HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the attending psychiatrist reviewed and signed the history and physical within 48 hours according to "Medical Consultation/History and Physical" policy and procedures for two (Patient #1, & 2) of 20 patients.

This failed practice had the potential to result in care that is harmful or not therapeutic for patients admitted to the hospital.

Findings:

A policy titled "Medical Consultation/History and Physical (IP, RTC, PHP and IOPP)" stated in part "the attending psychiatrist will sign the history and physical verifying it has been reviewed within 48 hours for Inpatient."

Review of records titled "History and Physical" showed:
- Patient #1 admitted on 02/28/19 at 8:52 pm and signed by Staff H on 03/04/19 at 9:00 am (3 days after admission).

- Patient #2 admitted on 03/04/19 at 6:29 pm and not signed by the physician as of 03/20/19 (16 days after admission).

On 03/21/19 at 1:30 pm, Staff C stated the history and physical should be signed by attending physician within 48 hours of patient admission.

Based on record review and interview, the hospital failed to ensure the registered nurse completed an incident report for patient self harm on one (Patient #11) of 20 patients.

This failed practice had the potential for increased complications of health by patients due to physical injuries and incidents not being documented and followed up on by staff.

Findings:

Review of the hospital policy titled, "Incident Report Protocol" stated in part "It is the responsibility of all staff to report all incidents (any event not consistent with routine operations) accidents, injuries, unsafe conditions, occupational illness or property damage involving patients, personnel, or visitors, and to report such occurrences using an Incident Report Form."

Patient #11

A review of documentation showed no incident report completion for patient # 11 who committed self harm by hitting head on the wall in the intake room on 01/13/19 at 9:15 pm.

A review of documentation showed no incident report completion for patient # 11 who commited self harm by banging head against headboard and wall while on the unit.

On 03/20/19 at 12:30 pm, Staff G stated "We did not complete an Incident Report Form because this was not a change in condition. We were already aware of patient banging head on wall during admission."

Based on record review and interview, the hospital failed to ensure the physician completed the discharge summary
for one (Patient #8) of 20 patients.

Findings:

A document titled "Appendix A stated in part "All records must document final diagnosis with completion of medical records within 30 days following discharge."

A review of record showed patient # 8 was admitted on 02/11/19 and discharged 02/15/19. There was no documented discharge summary as of 02/15/19 (33 days after discharge).

On 03/20/19 at 3:00 pm, Staff C stated the discharge summary for patient #8 was not completed timely.