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Based on record review and interview, the facility failed to perform and document findings from a neurological examination for 6 of 10 sample patients (PCU-4, N1-6, N1-17, N4-10, N2-12 and A-13). Failure to perform and document patients' neurological status on admission prevents future comparative examinations to assess changes in patients' neurological functioning.

Findings include:

A. Record Review

1. Patient PCU-4: The Neurological Examination of 5/13/10 described the cranial nerves as "grossly intact." The Romberg test and the plantar response test were "not
done." There were no reasons given for the omissions.

2. Patient N1-6: The Neurological Examination of 5/15/10 described the cranial nerves as "grossly intact." The Romberg test and the deep tendon reflexes were "not done." There were no reasons given for the omissions.

3. Patient N1-17: The Neurological Examination of 4/29/10 described the cranial nerves as "grossly intact." The Romberg test and the plantar response test were "not done." There were no reasons given for the omissions.

4. Patient N4-10: The Neurological Examination of 5/13/10 described the cranial nerves as "grossly intact." The Romberg test and the plantar response test were "not done." There were no reasons given for the omissions.

5. Patient N2-12: The Neurological Examination of 5/4/10 described the cranial nerves as "grossly intact." The Sensory examination was deferred, with no reason given.

6. Patient A-13: The Neurological Examination of 5/15/10 described the cranial nerves as "grossly intact." The Romberg test and the deep tendon reflexes test were "not done," with no reasons given for the omissions.

B. Interview:

In an interview on 5/19/10 at 10:30 a.m., the Medical Director stated that the above neurological examinations were incomplete.

Based on record review and interview, the hospital failed to ensure that 7 of 10 sample patients (B-21, N1-17, N2-12, N3-11, N4-2, N4-10 and PCU-11) received a psychiatric evaluation containing a mental status examination that was descriptive and specific enough to support the diagnosis and to establish a sufficient baseline for the evaluation of treatment outcomes. This failure hampers the staff's abililty to formulate a correct diagnosis and develop an individualized treatment plan for the patient.

Findings include:

A. Record Review

1. Patient B-21: The Psychiatric Evaluation dated 4/28/10 stated "average intelligence."
No bases for this judgment were given.

2. Patient N1-17: The Psychiatric Evaluation dated 4/29/10 recorded no testing of
memory. Intelligence was recorded as "average" without elaboration

3. Patient N2-12: The Psychiatric Evaluation dated 5/3/10 recorded no testing of memory. Intelligence was rated "average" and judgment "intact" without elaboration.

4. Patient N3-11: The Psychiatric Evaluation dated 5/13/10 stated that memory and
concentration were "WNL" [sic] (no specifics given). Judgment, intelligence, and
insight were not assessed.

5. Patient N4-2: The Psychiatric Evaluation dated 5/14/10 stated that judgment was
"intact" and intelligence was "average" without data for either of these conclusions.
Documentation of memory testing was incomplete and illegible.

6. Patient N4-10: The Psychiatric Evaluation dated 5/12/10 stated that intelligence was
"average" without giving any basis for this conclusion. No memory testing was
documented.

7. PatientPCU-11: The Psychiatric Evaluation dated 5/14/10 stated that judgment was
"intact" and intelligence was "below average." No data were given to support
these conclusions.

B. Interview

In an interview on 5/19/10 at 10:30 a.m., the Medical Director stated that the above mental status examinations were incomplete.

Based on record review and interview, the hospital failed to provide a Psychiatric Evaluation, detailing the onset of illness and the circumstances leading to admission for 2 of 10 sample patients (N1-17 and PCU-11). This deficient practice hampers staff's ability to clearly assess the patient's prior level of functioning so that appropriate treatment goals and interventions can be formulated.

Findings include:

A. Record Review

1. Patient N1-17: In the Psychiatric Evaluation dated 4/29/10, the section entitled History of Present Illness read in its entirety as follows: "MA [sic] AAM. [sic]; Paranoid/angry/ agitated/labile. Reported threatened violence to mom [sic]. Pacing/psychomotor restless. Urges to harm others. 0 [sic] CFS [sic] here." No onset of symptoms or description of precipitating events or circumstances was given. The section of the psychiatric evaluation requiring information about the duration of symptoms was left blank.

2. Patient PCU-11: In the Psychiatric Evaluation dated 5/11/10, the section entitled "History of Present Illness" read in its entirety as follows: "43 y/o AA (African American (symbol for female) single on a 201 [sic] (symbol for "with") c/o [sic] auditory hallucinations. 'Nobody will miss me; one way [sic] I should kill myself.' (illegible word) negativity and delusional beliefs that people want to kill her. SI [sic] with intent to cut her wrists." No onset of symptoms or description of precipitating events or circumstances was given. The section of the psychiatric evaluation requiring information about the duration of symptoms was left blank.

B. Interview

In an interview on 5/18/10 at 11:00 a.m., the Medical Director stated that the cited psychiatric evaluations were deficient in that the history of present illness sections were not detailed enough and did not address onset of illness, circumstances leading to admission, and duration of symptoms.

