HospitalInspections.org

Based on interview and record review it was determined the facility failed to maintain medical records that were accurately written for two (2) of four (4) sampled patients (Patients' #1 and #2).

The findings include:

1. Review of Patient #1's medical record revealed an admission date of 08/10/10, and diagnoses which included Mood Disorder. Review of the facility policy related to supervision of patients revealed all patients are to be observed every fifteen (15) minutes from 9:00 PM to 7:00 AM. Review of the 08/10/10, 11:00 PM to 7:00 AM shift's observations on the Patient Supervision Record form revealed Patient #1 was noted to be in his/her room asleep from 12:00 AM to 1:45 AM. Further review of this form revealed the patient was noted to be AWOL (Absent Without Leave) after 1:45 AM.

Interview on 08/17/10, at 5:58 PM with Registered Nurse #1, the Shift Coordinator for the facility on 08/10/10, 11:00 PM to 7:00 AM shift, revealed she received a phone call from a Security Guard at approximately 1:45 AM informing her an unidentified male had been found lying on the ground outside the facility. She stated she called all the units and informed staff to do a head count. Wendell 4, the unit on which Patient #1 resided, called her back within a few minutes and reported Patient #1 was missing. In addition, she stated the Risk Manager later showed her the Patient Supervision Record that documented Patient #1 in his/her room asleep at 1:45 AM. According to the Shift Coordinator, this patient could not have been in his/her room asleep at that time as he/she was found outside the facility by the Security Guards at approximately that same time.

Interview on 08/17/10, at 3:55 PM with Mental Health Associate (MHA) #1 revealed she had been assigned to perform the fifteen (15) minute observation. She stated she documented that Patient #1 was in his/her room asleep before actually performing the 1:45 AM observation. She further stated she should not have done that. The MHA stated when she performed the 1:45 AM observation check, the patient was not in his/her room and had been found outside the facility by the Security Guards at that time.

Interview on 08/17/10, at 10:45 AM with the Director of Nursing (DON) revealed MHA #1 should not have filled out the Patient Supervision Record before performing the observation.

Review of the General Hospital Policies, Section 3 revealed documentation of the fifteen (15) minute observations shall be placed on the Patient Supervision Record after completion of the observation.

2. Review of Patient #2's medical record revealed an admission date of 07/16/10, and diagnoses which included Schizo-Affective Disorder, and Psychosis. Review of the Physician's Orders revealed an order dated 07/30/10, for the patient to be placed on a safety level of supervision (patient could not leave the unit on which he/she resided).

Review of the Patient Supervision Records revealed on 08/04/10, the patient was placed on a support level of supervision (able to leave the unit with staff). However, there was no documented evidence of a Physician's Order for the change. Continued review of the record revealed Patient #2 eloped from the facility on 08/06/10.

Interview on 08/18/10, at 3:35 PM with Physician #1, who ordered Patient #2's safety level of supervision, revealed the patient had been placed on this supervision level after going AWOL (absent without leave) for a brief time on 07/30/10. He stated the patient's condition improved and was discussed by the Interdisciplinary Team. According to the Physician, the nurses probably asked for an order to change the patient's level of supervision to support and he forgot to write the order. He further stated the support level of supervision would have been appropriate for Patient #2.

Interview on 08/18/10, at 3:15 PM with the Director of Nursing (DON) revealed there should have been a Physician's Order to change the patient's level of supervision from safety to support. She further stated this was the facility's policy.

Review of the General Hospital Policies, Section 3 revealed a new Physician's Order was required for each change in Level of Supervision.