HospitalInspections.org

Based on observation, record review, and interviews, the facility failed to maintain clinical records on all patients as specified in §482.61 (Special Medical Record Requirements).

More specifically, the facility failed to accurately record progress notes so that a chronological picture of the patient's progress was given, outlined in A1655 - CFR §482.61(d).
This was evidenced by the facility's failure to ensure that newly disclosed information of an alleged sexual assault by the biological father of 1 of 1 patients (Patient #1) was documented in the progress notes by 4 of 4 staff members - Staff N (Risk Manager), Staff F (Nurse Supervisor), Staff M (Unit RN), and Staff V (Unit RN) - all involved in the investigation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim.

In addition, the facility failed topProvide an accurate recapitulation of the patient's hospitalization in the Discharge Summary, outlined in A1670 - CFR §482.61(e).
This was evidenced by the facility's failure to ensure that:
The Discharge Summary of 1 of 1 patients (Patient #1) included documentation of newly disclosed information of an alleged sexual assault by the biological father, and
The Discharge Summary of 1 of 1 patients (Patient #1) included documentation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim.

Findings were:

A1655 - CFR §482.61(d) - Recording Progress Notes.

Review of policy, "Mental Health Record Content, IM 107," revised 04/2022 by Staff W (HIM Director), showed: "It is the policy of Kingwood Pines Hospital that all mental health records shall contain sufficient information ... The medical record is a critical medical legal document which must be accurately and concisely compiled, in a timely manner to be an effective tool used to gauge and substantiate the quality of care and service provided to our patients ...
The progress notes give a pertinent chronological report of the patient's course in the hospital and reflect any change in condition and the results of treatment."

Record review of Staff N's (Risk Manager) interview with Patient #1 showed, "Patient ... reports that as a child she was sexually assaulted by her father ... [and that this] ... has never being [sic] reported."

Review of all progress notes in the medical record of Patient #1 showed that her allegations of sexual assault by her father had not been documented by Staff N (Risk Manager), Staff F (Nurse Supervisor), Staff M (Unit RN), and Staff V (Unit RN) - all involved in the investigation of an alleged incident of sexual misconduct on the unit between Patient #1, the alleged aggressor, and Patient #2, the alleged victim.

In an interview with Staff N (Risk Manager) on 02/05/2025 at 12:40 PM, he stated he interviewed Patient #1 on 01/27/2025 at 12:00 PM concerning allegations of sexual misconduct between her and Patient #2. He also stated that during the interview, Patient #1 alleged she had been sexually assaulted by her biological father and had never disclosed this information. Staff N concluded by saying he did NOT document this information in the medical record of Patient #1, adding, "I don't document in the chart."

In an interview with Staff B (CNO) on 02/05/2025 at 12:42 PM, she stated that Staff N (Risk Manager) can and should have documented his findings of alleged sexual assault by Patient #1's father in the medical record on the day it was disclosed to him by the patient. She was observed and overheard telling Staff N that he can add progress notes to medical records.

Review of the CPS report submitted 01/06/2025 at 5:57 PM by Staff F (Nurse Supervisor) showed:
Allegations - Sexual abuse
Who is the alleged victim? [blank]
Who is the alleged perpetrator? [blank]
Sexual abuse was reported by the child.
Who else knows about the abuse? "Per patient he is in jail right now."
Primary victim: Patient #1
Further review of the CPS report submitted 01/06/2025 at 5:57 PM by Staff F (Nurse Supervisor) showed that the alleged perpetration by Patient #1's biological father was NOT documented in the report.

On 02/05/2025 at 1:30 PM the CPS report was reviewed with Staff B (CNO). In an interview at that time, she stated the report filed by Staff F (Nurse Supervisor) did not capture all of the information disclosed by Patient #1 of the alleged sexual assault by her biological father. She stated she would resubmit a report to CPS with that information. The revised CPS report submitted to CPS by Staff B on 02/05/2025 at 2:28 PM was reviewed. It contained the information disclosed by Patient #1 of alleged sexual assault by her biological father.