Based on record review, staff interviews and policy review, the facility failed to follow procedure or properly document the use of restraints for one sample patient (N1-17) and three non-sample patients (N2-15, N4-13, and N4-21) added for the purpose of reviewing the use of restraints. This deficient practice exposes patients to potential harm and is a violation of patient rights.

Findings include:

A. Record Review

1. Patient N1-17: Review of the medical record revealed that on 05/14/10, the patient was placed in ankle and wrist restraints as an elopement and assault risk precaution while being transported to a medical hospital for an evaluation for a detached retina. The Seclusion/Restraint Record did not have a signature of a physician indicating a face-to-face assessment or a review of the nurse's face-to-face assessment. Recordings on the Seclusion/Restraint Observation Record documented that the patient was in restraints for three and one-half hours. No vital signs were recorded other than at the initiation of the restraints at 3:25 p.m.

2. Patient N2-15: A progress note on the patient's medical record, dated 04/28/10 at 9:00 p.m., stated that the patient was angry and agitated and unable to be redirected at 8:40 p.m. The patient was placed in a hold from 8:40 p.m. until 8:42 p.m. She received Benadryl 50 mg by mouth and began to calm down and apologized to staff. No additional progress note was written on the evening of 04/28/10. The next progress note was documented on 04/29/10 at 5:00 a.m. A doctor's order, dated 04/28/20 (9:50 p.m.), included a telephone order for Benadryl 50 mg. IM. The patient's medication record showed that the patient was administered Benadryl 50 mg. IM at 9:50 p.m. There was no progress note to indicate why the patient received the IM medication an hour after the 8:40 p.m. hold and oral dose of the medication. Furthermore, the PRN justification form dated 04/28/10 (9:50 p.m.) did not include the name or the dosage of the PRN medication administered.

3. Patient N-15: The Seclusion/Restraint Record dated 04/30/10 did not include a time of contact for the RN's or the attending physician's face-to-face evaluation of the patient in restraints.

4. Patient N4-13: The Seclusion/Restraint Record dated 04/01/10 documented that both a restraint and seclusion were used. The name of the physician was missing from the 04/01/10 restraint record. The physician order form dated 04/01/10 documented that "locked seclusion" was ordered, whereas the telephone order stated that "4-point leather restraint for assaultive behavior" were to be used.

5. Patient N4-21: The patient had multiple episodes of 4-point restraint during hospitalization. The treatment plan problem sheet (FBHS-565) [sic] listed as problem #5: "Aggressive acting out behavior requiring the use of seclusion/restraint." However, the remainder of the treatment plan form, including a specific description of behavior, long and short-term goals, and interventions, was left blank.

B. Staff Interviews

1. In an interview with RN4 on 05/18/10 at 8:40 a.m., RN4 stated that no physician signature was present on the face-to-face Seclusion/Restraint Assessment form dated 05/14/10 for patient N1-17.

2. In an interview on 4/18/10 at 4:00 p.m., RN5 stated that Patient N1-17's vital signs should have been taken every two hours while he was in restraints. She stated that if vital signs had been taken, they would have been recorded, and that since no vital signs were recorded, she assumed they were not taken. She stated that the absence of documented vital signs is an "obvious error."

3. In an interview on 05/17/10 at 3:00 p.m., RN2 stated that the progress note for patient N2-15 on 04/28/10 should have stated the reason that Benadryl 50 mg IM was administered at 9:50 p.m. In the same interview, RN2 stated that the nurse's and the physician's face-to-face assessments of patient N2-15 while in restraints on 04-30-10 should have included the time of the assessments.

4. In another interview on 05/19/10 at 8:30 a.m., RN2 stated that the PRN justification form for patient N2-15 did not indicate the name and the dosage of the medication given, and that it should have done so.

5. In an interview on 05/18/10 at 11:00 a.m., the Medical Director stated that the restraint form for patient N4-13 was incorrectly completed and that seclusion is not used at the hospital. He also acknowledged that the treatment plan problem sheet for patient N4-21 was left blank.

C. Policy Review

1. Policy No. PC.093 entitled: "Use of Restraints When Taking Patients to Off-Site Civil Commitment Hearings" (reviewed 02/10) states "Vital signs shall be taken upon initiation and as clinically indicated, but at least every 2 hours."

2. Policy No. PC.092 entitled "Restraints and Seclusion" (reviewed 04/10) states in section 6.4.1 "The evaluation will include the date of time of the evaluation."

Based on record review, policy review and staff interview, the hospital failed to ensure that discharge summaries:

I. Were authenticated and signed by the physician within 30 days of discharge in five of ten discharge records reviewed (D1, D2, D3, D4, D5) This deficiency results in failure to communicate in a timely manner with outpatient providers, essential information (e.g., the final diagnoses, current medications, course of treatment, summary of relevant information, anticipated problems and discharge plans).

II. Included information about the treatment the patient received in the hospital and the patient's response to treatment for two of ten patients (D6, D7) whose discharge records were reviewed. Failure to provide information regarding effective and/or ineffective treatment strategies for an individual patient compromises the effective transfer of the patient's care to the next care provider.

III. Used only approved abbreviations and symbols in two of ten discharge records
(D4 and D5). Failure to use approved language potentially results in misunderstanding of information critical to the individual's outpatient treatment.

