HospitalInspections.org

Based on facility document review, medical record review and staff interview, the facility failed to ensure that medical staff document patient's progress.

Findings included:

AMA-Against Medical Advice

Record review of 10 Sample Charts revealed that 7 were Against Medical Advice. 3 out of 7 charts were patients that were listed as AMA charts and have incomplete documentation (patient #1, #2, #3).

Review of patient #1's medical record revealed:
Failure to document a change in patient's status as evidenced by a change in doctor's order for discharge. Record Review of patient #1's medical chart revealed there was a verbal discharge order written 8/14/2017 at 4:13 pm by Employee C from Doctor M Stating Patient may be discharged on 8/15/2017. No progress note by nurse explaining reason for call to/from doctor reason for discharge order being given verbally the night before. failure to document by the physician giving an accurate assessment of the patient stating improvement and safety for discharge.

On Record Review of doctor's orders on 8/15/2017 at 0900 revealed that another verbal doctor's order was obtained by Employee B from Doctor M and discharge was changed to be Against Medical Advice. Failure of nurse to document a change in condition of patient number (1). Failure of Doctor M to document a progress note indicating a change in patient's level of condition that required a change in discharge.

Interview with Director of Nursing Services revealed that she was unable to find any documentation from either a nurse or a doctor revealing the patient's condition and cause for change in orders.
Interview with Employee O revealed that she was unable to find documentation regarding patient's condition or reason for discharge. When asked if it was supposed to be there; she indicated that every discharge should have a condition of patient at time of discharge and a reason for discharge, AMA or progress made, meeting criteria for discharge.

Review of patient #2's medical record revealed the following:
Patient (#2) Admitted on 12/12/2017 discharged AMA on 12/13/2017 The medical doctor failed to write a discharge order. The nurse caring for the patient failed to document the patient's condition at discharge, failed to obtain an order for discharge and failed to chart a discharge note.

Interview with Employee A revealed that she was unable to find a reason for discharge in the chart.Eployee O was asked to find a discharge order and a reason for discharge. She also was unable to do so. When asked if there is supposed to be one she said, "absolutely".

Review of Medical Record for patient (#3) revealed the following information from Intake Assessment:
" Date and time: not completed
" Signature/Credentials of person completing form: not completed
" Risk assessment not completed
" Patient Plan: no completed
" Level of care: not completed
" Exclusion criteria: not completed

Interview with Employee O revealed that she also was in agreement that the form was incomplete without the appropriate assessment in which Patient #3's progress would be reflected.

Record review of 10 Sample Charts revealed that 7 were Against Medical Advice. 3 out of 7 charts were patients that were listed as AMA charts and have incomplete documentation (patient #1, #2, #3).

Based on facility document review, medical record review and staff interview, the facility failed to ensure progress notes were recorded by the nurse responsible for the care of the patient.

Findings included:
Review of patient #1's medical record revealed:

Failure to document a change in patient's status as evidenced by a change in doctor's order for discharge. Record Review of patient #1 medical chart revealed there was a verbal discharge order written 8/14/2017 at 4:13 PM by employee C from Doctor M Stating Patient may be discharged on 8/15/2017. Failure by nurse to document explanation of reason for call to/from doctor reason for discharge order being given verbally the on 8/14/2017. Failure to document by the physician giving an accurate assessment of the patient stating improvement and safety for discharge.

On Record Review of doctor's orders on 8/15/2017 at 0900 revealed that another verbal doctor's order was obtained by Employee B from Doctor M and discharge was changed to be Against Medical Advice. Failure of nurse to document a change in condition of patient number (1). Failure of Doctor M to document a progress note indicating a change in patient's level of condition that required a change in discharge.

Interview with Director of Nursing Services revealed that she was unable to find any documentation from either a nurse or a doctor revealing the patient's condition and cause for change in orders.

Interview with Employee O revealed that she was unable to find documentation regarding patient's condition or reason for discharge. When asked if it was supposed to be there; she indicated that every discharge should have a condition of patient at time of discharge and a reason for discharge, AMA or progress made, meeting criteria for discharge.

Review of patient #2's medical record revealed the following:

Patient (#2) Admitted on 12/12/2017 discharged AMA on 12/13/2017 The medical doctor failed to write a discharge order. The nurse caring for the patient failed to document the patient's condition at discharge, failed to obtain an order for discharge and failed to chart a discharge note.

Interview with Employee A revealed that she was unable to find a reason for discharge in the chart. Employee O was asked to find a discharge order and a reason for discharge. She also was unable to do so. When asked if there is supposed to be one she said, "absolutely".

Review of Medical Record for patient (#3) revealed the following information from Intake Assessment:
" Date and time: not completed
" Signature/Credentials of person completing form: not completed
" Risk assessment not completed
" Patient Plan: no completed
" Level of care: not completed
" Exclusion criteria: not completed

Interview with Employee O revealed that she also was in agreement that the form was incomplete without the appropriate assessment in which Patient #3's progress would be reflected.

