HospitalInspections.org

Based on record review and interview, the facility failed to ensure family was notified of a change of condition for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Medical record review revealed Patient #1 arrived at Hospital #1's Emergency Department (ED) on 7/3/2021 around 11:04 PM via the police department. The patient was responding to internal stimuli, believed the year was 1992, threw a light at officers, and damaged neighbor's property.

The Medical Screening Exam (MSE) note dated 7/3/2021 at 11:05 PM revealed, " ...not being cooperative and is not answering any questions ...instructed me to get out of her face ..."

The physician orders dated 7/3/2021 at 11:05 PM revealed, "...Haldol [an anti-psychotic used to improve thinking and behavior] 5 mg [milligrams] IM [intramuscular]...Ativan [a benzodiazepine used to treat anxiety] 2 mg IM...Benadryl [an antihistamine] 50 mg IM X1 dose..."

The Standardized Intake Assessment form dated 7/3/2021 at 11:55 PM revealed, "...collateral (husband)...thought it was lack of sleep..."

The Emergency Medical Treatment and Labor Act (EMTALA) form dated 7/4/2021 at 1:40 AM, revealed Patient #1 was transferred to Hospital #2's ED with a diagnosis of "fall/hit head."

There was no documentation in the medical record the husband was informed when Patient #1 was transferred to a higher level of care.

2. In an interview in the conference room on 2/9/2022 at 2:51 PM, the Executive Director revealed the Intake Department medical staff made decisions on advising family members regarding patient status.

Based on policy review, record review, interview, and document review, the facility failed to ensure the patient received a copy of their medical record in a timely manner for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "Patient's Bill of Rights" policy dated 2/2020 (11/2021), revealed an individual entering the facility for treatment was treated with dignity and respect. The patients have access to information in the medical record.

Review of the facility's "CONFIDTIALITY/ACCESS AND RELEASE OF PATIENT INFORMATION" policy dated 1/2019 (1/2022) revealed, "...PURPOSE...To preserve the patient's right to access his/her information...PROCEDURES...Post Discharge Release of Information (closed)...HIM [Health Information Management] is responsible for the release of all information post discharge..."

2. Medical record review revealed Patient #1 arrived at Hospital #1's Emergency Department (ED) on 7/3/2021 around 11:04 PM via the police department. The patient was responding to internal stimuli, believed the year was 1992, threw a light at officers, and damaged neighbor's property.

On 7/3/2021 at 11:05 PM, Patient #1 continued to be uncooperative during the admission process and was given medication.

On 7/4/2021 at 1:40 AM, the patient was transferred to Hospital #2's ED due a fall and returned to Hospital #1's ED at 7:40 AM.

Hospital #1 completed the Intake Assessment process and Patient #1 was discharged at 12:49 PM, with recommendations for outpatient treatment.

3. Review of a "AUTORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION" dated 7/22/2021, revealed Patient #1 completed the form for the release of records from Hospital #1 for the dates 7/3/2021-7/4/2021.

Review of a "Request Exception Notification" form, from Hospital #1, undated revealed, "...We show no treatment at this facility for the dates of service you requested...We have been unable to locate a record for the above-named patient..."

4. In a telephone interview on 2/2/2022 at 1:05 PM, Reporting Source #1 verified they requested medical records from Hospital #1 and were informed they were never a patient.

In an interview in the conference room on 2/9/2022 at 2:51 PM, the Executive Director verified the "Request Exception Notification" came from the eDelivery system.