HospitalInspections.org

Bases on clinical records review and staff interviews it was determined that the facility failed to always complete a patient social history as part of the intake assessment process related to sexual acting out behavior.

Findings included:

Facility policy entitled Intake Process, Revised 8/15 reads in part,
"Procedure:
1. Pre-assessment information from another facility or provider is reviewed for clinical and financial appropriateness.
5. The Intake Department is responsible for providing the following documents in the medical record.
Initial Assessment (completed at Intake by the Intake Specialist).
Intake Questionnaire"

In an interview with the Risk Manager (RM) on the morning of 11/13/17, RM reported they did not know that the 8 year-old had a history of sexually acting out behavior but that there was documentation of sexually acting out behavior in the patient's previous admission to Cedar Crest Hospital. RM stated, "intake staff did not review the patient's previous admission medical record."
RM stated that assessment for Sexually Acting Out behavior was not part of the Intake Assessment. The Hand - Off communication form, also did not include sexually acting out history. RM stated, "The Director of Intake revised Intake Assessment Form by adding a sexually acting out history prompt line to the Intake Form, and trained intake staff.
Hand Off form was also revised by adding a sexually acting out history prompt line and staff were trained accordingly."

The above findings were confirmed by the Risk Manager the afternoon on 11/13/2017.