HospitalInspections.org

The Psychiatric hospital reported a census of 40 inpatients. Based on medical review, staff interview, and policy review the hospital failed to ensure patients received their patient rights for one of ten medical records reviewed (patient # 5). The hospital's failure to provide the written patient rights could jeopardize the patient's ability to understand their rights and responsibilities for making decisions about their healthcare, patient experience, and impact their quality of care.

Findings include:

- Patient #5's medical record reviewed on 9/7/2016 revealed an admission date of 3/2/2016 with a diagnosis of Depressive disorder. Patient #5's medical record lacked evidence the patient or their representative was informed of his/her patient rights at admission.

Director of Quality Staff C interviewed on 9/7/2016 at 11:30 AM acknowledged the medical record did not have documentation that patient #5 or their representative received their patient rights.

- Policy titled "Patient Bill of Rights" reviewed on 9/7/2016 at 11:00 AM directed staff "...each patient is informed of the facility's policies regarding patient rights during the admission process..."

The Psychiatric hospital reported a census of 40 inpatients. Based on medical record review, staff interview, and policy review the hospital failed to ensure the physicians (Staff J and Staff P) signed their telephone orders with date, time and authenticated in written or electronic form per the facility policy for 1 of 10 patient medical records reviewed (patient #7). This deficient practice had the potential to make medical errors and harm to patients.

Findings Include:

- Patient #7's medical record reviewed on 9/7/2016 revealed an admission date of 6/30/2016 with a diagnosis of Depressive disorder and Alcohol use disordered. Patient #7's medical record contained two telephone orders taken by two Registered Nurses (Staff B and Staff L) with no physician's signature and date after patient was discharged on 7/7/2016 and per facilities policy.

Director of Quality Staff C interviewed on 9/7/2016 at 12:30 PM acknowledged the two telephone orders were missing the physician's signature and date.

- Policy titled "Provider Orders" reviewed on 9/7/2016 at 1:00 PM directed "...Any written physician order shall be signed by the attending physician or prescriber within 48 hours".

The Psychiatric hospital reported a census of 40 inpatients. Based on medical review, staff interview, and policy review the hospital failed to ensure the physicians (Staff I and Q) completed a discharge summary within thirty days after patients discharge for 4 of 10 discharged patients reviewed (patient #2, #3, #4, and #7). This deficient practice had the potential for providers to have information needed to care for the patients after discharge.

Findings Include:

- Patient #2's medical record reviewed on 9/6/2016 revealed an admission date of 6/29/2016 with a diagnosis of Schizoaffective Disorder Bipolar type Unspecific Psychosis (illness with symptoms like hallucinations-something not there, or delusions-false belief, occurring with mood problems of depressive, manic-elevated mood, or mixed episodes). Patient #2's medical record contained no discharge summary 30 days after the patient discharged on 7/8/2016.

- Patient #3's medical record reviewed on 9/6/2016 revealed an admission date of 6/30/2016 with a diagnosis of Bipolar Disorder Psychosis hypomanic(mood swings between short periods of mild depression and elevated mood and hallucinations). Patient #3's medical record contained no discharge summary 30 days after the patient discharged on 7/6/2016.

- Patient #4's medical record reviewed on 9/7/2016 revealed an admission date of 6/29/2016 with a diagnosis of Unspecified Psychosis. Patient #4's medical record contained no discharge summary 30 days after the patient discharged on 7/5/2016.

- Patient #7's medical record reviewed on 9/7/2016 revealed an admission date of 6/30/2016 with a diagnosis of Depressive disorder and Alcohol use disordered. Patient #7's medical record contained no discharge summary 30 days after the patient discharged on 7/7/2016.

Director of Quality Staff C interviewed on 9/7/2016 at 12:45 PM acknowledged some of their physicians did not complete a discharge summary within the 30 days per policy.

- Policy titled "Closing a Medical Record" reviewed on 9/7/2016 at 1:00 PM directed " ...All Medical Records must be "closed within 30 days of a patient's discharge date. To be able to "close" a medical record, the following items must be completed as failure to complete these as required would result in a delinquent and incomplete record..." "...Discharge Summary..".

The Psychiatric hospital reported a census of 40 inpatients. Based on medical review, staff interview, and policy review the hospital failed to ensure the physician completed the discharge summary within thirty days after discharge for 2 of 10 discharged patients (patient #5 and # 6). This deficient practice had the potential for providers to not have the information needed to care for the patients after discharge.

Findings Include:

- Patient #5's medical record reviewed on 9/7/2016 revealed an admission date of 3/2/2016 with a diagnosis of Depressive disorder. Patient #5's medical record contained a discharge summary with no documentation of the date the discharge summary was completed or the physician's signature.

- Patient #6's medical record reviewed on 9/7/2016 revealed an admission date of 3/16/2016 with a diagnosis of Bipolar disorder. Patient #6's medical record contained a discharge summary dated 6/13/2016 (89 days after discharge) with no physician's signature.

Director of Quality Staff C interviewed on 9/7/2016 at 12:30 PM acknowledged some of their physicians were late completing their discharge summaries, more than the 30 days per policy.

- Policy titled "Closing a Medical Record" reviewed on 9/7/2016 at 1:00 PM directed " ...All Medical Records must be "closed' within 30 days of a patient's discharge date. To be able to "close" a medical record, the following items must be completed as failure to complete these as required would result in a delinquent and incomplete record..." "...Discharge Summary..."