HospitalInspections.org

Based on the review of medical records, it was determined that in one of one medical record with documentation to reflect the use of restraints, medical record # 8, the hospital failed to ensure that the use of restraint was in accordance with the order of a physician. Findings:

Medical record # 8 was reviewed. Documentation reflects that Patient # 8 presented to the Emergency Department (ED) on 01/28/2010 with paranoid delusional behavior and evidence of suicidal ideation. Documentation reflects that at 2030 hours Patient # 8 evidenced an emotional outburst and began throwing things in his/her room in the ED.

Medical record # 8 contained the form entitled LHS Behavioral Management Seclusion/Restraint Observation Record for Adult & Pediatric Patients (24 hours). Documentation on the form reflects that Patient # 8 was placed in bilateral 4 point restraint at 2030 hours on 01/28/2010. The restraints were maintained continuously until 2200 hours on 01/28/2010. At 2200 hours the restraints were reduced to 2 point restraint, right wrist and left leg. The restraints were removed at 2245 hours on 01/28/2010. The medical record lacked a physician's order for the use of restraints.


These findings also represent noncompliance with the following Oregon Administrative Rule for Hospitals, 333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients' rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).

Based on the review of medical records, it was determined that in ten of ten medical records, medical records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, the hospital failed to ensure that all patient medical record entries were dated, timed, and authenticated. Findings:

1. The LHS Patient Care Profile Acute Psychiatric Initial Treatment Plan in ten of ten medical records, medical records # 1 through # 10, lacked documentation of the time the plan was developed and documented.

2. The LHS Patient Care Profile Acute Psychiatric Treatment Plan Review/ Evaluation Form in seven of seven applicable records, medical records # 1, 2, 3, 5, 6, 7, and 9, lacked documentation of the time of entries on the form.

3. The Routine Admit Orders Adult Psychiatric Services Pre-Printed Orders form in ten of ten medical records, medical records # 1 through # 10, lacked authentication by the physician who provided the orders. Documentation on the form in ten of ten medical records reflected that all of these orders were documented as a result of telephone orders from a physician.

Additional physician telephone or verbal orders in medical records # 2, 3, 4, 5, 6, 7, and 9 lacked authentication by the physician.

Cross refer to A0457, all verbal orders must be authenticated based on Federal and State laws. If there is no State law that designates a specific time frame for the authentication of verbal orders, verbal orders must be authenticated within 48 hours. State law designates 48 hours.

4. Physician-written orders in medical records # 3, 5, and 7 lacked documentation of the date and/or time and/or authentication.

Cross refer to A0454, all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner.

5. The handwritten Psychiatric Admission Note in medical records # 1, 3, 5, 7, and 9 lacked documentation of the time. The note in medical record # 3 also lacked authentication by the physician.


These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals, 333-505-0050(7) All entries in a patient's medical record shall be dated, timed and authenticated.

Based on the review of medical records, it was determined that in ten of ten medical records, medical records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, the hospital failed to ensure that all orders, including verbal orders were dated, timed, and authenticated promptly by the ordering practitioner. Findings:

The Routine Admit Orders Adult Psychiatric Services Pre-Printed Orders form in ten of ten medical records, medical records # 1 through # 10, lacked authentication by the physician who provided the orders. Documentation on the form in ten of ten medical records reflected that all of these orders were documented as a result of telephone orders from a physician.

Physician-written orders in medical records # 3, 5, and 7 lacked documentation of the date and/or time and/or authentication.


These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals:
333-505-0050(2)(f)(A)-All patient orders shall be initiated, dated, timed and authenticated by a licensed health care practitioner.

Based on the review of medical records, it was determined that in ten of ten medical records, medical records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, the hospital failed to ensure that all verbal orders were authenticated within 48 hours. Findings:

The Routine Admit Orders Adult Psychiatric Services Pre-Printed Orders form in ten of ten medical records, medical records # 1 through # 10, lacked authentication by the physician who provided the orders. Documentation on the form in ten of ten medical records reflected that all of these orders were documented as a result of telephone orders from a physician.