Findings include:

A. Record Review

1. Record D1: The patient was discharged on 04/17/10. The discharge summary was dictated by an R.N. on 04/25/10. No physician signature present when the record reviewed on 05/18/10.

2. Record D2: The patient was discharged on 04/17/10. The discharge summary was dictated by an M.S.W. on 04/24/10. No physician signature was present when the record was reviewed on 05/18/10.

3. Record D3: The patient was discharged on 04/16/10. The discharge summary was dictated by an M.S. on 05/05/10. No physician signature was present when the record was reviewed on 05/18/10.

4. Record D4: The patient was discharged on 04/17/10. The discharge summary was dictated on 04/2/10. No physician signature was present when the record was reviewed on 05/18/10. Record D4 also used the abbreviation "PMR" which is not an abbreviation approved by the Medical Executive Committee.

5. Record D5: The patient was discharged on 04/17/10. The discharge summary was dictated by an M.S.W. on 04/24/10. No physician signature present when the record was reviewed on 05/18/10. Record D5 also contained the abbreviations "HCV" [sic] and "RSD" [sic] which are not abbreviations approved by the Medical Executive Committee.

6. Record D6: The patient was discharged on 03/24/10. The discharge summary did not include information about the treatment the patient received in the hospital. Instead, the "course of treatment" noted in the discharge summary was a summary of the patient's mental status examination at the time of discharge and a statement about the absence of suicidal and homicidal ideation.

7. Record D7: The patient was discharged on 02/18/10. The discharge summary did not include information about the treatment the patient received in the hospital. Instead, the "course of treatment" noted in the discharge summary was a summary of the patient's mental status examination at the time of admission and discharge.

B. Staff Interviews

1. In an interview on 05/18/10 at 2:20 p.m. RN2 stated that there were no physicians' signatures present on discharge records D1, D2, D3, D4, and D5. Furthermore, she stated that the physicians' signatures are "by policy" supposed to be on the discharge records within 30 days after discharge.

2. In an interview on 5/18/10 at 11:30 a.m., the Coordinator of Social Work and Allied Therapy stated that the social worker responsible for dictating discharge summaries is not supervised by any social worker, but that her supervision comes directly from the Director of Medical Records.

3. In an interview on 05/18/10 at 12:15 p.m., the Director of Medical Records stated that she supervises the process of discharge summaries. She stated "I started here right after high school in the medical records department as a typist." She stated she is not a RHIA (Registered Health Information Administrator) or a RHIT (Registered Health Information Technician). She stated that, after the discharge summary is dictated by a social worker or a counselor (specifically hired for the process of dictating discharge summaries), she proofreads and edits the summaries and sends them to the doctor for his/her signature. The individual dictating the summaries does not proofread or edit his/her own work.

4. In an interview on 05/18/10 at 12:30 p.m., the Director of Quality Management stated that she was not aware that the Coordinator of Social Services did not supervise the individuals dictating the discharge summaries. She also stated that she was unaware that the only person supervising the individuals dictating the discharge summaries was the Director of Medical Records.

C. Policy Review

1. Fairmount Behavioral Health System Policy/Procedure No. IM.015 entitled "Abbreviations and Symbols" (reviewed 03/10) states: "Abbreviations and symbols are used in the medical record only when they have been approved by the Medical Executive Committee." The list of approved abbreviations did not include "PMR" used in Record D4 or "HCV and RSD" used in Record D5.

2. Fairmount Behavioral Health System Policy/Procedure No. IM.029 entitled "Medical Discharge Summary" (reviewed 03/10) reads: "Medical Discharge Summaries will be completed within 30 days of discharge, which is the time frame set forth in the Medical Staff Rules and Regulations."

Based on record review and interview, the hospital's Medical Director failed to:

I. Monitor the completeness of neurological examinations for 6 of 10 sample patients (PCU-4, N1-6, N1-17, N4-10, N2-12 and A-13). Failure to document neurological status at admission status precludes future comparative examinations to assess the patient's neurological functioning. (Refer to B109)

II. Ensure that 7 of 10 sample patients (B-21, N1-17, N2-12, N3-11, N4-2, N4-10 and PCU-11) received a psychiatric evaluation that included a mental status examination that was descriptive and specific enough to support the diagnosis and to establish a baseline sufficient for the evaluation of treatment outcomes. This failure hampers the staff's abililty to formulate a correct diagnosis and develop an individualized treatment plan for the patient. (Refer to B113)

III. Ensure that a Psychiatric Evaluation detailing the onset of illness and the circumstances leading to admission was completed for 2 of 10 sample patients (N1-17 and PCU-11). This failed practice hampers staff's ability to clearly assess the patient's prior level of functioning so that appropriate treatment goals and interventions can be formulated. (Refer to B114)

IV. Ensure that the correct Seclusion and/or Restraint procedures, including adequate documentations were completed for one sample patient (N1-17), and three non-sample patients (N2-15, N4-13, and N4-21) added for the purpose of reviewing the use of restraints. This deficient practice exposes patients to potential harm and is a violation of patient rights. (Refer to B125)