at 11:47 a.m., revealed, "...suicidal ideation...has a plan..."

Medical record review of a physician's order dated November 23, 2013, at 1:05 p.m., revealed, "Consult Orders - Mobile Crisis Unit (Psychiatry)..."

Medical record review of a nurse's note dated November 23, 2013, at 1:17 p.m., revealed, "...currently waiting for Mobile Crisis consultation..."

Medical record review on November 25, 2013, revealed no documentation every fifteen minutes as required by facility policy.

Medical record review of a Case Management note dated November 23, 2013, at 4:51 p.m., revealed, "...asked by Mobile Crisis and the ER to see this patient...After an assessment...was accepted to (facility's psychiatric unit)..."

Medical record review on November 25, 2013, revealed no documentation of the Mobile Crisis assessment.

Medical record review revealed the patient was admitted to the facility's psychiatric unit on November 23, 2013, at 5:06 p.m.

Interview with the ER's Clinical Leader on November 25, 2013, at 2:00 p.m., in a conference room, revealed documentation of fifteen minute checks was handwritten, sent to be scanned into the electronic record, and unavailable at that time. Continued interview confirmed the facility failed to maintain a complete medical record for Patient #1.



Patient #2 presented to the facility's (ER) on November 18, 2013.

Medical record review of a nurse's note dated November 18, 2013, at 5:50 p.m., revealed, "...EMS (Emergency Medical Services) states...were called out for possible overdose, suicide attempt...Pt. (patient) stated...took 9 200 mg (milligrams) of Trazadone (an anti-depressant medication) to try and kill...self..."

Medical record review of a Triage Assessment dated November 18, 2013, at 5:54 p.m., revealed, "...Total Suicide Risk Assessment Score...3 or Greater (Substantial Risk for Suicide) Patient placed in safe environment. 1:1 sitter with pt. 72 hour involuntary hold process initiated..."

Medical record review of a nurse's note dated November 18, 2013, at 6:00 p.m., revealed, "...waiting on MCU (Mobile Crisis Unit) consult..."

Medical record review of a history and physical authored by Medical Doctor (M.D.) #2 dated November 18, 2013, at 6:04 p.m., revealed, "...presents via (ambulance service) with complaints of Suicidal Ideation...psychosis...voices are telling patient to commit suicide...symptoms...began...gradually, 3 month(s) ago, and became worse today, was nearly hit by car trying to avoid...hallucinations...At their worst symptoms were severe in the emergency department the symptoms are unchanged."

Medical record review of the Emergency Room record dated November 18, 2013, at 11:49 p.m., revealed, "Outcome: Discharge ordered by MD."

Medical record review of a Disposition Summary dated November 18, 2013, at 11:49 p.m., revealed, "Discharged to Home/Self Care...Impression: Psychosis, Major Depression with Suicidal Ideation...Condition is Stable...Problem is an ongoing problem. Symptoms are unchanged."

Medical record review of a physician's progress note dated November 18, 2013, at 11:51 p.m., revealed, "...Response to treatment: There is no appreciated change of the patient's symptoms at this time."

Medical record review of a nurse's note dated November 18, 2013, at 11:58 p.m., revealed, "...has been accepted at CSU (Crisis Stabilization Unit), waiting on transport. Discharged to home ambulatory...Discharge instructions given to patient..."

Medical record review of a nurse's note dated November 18, 2013, at 11:59 p.m., revealed, "Commitment: pt (patient) going to CSU (Crisis Stabilization Unit)."

Medical record review of a nurse's note dated November 19, 2013, at 12:04 a.m., revealed, "Patient left the ED (Emergency Department)."

Medical record review on November 25, 2013, revealed no documentation regarding a physician's order for a mental health consultation, a mental health evaluation, or involuntary commitment documents.

Interview with the Interim Quality Director on November 25, 2013, at 12:57 p.m., in a conference room, revealed the patient was admitted to a psychiatric facility (not discharged) but the patient's disposition could not be determined by the facility's medical record documentation and confirmed the facility failed to maintain a complete, accurate medical record for Patient #2.

Based on review of facility policy, medical record review and interview, the facility failed to document physician orders and report of a crisis unit assessment for one patient (#2) of five patients reviewed.

The findings included:

Review of facility policy Reference # 4254 titled Mobile Crisis Unit (MCU) Assessments within Hospital Setting most recently reviewed September 6, 2013, revealed, "...MCU is to provide documentation of their assessment & recommendation to the ED (Emergency Department)."

Patient #2 presented to the facility's Emergency Room (ER) on November 18, 2013.

Medical record review of a nurse's note dated November 18, 2013, at 5:50 p.m., revealed, "...EMS (Emergency Medical Services) states...were called out for possible overdose, suicide attempt...Pt. (patient) stated...took 9 200 mg (milligrams) of Trazadone (an anti-depressant medication) to try and kill...self..."

Medical record review of a Triage Assessment dated November 18, 2013, at 5:54 p.m., revealed, "...Total Suicide Risk Assessment Score...3 or Greater (Substantial Risk for Suicide) Patient placed in safe environment. 1:1 sitter with pt. (patient) 72 hour involuntary hold process initiated..."

Medical record review of a nurse's note dated November 18, 2013, at 6:00 p.m., revealed, "...waiting on MCU (Mobile Crisis Unit) consult..."

Medical record review of a history and physical authored by Medical Doctor (M.D.) #2 dated November 18, 2013, at 6:04 p.m., revealed, "...presents via (ambulance service) with complaints of Suicidal Ideation...psychosis...voices are telling patient to commit suicide...symptoms...began...gradually, 3 month(s) ago, and became worse today, was nearly hit by car trying to avoid...hallucinations...At their worst symptoms were severe in the emergency department the symptoms are unchanged."

Medical record review of the Emergency Room record dated November 18, 2013, at 11:49 p.m., revealed, "Outcome: Discharge ordered by MD."

Medical record review of a Disposition Summary dated November 18, 2013, at 11:49 p.m., revealed, "Discharged to Home/Self Care...Impression: Psychosis, Major Depression with Suicidal Ideation...Condition is Stable...Problem is an ongoing problem. Symptoms are unchanged."

Medical record review of a physician's progress note dated November 18, 2013, at 11:51 p.m., revealed, "...Response to treatment: There is no appreciated change of the patient's symptoms at this time."

Medical record review of a nurse's note dated November 18, 2013, at 11:58 p.m., revealed, "...has been accepted at CSU (Crisis Stabilization Unit), waiting on transport. Discharged to home ambulatory...Discharge instructions given to patient..."

Medical record review of a nurse's note dated November 18, 2013, at 11:59 p.m., revealed, "Commitment: pt (patient) going to CSU (Crisis Stabilization Unit)."

Medical record review of a nurse's note dated November 19, 2013, at 12:04 a.m., revealed, "Patient left the ED (Emergency Department)."

Medical record review on November 25, 2013, revealed no documentation regarding a physician's order for a mental health consultation, a mental health evaluation, or involuntary commitment documents.

Review of a crisis unit assessment dated November 18, 2013, and faxed to the facility on November 25, 2013, revealed, "...Active suicidal ideation with no plan or intent...client admitted...(M.D. #2) agrees with disposition..."

Interview with the Interim Quality Director on November 25, 2013, at 12:57 p.m., in a conference room, confirmed the facility failed to document all physician orders and reports necessary to monitor the patient's condition for Patient #2.