HospitalInspections.org

Based on medical record review and interview, the hospital failed to ensure nursing staff followed physician's orders for timely laboratory samples for 1 of 5 (Patient #1) sampled patients.

The findings included:

Medical record review for Patient #1 revealed an admission date of 4/21/21 and a discharge date of 5/7/21 with diagnoses which included Bipolar Disorder.

A physician's order dated 4/24/21 revealed, "...Lithium level 4/26/21 - Monday..."

A Lab result revealed, "Collected 04/29/21...Lithium L <0.2 mmol/L [millimoles per liter]...Reference Range (0.6-1.2)..." The lab result was signed by Named Physician #1 and dated 5/4/21.

The Lithium level was drawn 3 days past the order date of 4/26/21.

In an interview with the Risk Manager on 9/22/21 at 2:00 PM, it was confirmed the lab was drawn 3 days late.

Based on document review, medical record review and interview, the hospital failed to timely provide the complete medical record for 1 of 5 (Patient #1) sampled residents to an outside provider who requested the record in writing, and failed to ensure staff documented accurate and complete information concerning patients' care and treatment in nursing notes, in the medical records for 2 of 5 (Patient #1, 2) sampled patients.

The findings included:

1. Review of the Individuals' Right under HIPAA [Health Insurance Portability & Accountability Act] to Access their Health Information 45 CFR 164.524 revealed, "...Individuals have a right to access PHI [Protected Health Information] in a "designated record set" is defined at 45 CFR 164.501 as a group of records maintained by or for a covered entity that comprises the: Medical records and billing records about individuals maintained by or for a covered health care provider...two categories of information are expressly excluded from the right of access: Psychotherapy notes, which are the personal notes of a mental health provider documenting or analyzing the contents of a counseling session, that are maintained separate from the rest of the patient's medical record...In providing access to the individual, a covered entity must provide access to the PHI requested, in whole...no later than 30 calendar days in an outer limit and covered entities are encouraged to respond as soon as possible.

2. Medical record review for Patient #1 revealed an admission date of 4/21/21 and discharged on 5/7/21 with diagnoses which included Bipolar Disorder.

In a face to face interview with Patient #1's spouse, on 4/23/21, the spouse provided this surveyor with a copy of the medical record that was faxed to Patient #1's Primary Care Provider (PCP). It was a total of 47 pages. In reviewing the entire medical record this surveyor received from the hospital, there were multiple pages missing in the 47 page fax. There were no Nurses Notes, group notes, or Social Services Progress Notes faxed to the PCP. The above notes were part of the patient's complete medical record.

In an interview with Patient #1's Spouse on 9/20/21 beginning at 8:18 AM, the Spouse confirmed Patient #1's Primary Care Provider requested the Medical Record from the Hospital. The Spouse confirmed the physician's office manager only received 47 faxed pages and did not include therapy notes, nurses notes or daily group notes.

In an interview with the Risk Manager, on 9/22/21 at 2:00 PM, the Risk Manager stated it is not part of the standard to send therapy notes because they are confidential between the therapist and the patient. The Risk Manager stated they would only be released with a court order or a subpoena. The Risk Manager stated the treatment plan should cover everything the new therapist/psychiatrist would need to continue care. The Risk Manager stated they use the Individuals' Right under HIPAA to Access their Health The Risk Manager confirmed there was no nursing assessment for 4/27/21.

In a telephone interview with the office employee, on 9/23/21 at 12:18 PM, with Patient #1's Primary Care Provider, the office employee confirmed she was sent 47 sheets via a fax. The office employee confirmed she did not receive any Social Work therapy notes, group notes or daily progress nursing notes. The office employee stated the hospital's Medical Records department was called and medical record clerk stated, "I'll get those to you". The office worker stated they waited a couple of days and called back 2 more times to the medical records department and left a voice mail each time. The office worker stated the hospital's medical record department never called back and finally just gave up.

The medical record revealed no nursing assessments were done or documented for 4/27/21.

3. Medical record review for Patient #2 revealed an admission date of 7/13/21 with diagnoses including Bipolar. Patient #2 was discharged on 7/19/21.

Medical record review revealed no nursing assessments were done on 7/14/21 and 4/17/21.

In an interview with the Risk Manager on 9/22/21 at 2:00 PM, the Risk Manager confirmed there were no nursing assessments completed on 4/27/21 for Patient #1 and no nursing assessments completed on 7/14/21 and 7/17/21 for Patient #2.

Based on document review, medical record review and interview, the hospital failed to ensure the physician assessed and documented Psychiatric Progress Notes for 5 of 7 days for 1 of 5 (Patient #1) sample patients.

The findings included:

1. A review of Named Hospital's Rules and Regulations of the Medical Staff revealed, "CARE AND TREATMENT OF PATIENTS...The Attending Physician or designee will see each of his patients not fewer than five (5) times in seven (7) days for acute care programs and will complete progress notes of each visit.

2. Medical record review for Patient #1 revealed an admission date of 4/21/21 and discharged on 5/7/21 with diagnoses which included Bipolar Disorder.

The medical record revealed in the first seven (7) days of admission beginning on 4/21/21 through 4/27/21, a physician saw Patient #1 and wrote progress notes on 4/22/21, 4/24/21, 4/25/21, and 4/27/21 which was only 4 days instead of 5 days.

In an interview with the Risk Manager on 9/22/21 at 2:00 PM, the Risk Manager confirmed the physician did not follow the hospital's rules and did not see or write a progress note for 5 out of 7 days.