In an interview with Staff F (Nurse Supervisor) on 02/05/2025 at 3:02 PM, she stated that Patient #1's foster mother said she knew about the alleged abuse by the biological father. Staff F also said she filed a CPS report on this and put it in Patient #1's medical record, adding she did not make a progress note about the alleged perpetration.

In an interview with Staff B (CNO) on 02/05/2025 at 1:30 PM, she stated Staff F (Nurse Supervisor) should have documented the alleged abuse by the biological father of Patient #1 in the medical record.

In a phone interview with Staff M (RN) on 02/05/2025 at 1:05 PM, she stated she was working as the medication nurse on 01/26/2025, the day of the alleged incident of sexual misconduct between Patient #1 and Patient #2. She said she and Staff V (RN) interviewed Patient #1 and it was during that interview that the patient made an allegation of sexual abuse by her biological father. She also said she spoke with the foster mother that evening, adding that the foster mother did NOT know there were allegations of sexual abuse by the biofather toward Patient #1. She stated the RN Shift Assessments had been divided between her and Staff V, the charge RN, with each having 7 or 8 patients to write notes on. She also stated that Staff V had Patient #1; therefore, it was Staff V's responsible to write that progress note, adding, "Staff V said she would document it and didn't." Staff M did state that the allegation of sexual abuse by Patient #1's biological father should have been documented in the medical record. Staff B (CNO) was present during the phone interview with Staff M.

In an interview with Staff B (CNO) on 02/05/2025 at 1:10 PM, she told Staff M (RN) she was one of two RNs who received the information of alleged sexual abuse by her biofather from Patient #1; therefore, she should have documented the allegation in the medical record. Staff B also stated that it was the responsibility of Staff M to follow up to see that this information had been captured in the medical record.

In a phone interview with Staff V (RN) on 02/05/2025 at 1:10 PM, she confirmed that the RN Shift Assessments had been divided between her and Staff M (RN), adding that Patient #1 had been assigned to her. Staff V stated Patient #1 alleged her biological father sexually abused her, adding, "Don't tell my foster parents." Staff M also said that the allegation should have been documented in the medical record. Staff B (CNO) was present during the phone interview with Staff V.

In an interview with Staff B (CNO) on 02/05/2025 at 1:15 PM, she told Staff V (RN) she should have documented allegations made by Patient #1 of sexual abuse by her biological father.

A1670 - CFR §482.61(e) - Discharge Summary.

Review of policy, "Mental Health Record Content, IM 107," revised 04/2022 by Staff W (HIM Director), showed: ""The Discharge/Clinical Summary is a comprehensive summary of the patient's treatment ... including ... Significant Findings ... Hospital Course of Treatment."

Review of the Discharge Summary for Patient #1 dictated 01/27/2025 at 12:49 PM by Staff X (NP) and signed by Staff C (Attending Physician) showed:
An admission date of 01/21/2025.
The discharge date was not documented.
The alleged sexual misconduct with Patient #2 was not documented.
The disclosure of alleged sexual abuse by her biological father was not documented.

Review of the Psychiatric Progress Note for Patient #2 by Staff X (NP) dated 02/01/2025 showed that the patient was discharged on 02/01/2025. Further review of the medical record on 02/05/2025 for Patient #2 showed that the Discharge Summary had not been dictated.

In an interview with Staff C (Attending MD) on 02/05/2025 at 10:05 AM, he reviewed the documentation in the medical records of Patient #1 and Patient #2 of the incident of alleged sexual misconduct between the two patients. He noted that there was no documentation of the alleged sexual misconduct by the Nurse Practitioners or himself in the Psychiatric Progress Notes and/or the Discharge Summary. He stated that he "probably should have put it in the notes," adding that it was "an omission on my part." Additionally, Staff C acknowledged the importance of an accurate recapitulation of the patient's hospitalization in the Discharge Summary for continuity of care should the records be requested by another facility and/or providers.