HospitalInspections.org

Based on medical record review, document review and interview, medical staff did not ensure consults are performed within 24 hours as required by the facility's bylaws for 1 of 25 patients (Patient #1). A delay in consultation could affect patient outcome and the care provided.

Findings include:

Review of Medical Dental Staff Bylaws/Rules and Regulations revealed the consultant's report is to be completed and included in the patient's medical record within twenty-four (24) hours of the request for such a consultation.

Review of Physician Orders for Patient #1 dated 6/3/17 at 8:22 PM revealed an order for a medicine consult. There was no documentation in the medical record to indicate the consult was obtained.

Interview with Staff (A), patient safety and (Z), patient safety on 11/29/17 at 11:00 AM verified there was no evidence to indicate the medicine consult had been obtained.

Based on observation and interview, the facility did not maintain a sanitary and comfortable environment for patients in the Comprehensive Psychiatric Emergency Program (CPEP) unit. This could lead to infection control problems for patients and staff.

Findings include:

Observation in CPEP on 11/27/17 at 10:00 AM revealed the floors in the common areas were dust filled along entire wall border and corner areas, along with several dirt-stained patches noted on the floor. Patches of paint were missing on several wall areas. In the overflow area, where patients were lying on floor mattresses, the border edges were dust filled with areas of dirt-stained patches on the floor. In the shower room (2ESA) a used washcloth was noted on the the wall hand bar.

Interview with Staff (A), patient safety and Staff (D), director verified the above noted findings.

Based on medical record review, policy review and interview, the facility has not ensured patients are provided with complete discharge instructions in accordance with facility policy in 1 of 25 patients (Patient #1). Failure to provide complete discharge instructions could lead to re-admission or inadequate care.

Findings include:

Review of Discharge Planner Note dated 6/6/17 revealed arrangements were made for the patient to follow-up with a clinic social worker on 6/8/17 at 2:30 PM.

Review of Patient Discharge Instructions dated 6/6/17 revealed no documentation to indicate the patient was informed of the upcoming social work appointment. In addition, the discharge instructions lacked a patient signature verifying receipt of the instructions.

Review of facility policy and procedure titled "Discharging an Inpatient" revised 7/2015 revealed discharge instructions are to be reviewed with the patient, which includes any follow-up appointments. The nurse and patient are to sign the discharge form with a copy provided to the patient.

Interview with Staff (A), patient safety, (B), CPEP administration and (C), physician on 11/29/17 at 2:30 PM verified above findings.