HospitalInspections.org

Based on record review and interview, the hospital failed to ensure completion of the medication consent form by a registered nurse for four (Patient # 2, 5, 8, & 17) of 17 patients.

This failed practice had the potential to result in no observance of patient of rights to refuse medications, or receive education about prescribed psychotropic medications.

Findings:

Review of hospital policy titled "Rules and Regulations of the Medical Staff of Griffin Memorial Hospital" stated in part "informed consent is required for the administration of psychoactive medications

Patient # 2

A review of record showed the anti-depressant consent form was not signed by physician for patient # 2 who was taking Trazodone as of 12/19/18.

Patient # 5

A review of record for patient # 5 showed the mood stabilizer consent form was not signed by physician for patient # 5 who was taking Depakote as of 12/19/18

Patient # 8

A review of record for patient # 8 showed the psychoactive consent form was not signed by physician for patient # 8 who was taking Thorazine as of 03/12/19.

Patient # 17

A review of record for patient # 17 showed the mood stabilizer consent form was not completed for patient # 17 who was taking Depakote as of 01/30/19.

On 05/02/19 at 12:57 pm, Staff E stated when a medication is added a consent should have been signed.

On 05/03/19 at 11:02 am, Staff A stated when medications are started later it is tougher to obtain consent; and a struggle with getting consent for added medications.

Based on record review and interview, the hospital failed to ensure incident reports were completed for assaultive behavior for two (Patient # 8 and 14) of 17 records reviewed.

This failed practice had the likelihood to put all patients at risk of exposure to preventable assaultive behavior, and risk of mistreatment.

Findings:

Review of hospital policy titled "Critical Incident Report" stated in part "any staff who observes an event or incident that is out of the ordinary will immediately notify the consumer's RN, who will delegate responsibility of documentation in the clinical record.

Review of hospital policy titled "Abuse/Neglect" stated in part "anyone witnessing what is perceived to be misconduct by a consumer toward a consumer shall immediately make an initial report to his/her immediate supervisor...the witness shall ensure an Electronic Incident Report (e-IR) is completed for each alleged occurrence of abuse.

Patient # 8

Review of "nursing progress note" on 04/20/19 showed patient # 8 jumped over the counter at the nurse's station at least three times. There was no documentation to show completion of incident report, no timeline of the patient event, no follow-up and no documented supervisory notification.

Patient # 14

Review of "Nursing Progress Note" on 04/30/19 showeed patient # 14 "was overly social with peers and touched them inappropriately." There was no documentation to show completion of incident report, no timeline of the patient event, no follow-up and no documented supervisory notification.

On 05/03/19 at 10:58 am, Staff F stated an incident report should have been completed by the nurse or whoever saw the incidents for patient #8 and 14.

On 05/03/19 at 11:12 am, Staff E stated documentation should be descriptive and contain detail.

Based on record review and interview, the hospital failed to ensure the physician completed the discharge summary for one (Patient # 12) of 17 patients.

This failed practice resulted in a delinquent chart for patient # 12.

Findings:

Review of hospital policy titled "Discharge" stated in part "a summary of the individual's course of hospitalization shall be dictated within thirty (30) days following discharge.

A review of record showed patient # 12 was admitted on 07/30/18 and discharged on 03/25/19. There was no discharge summary as of 05/03/19 (39 days after discharge).

On 05/02/19 at 12:57 pm, Staff E stated the discharge summary had not been completed.

On 05/03/19 at 10:45 am, Staff F stated he/she did not know when the discharge summary should be completed.

On 05/03/19 at 11:04 am, Staff A stated the discharge summary should have been completed within thirty days.