HospitalInspections.org

Based on review of the hospital's policy/procedure, documents, medical records, and interviews, it was determined that the administrator failed to require that an incident report was completed at the time of Patient #1 leaving the facility Against Medical Advice (AMA). This deficient practice poses a risk to the health, and safety of patients, when the facility does not track patients leaving AMA, ensuring that all required documentation is completed.

Findings include:

Policy titled "Against Medical Advice (AMA)" (10/2016), revealed: "...To provide guidelines for hospital staff when a choice is made by a patient to reject their prescribed treatment plan, and leave the hospital self-discharge...when a patient makes known their desire to reject their prescribed treatment plan and leave the hospital...AMA...notify the house supervisor and Administrator On Call (AOC)...notify the physician...document in the Nursing Narrative...note the patient or patient's legal representatives request regarding the patient's leaving AMA...reason for leaving...efforts made regarding the circumstance...what documents have been completed or refused to be completed...note what persons have been notified...an Occurrence Report is completed when a patient self-discharges...leaves AMA...."

Medical Record review for Patient #1, conducted 05/12/2020, revealed no documented evidence that the patient's physician was notified of the patient's request to leave AMA.

Personnel #4 confirmed during a telephone interview conducted 05/13/2020 (1000), that s/he did not complete an Occurrence Report/Incident Report regarding Patient #1's leaving AMA.

Personnel #1 confirmed during a telephone interview conducted 05/13/2020 (1030), the facility had no documented evidence of an Occurrence Report/Incident Report being completed for Patient #1. Additionally, Personnel #1 revealed that the hospital's policy requires that an Occurrence Report/Incident Report is required to be completed when a patient leaves the hospital AMA.

Personnel #9 confirmed during a telephone interview conducted 05/13/2020 (1045), that an Occurrence Report/Incident Report is required to be completed if a patient leaves AMA, and that it would be the responsibility of the patient's nurse to complete the report.

Based on review of hospital personnel files, documents, and interview, it was determined that the hospital failed to require that orientation for the House Supervisor was completed. This deficient practice poses a risk to the health, and safety of the patients, when the House Supervisor who is in charge, having responsibility/oversight of patient care services, has no documented evidence in their personnel file ensuring that s/he has been trained, and that the required competencies per his/her job description has been verified and validated.

Findings include:

Document titled "KPC Promise Hospital, Job Description, House Supervisor" listed multiple skills and competencies, required for the House Supervisor position. The "KPC Promise Hospital, Job Description, House Supervisor" was signed by Personnel #9 on 11/14/2019.

Document titled "KPC Promise Healthcare, Understanding House Supervisor's Role", listed multiple responsibilities, and requirements specific to the House Supervisor's position. The "KPC Promise Healthcare, Understanding House Supervisor's Role" was signed by Personnel #9 on 09/26/2019.

Document titled "KPC Promise Hospital of Phoenix, Organizational Plan for Providing Patient Care" (2019), revealed: "...Patient Care Services...Nursing Services...Leadership...A House Supervisor is assigned to the hospital units to provide clinical supervision 24/7, and reports to the Nurse Manager...After business hours and weekends, the House Supervisor represents administration...."

Personnel #1 confirmed by email sent 05/14/2020 (0751), that Human Resources had no documented evidence of Personnel #9's orientation specific to House Supervisor.

Based on review of the hospital's Medical Staff Rules & Regulations, medical records, and interviews, it was determined that the hospital failed to require that verbal/telephone orders given by the physician for Patient #1, were authenticated within the required forty-eight (48) hours. This deficient practice poses a risk for the health and safety of the patients, when physicians do not authenticate a verbal/telephone order ensuring that the verbal/telephone order was correct, and provided to the correct patient.

Findings include:

Document titled "KPC Promise Healthcare, KPC Promise Hospital, Medical Staff Rules & Regulations" (10/2019), revealed: "...All orders for treatment shall be in writing, timed, and dated, and then signed by the physician...The person to whom a telephone order is dictated to and the name of the physician giving the orders documented shall sign, date, and time such orders...A verbal telephone order shall be considered in writing if given to a...Registered Nurse, Licensed Practical Nurse, Registered Respiratory Care Practitioners, Physical Therapists, Occupational Therapists, Speech Therapists, Registered Dieticians, and Pharmacists...all orders dictated over the telephone shall be dictated by the practitioner and shall be signed by the appropriately authorized persons...the responsible practitioner shall authenticate such order within forty-eight (48) hours...."

Medical record review for Patient #1, conducted 05/12/2020, revealed the following:

i. [02/13/2020 - 03/17/2020] - A total of fourteen (14) verbal/telephone orders were not authenticated by the physician.

Personnel #1 confirmed during an interview conducted 05/12/2020 (1125), that Patient #1's medical record contained verbal/telephone orders that had not been authenticated, and that Physician #2 was informed.

Personnel #8 confirmed during an interview conducted 05/12/2020 (1130), that verbal/telephone orders are to be authenticated by the physician within forty-eight (48) hours.

Based on review of the hospital's Medical Staff Rules & Regulations, medical records, and interviews, it was determined that the hospital failed to require that a Discharge Summary for Patient #1, was completed within the required thirty (30) days. This deficient practice poses a risk to the health and safety of the patients, when physicians do not complete a Discharge Summary, detailing the patient's treatment, and outcomes, for continuity of care.

Findings include:

Document titled "KPC Promise Healthcare, KPC Promise Hospital, Medical Staff Rules & Regulations" (10/2019), revealed: "...A physician member of the Medical Staff shall be responsible for the overall medical care of each patient in the hospital...attending practitioners shall be responsible for the treatment, and the prompt completeness and accuracy of the medical record...responsible for the preparation of a complete and legible medical record for each patient...contents shall be pertinent and current...a discharge summary shall be completed on patients hospitalized...responsible physician shall sign all summaries...Discharge Summaries must be completed within thirty (30) days of the patient's discharge...."

Medical record review for Patient #1, conducted 05/12/2020, revealed the following:

i. [03/18/2020] - Confirmed patient's discharge on this date, but no documented evidence of a completed Discharge Summary.

Personnel #2 confirmed during an interview conducted 05/12/2020 (1015), that there was no Discharge Summary completed for Patient #1, and that the physician is required to complete the Discharge Summary within thirty (30) days after the patient's discharge. Additionally, Personnel #2 revealed that Patient #1 was discharged on [03/18/2020], which is greater than thirty (30) days.

Personnel #1 confirmed during an interview conducted 05/12/2020 (1125), that Patient #1's medical record contained no documented evidence of a Discharge Summary, and that Physician #2 was informed.