HospitalInspections.org

Based on a review of documentation and clinical records, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital for 1 of 10 patients. Failure to follow facility policy can result in a violation of patient rights as well as compromise patient safety.

Findings were:

A review of physician orders for patient #1 revealed the following order written on 2-2-15 at 7:45 am by the patient's attending physician: "1) Pt can sign in voluntary." Further review of the clinical record for patient #1 revealed no Application for Voluntary admission.

Facility policy #PC-104 titled "Types of Hospital Admissions" states, in part:
"Voluntary Admissions:
A patient, age 18 or older, who voluntarily admits himself into ALH must sign an Application for Voluntary Admission."

A review of documentation for patient #1 titled "Mental Health Tech Daily Note" reveals missing signatures from the Registered Nursing staff for 5 of the 6 days of the patient's admission (dates January 30th through February 3rd 2015).

A review of facility policy #PC-154 titled "Level of Observation Protocols" states, in part:
"Procedures:
1.e. RN oversight of patient observation rounds sheets is conducted at a minimum of six times evenly distributed over a 24 hour period."

The above was verified in an interview with the Chief Executive Officer, the Chief Nursing Officer and the Director of Risk Management on the afternoon of 3-18-15 in the facility conference room.

Based on an interview, a review of clinical records and a review of documentation, the governing body failed to be responsible for contracted services furnished in the hospital for 1 of 10 patients. Failure to do so has the potential to compromise patient safety.

Findings were:

In an interview with staff #3 on 3-18-15, staff #3 stated that staff #4 was a contracted employee.

A review of physician orders for patient #1 revealed the following order written on 2-3-15: "TORB: Please change diet to pescetarian." The order was signed by staff #4 but was not signed by the patient's attending physician or his/her designee.

A review of the contract titled "Dietary Services Agreement" for staff #4 lists the delineation of privileges for staff #4 as:
"Obligations of Dietitian
Group shall engage a qualified, licensed dietitian ("Dietitian") to provide consultant dietary services to the Hospital. In providing such services, Dietitian's services shall include the following:
1. Nutritional assessments;
2. Approval of menus
3. Monitoring diets;
4. Conducting in-services on therapeutic diets/menus for both inpatient and outpatient services;
5. Participation in P&T Committee;
6. Monitoring PI for dietitian services;
7. Refrigerator inspection weekly;
8. Inspect trays for correctness of diet order and allergies; weekly for both lunch and dinner; and
9. Audit trays for tray accuracy and temperature checks."

The above was verified in an interview with the Chief Executive Officer, the Chief Nursing Officer and the Director of Risk Management on the afternoon of 3-18-15 in the facility conference room.

Based on a review of documentation and clinical records, the hospital failed to ensure that the notice of rights requirement was met for 1 of 10 patients. Failure to ensure this requirement resulted in a patient being involuntarily hospitalized for two days.

Findings were:


A review of physician orders for patient #1 revealed the following order written on 2-2-15 at 7:45 am by the patient ' s attending physician: "1) Pt can sign in voluntary." Further review of the clinical record for patient #1 revealed no Application for Voluntary admission.

Facility policy #PC-104 titled "Types of Hospital Admissions" states, in part:
"Voluntary Admissions:
A patient, age 18 or older, who voluntarily admits himself into ALH must sign an Application for Voluntary Admission."

The above was verified in an interview with the Chief Executive Officer, the Chief Nursing Officer and the Director of Risk Management on the afternoon of 3-18-15 in the facility conference room.

Based on an interview with staff, a review of documentation and a review of clinical records, 1 of 10 patients did not receive care in a safe setting. Failure to enforce this right has the potential to compromise patient safety.

Findings were:

In an interview with staff #3 on 3-18-15, staff #3 stated that staff #4 was a contracted employee.

A review of the contract titled "Dietary Services Agreement" for staff #4 lists the delineation of privileges for staff #4 as:
"Obligations of Dietitian
Group shall engage a qualified, licensed dietitian ("Dietitian") to provide consultant dietary services to the Hospital. In providing such services, Dietitian's services shall include the following:
1. Nutritional assessments;
2. Approval of menus
3. Monitoring diets;
4. Conducting in-services on therapeutic diets/menus for both inpatient and outpatient services;
5. Participation in P&T Committee;
6. Monitoring PI for dietitian services;
7. Refrigerator inspection weekly;
8. Inspect trays for correctness of diet order and allergies; weekly for both lunch and dinner; and
9. Audit trays for tray accuracy and temperature checks."

A review of physician orders for patient #1 revealed the following order written on 2-3-15: "TORB: Please change diet to pescetarian." The order was signed by staff #4 but was not signed by the patient's attending physician or his/her designee.

A review of facility document titled "Patient's Bill of Rights" states, in part:
"Basic Rights for All Patients
3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

Failure to involve the treating physician when changing the patients therapeutic diet can compromise patient safety, as possible food-drug interactions could occur.

The above was verified in an interview with the Chief Executive Officer, the Chief Nursing Officer and the Director of Risk Management on the afternoon of 3-18-15 in the facility conference room.

Based on a review of documentation and clinical records, the hospital failed to maintain an accurately written medical record for 1 of 10 patients.

Findings were:


A review of facility incident reports reveals a completed incident report for patient #1 dated 1-31-15. The report states "c/o male pt sexually harrasing(sic) her & refusing to move away." The report identifies the male patient as patient #10.

A review of the clinical record for patient #1 reveals no documentation of the incident on 1-31-15 involving patient #1 and patient #10.

The above was verified in an interview with the Chief Executive Officer, the Chief Nursing Officer and the Director of Risk Management on the afternoon of 3-18-15 in the facility conference room.