Additional physician telephone or verbal orders in medical records # 2, 3, 4, 5, 6, 7, and 9 lacked authentication by the physician.


These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals, OAR 333-505-0050(2)(f)(C)- Verbal orders shall be dated, timed, and authenticated within 48 hours by the ordering health care practitioner who is responsible for the care of the patient.

Based on the review of medical records, it was determined that in four of ten medical records of individuals admitted to the inpatient behavioral health unit, medical records # 1, 5, 7, and 9, the hospital failed to ensure a medical history and physical examination completed, documented, and placed in the patient's medical record within 24 hours after admission. Findings:

The hard copy of medical records # 1, 5, 7, and 9 was reviewed. Each of the medical records contained a Psychiatric Admission Note hand written by the admitting physician on the day of admission. The note contained only the following elements: Date of Admit; Brief Problem Statement; Diagnoses for Axis I, II, III, IV, and V as appropriate for the patient; and a treatment plan. The Psychiatric Admission Note lacked documentation of all of the elements normally contained in a History and Physical Examination (H&P).

The electronic medical record for Patients # 1, 5, 7, and 9 was reviewed on line with the assistance of a hospital medical records specialist. Findings were confirmed by the specialist.

Medical record # 1: Patient # 1 was admitted to the hospital on 01/16/2010 and discharged on 01/19/2010.
The H&P in medical record # 1 was dictated on 03/06/2010, seven weeks after admission.

Medical record # 5: Patient # 5 was admitted to the hospital on 01/14/2010 and discharged on 01/26/2010.
The H&P was dictated on 01/20/2010, six days after admission.

Medical record # 7: Patient # 7 was admitted to the hospital on 01/15/2010 and discharged on 01/25/2010. The H&P was dictated on 01/20/2010, five days after admission.

Medical record # 9: Patient # 9 was admitted to the hospital on 01/15/2010 and discharged on 01/25/2010. The H&P was dictated on 01/20/2010, five days after admission.


These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals:
333-510-0010(2)(a) Patient Admission and Treatment Orders, within 24 hours of a patient's admission, a hospital shall ensure that the patient's medical history is taken and a physical examination performed.

Based on the review of medical records, it was determined that in four of ten medical records, of individuals who were discharged following the provision of inpatient behavioral health services, medical records # 3, 5, 7, and 9, the hospital failed to ensure the record contained a discharge summary. Findings:

Medical record # 5: Documentation reflects Patient # 5 was discharged on 01/26/2010. The hard copy and the electronic medical record lacked a discharge summary.

Medical record # 9: Documentation reflects Patient # 9 was discharged on 01/25/2010. The hard copy and the electronic medical record lacked a discharge summary.

Medical record # 7: Documentation reflects Patient # 7 was discharged on 01/25/2010. The review of the electronic medical record reflects the discharge summary was dictated on 03/07/2010. The discharge summary was not transcribed and was not incorporated into the medical record on the date of survey, 03/09/2010.

Medical record # 3: Documentation reflects Patient # 3 was discharged on 01/15/2010. The review of the electronic medical record reflects the discharge summary was dictated on 03/07/2010. The discharge summary was not transcribed and was not incorporated into the medical record on the date of survey, 03/09/2010.


These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals, 333-505-0050(2)(k) Medical Records, A legible reproducible medical record shall include a discharge summary including final diagnosis.

Based on the review of medical records, it was determined that in five of ten medical records of individuals who had received inpatient behavioral health services, medical records # 1, 3, 5, 7, and 9, the hospital failed to ensure completion of all medical records within 30 days following discharge. Findings:

Cross refer to the findings listed at A-0468, Medical records # 3, 5, 7, and 9 lacked a discharge summary completed and incorporated into the medical record within 30 days following discharge.

Medical record # 1: Documentation reflects Patient # 1 was discharged from the hospital on 01/19/2010. The review of the electronic medical record reflects the discharge summary was authenticated by the physician on 03/06/2010, 46 days following discharge.


These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals, 333-505-0050(9)(a) Medical Records, medical records shall be completed by a licensed health care practitioner and closed within four weeks following the patient's discharge.