Based on facility document review, medical record review and staff interview, the facility failed to ensure progress notes were recorded by the nurse responsible for the care of the patient.

Findings included:

Review of patient #1's medical record revealed:

Failure to document a change in patient's status as evidenced by a change in doctor's order for discharge. Record Review of patient #1 medical chart revealed there was a verbal discharge order written 8/14/2017 at 4:13 pm by employee C from Doctor M Stating Patient may be discharged on 8/15/2017. No progress note by nurse explaining reason for call to/from doctor reason for discharge order being given verbally the night before. failure to document by the physician giving an accurate assessment of the patient stating improvement and safety for discharge.

On Record Review of doctor's orders on 8/15/2017 at 0900 revealed that another verbal doctor's order was obtained by Employee B from Doctor M and discharge was changed to be Against Medical Advice. Failure of nurse to document a change in condition of patient number (1). Failure of Doctor M to document a progress note indicating a change in patient's level of condition that required a change in discharge.

Interview with Director of Nursing Services revealed that she was unable to find any documentation from either a nurse or a doctor revealing the patient's condition and cause for change in orders.

Interview with Employee O revealed that she was unable to find documentation regarding patient's condition or reason for discharge. When asked if it was supposed to be there; she indicated that every discharge should have a condition of patient at time of discharge and a reason for discharge, AMA or progress made, meeting criteria for discharge.

Review of patient #2's medical record revealed the following:

Patient (#2) Admitted on 12/12/2017 discharged AMA on 12/13/2017 The medical doctor failed to write a discharge order. The nurse caring for the patient failed to document the patient's condition at discharge, failed to obtain an order for discharge and failed to chart a discharge note.

Interview with Employee A revealed that she was unable to find a reason for discharge in the chart. Employee O was asked to find a discharge order and a reason for discharge. She also was unable to do so. When asked if there is supposed to be one she said, "absolutely".

Review of Medical Record for patient (#3) revealed the following information from Intake Assessment:

" Date and time: not completed
" Signature/Credentials of person completing form: not completed
" Risk assessment not completed
" Patient Plan: no completed
" Level of care: not completed
" Exclusion criteria: not completed

Interview with Employee O revealed that she also was in agreement that the form was incomplete without the appropriate assessment in which Patient #3's progress would be reflected.

Based on facility document review, medical record review and staff interview, the facility failed to ensure progress notes were recorded by the nurse responsible for the care of the patient.

Findings included:


Record review of 10 Sample Charts revealed that 7 were Against Medical Advice. 3 out of 7 charts were patients that were listed as AMA charts and have incomplete documentation (patient #1, #2, #3).

Review of patient #1's medical record revealed:

Failure to document a change in patient's status as evidenced by a change in doctor's order for discharge. Record Review of patient #1 medical chart revealed there was a verbal discharge order written 8/14/2017 at 4:13 pm by employee C from Doctor M Stating Patient may be discharged on 8/15/2017. No progress note by nurse explaining reason for call to/from doctor reason for discharge order being given verbally the night before. failure to document by the physician giving an accurate assessment of the patient stating improvement and safety for discharge.
On Record Review of doctor's orders on 8/15/2017 at 0900 revealed that another verbal doctor's order was obtained by Employee B from Doctor M and discharge was changed to be Against Medical Advice. Failure of nurse to document a change in condition of patient number (1). Failure of Doctor M to document a progress note indicating a change in patient's level of condition that required a change in discharge.

Interview with Director of Nursing Services revealed that she was unable to find any documentation from either a nurse or a doctor revealing the patient's condition and cause for change in orders.

Interview with Employee O revealed that she was unable to find documentation regarding patient's condition or reason for discharge. When asked if it was supposed to be there; she indicated that every discharge should have a condition of patient at time of discharge and a reason for discharge, AMA or progress made, meeting criteria for discharge.

Review of patient #2's medical record revealed the following:
Patient (#2) Admitted on 12/12/2017 discharged AMA on 12/13/2017 The medical doctor failed to write a discharge order. The nurse caring for the patient failed to document the patient's condition at discharge, failed to obtain an order for discharge and failed to chart a discharge note.

Interview with Employee A revealed that she was unable to find a reason for discharge in the chart. Employee O was asked to find a discharge order and a reason for discharge. She also was unable to do so. When asked if there is supposed to be one she said, "absolutely".

Review of Medical Record for patient (#3) revealed the following information from Intake Assessment:

" Date and time: not completed
" Signature/Credentials of person completing form: not completed
" Risk assessment not completed
" Patient Plan: no completed
" Level of care: not completed
" Exclusion criteria: not completed

Interview with Employee revealed that she also was in agreement that the form was incomplete without the appropriate assessment in which Patient #3's progress would be reflected.