HospitalInspections.org

Based on document review and interview, the hospital failed to ensure for timely referral of patient concerns regarding quality of care to an appropriate Utilization and Quality Improvement Organization for 1 of 1 patient (P2) expressing concern.

Findings include:

1. Review of the policy titled Patient Complaint/Grievance Process, Last Approved 02/2020, indicated the following:
Definition of Complaint: An expression of dissatisfaction with some aspect of care and/or services.
Definition of Grievance: A written or verbal expression of dissatisfaction with some aspect of care and/or service that has not been resolved to the patient's satisfaction and the patient desires that the complaint be addressed by investigation, review, and evaluation.
The Patient Problem Solving Process: In order to provide a mechanism whereby patient/family concerns and/or complaints regarding hospital services are addressed and resolved in a timely and appropriate manner, the following is done: Patient/family complaints meeting the definition of a grievance will be documented on the Patient Complaint Form by the person receiving the complaint and forwarded as soon as possible to the most appropriate Department Director for investigation and action.
Upon completion of this policy's requirements regarding complaints and grievances, the original Patient Complaint Form, along with all supporting data is sent to Administration for policy and compliance review... The "QRM" (Quality Risk Manager)/Social Service (SS) staff will make every effort to ensure that complaint, grievance information is accurately entered in the database...

2. The MR of patient P2 indicated the following: SS Note 7/12/21 at 1655 hours, recorded as "Late entry from 15:30 (hours) 7/12/21" indicated the following: Writer was asked to come talk to patient...Patient also requested to speak to administration about how he/she was treated in the ED (Emergency Department) upon his/her arrival. Writer stated he/she would pass that "info" onto the ED director... SS Note on 7/12/21 at 1548 hours: Writer inform (sic) A7, ED Director, of patient request to speak to administration. A7 stated he/she was aware and the house supervisor had already spoken to patient. Nurse's Notes on 7/12/21, at 1854 hours indicated the following: Updated Director, A6, awaiting ER (Emergency Room) director to come talk to patient regarding complaints of how he/she was treated in the ER.

3. Review of facility administrative records between 7/1/21 and 9/14/21 lacked documentation of a complaint/grievance by P2 having been sent to Administration for review.

4. On 9/15/21 beginning at approximately 9:30 AM, A1, Chief Nursing Officer/Vice President of Inpatient Services, verified lack of administrative documentation of a complaint/grievance having been expressed by P2.

Based on document review and interview, the hospital failed to ensure nursing staff adhered to policies and procedures (P&P) of the hospital for 1 of 1 patients (P9) who experienced a fall event during hospitalization.

Findings include:

1. Review of the policy titled Event/Incident Reporting, Last Revised 09/2020, indicated the following:
An event/incident is any happening which is not consistent with the routine operation of the facility or routine care of a particular patient. Examples of events/incidents include, but are not limited to, the following: Falls.
Only medically relevant information shall be recorded in the patient's medical record (MR). The incident must be described, the time of the the event/incident recorded, all actions taken, (notification of supervisor and attending physician, diagnostic procedures and treatment performed), results of interventions, and all subsequent monitoring of the patient's conditions shall also be recorded.

2. Review of facility incidents/events indicated patient P9 experienced a fall on 7/16/21, unable to determine time.

3. The MR of patient P9, admitted through ED 7/15/21 and discharged 7/17/21, lacked documentation of the patient having experienced a fall and/or actions taken with results of interventions.

4. Beginning at approximately 1:00 PM, A2, IT (Information Technology) Analyst RN, verified the MR of patient P9 lacked documentation of the patient having experienced a fall.

Based on document review and interview, the hospital failed to ensure completion of medical records for 2 of 2 transferred patients (P1 and P2) within 30 days of discharge.

Findings include:

1. A. Review of the policy titled Patient Transfers, Last Revised 02/2021, indicated the following:
Emergency Services and Care: an appropriate medical screening examination (MSE) and evaluation within the capability of the facility, including ancillary services routinely available to the Emergency Department (ED), by an ED physician or other practitioner qualified to determine whether an emergency medical condition exists.
Where necessary, the examination and evaluation shall include consultation with specialty physicians qualified to give an opinion or to render treatment necessary to stabilize the individual. Such consultations may be obtained by telephone.
Non-Emergency Transfer of Patients to Another Acute Care Facility: An order for transfer must be written by the attending physician... The transfer form is filled out, with the original staying with the patient's permanent medical record...

B. Review of the policy titled Medical Staff Documentation Requirements & Record Completion, Last Revised 07/2019, indicated the following:
Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) requires all medical records to be: Promptly completed. Contain documentation, reports, recordings, test results, assessments, etc. to: Support the diagnosis. Complete information/documentation regarding evaluations, interventions, care provided, services, care plans, discharge plans, and the patient's response to those civilities. All medical records must be completed within 30 days of discharge...
When pertinent both inpatient and outpatient records must contain: Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.
Transfer Summary: When patients are transferred to another acute care facility, the transferring physician must complete a transfer summary including that the patient was advised of the risks/benefits of transfer at the time of transfer...

2. Review of the contract between the hospital and acute psychiatric hospital PH1, titled Mobile Assessment Services Agreement, Beginning 5/29/17 - Ending (Auto renew) indicated the following:
Provider shall provide appropriately qualified individuals to perform on-site psychological needs assessments and telemedicine assessments of Facility's patients both in the acute care and emergency room areas in response to a written order and/or a phone call from a Facility Medical Staff physician.
Following completion of the psychological needs assessment, the Clinician shall provide the ordering Facility physician with a copy of the psychological needs assessment, and using best efforts, provide a minimum of one (1) and up to a maximum of three (3) recommendations for further treatment.

3. The MR of patient P1, a minor, indicated the patient presented to the ED with a parent on 7/9/21 at 1504 hours. The Medical Screening Exam (MSE), at 1524 hours, indicated the following: Patient was coerced for psychiatric evaluation... On 7/9/21 at 1942 hours "Teleassessment (ED Teleassess PH1)" was ordered and was indicated as completed on 7/9/21 at 2153 hours. MR documentation indicated the "Time Telemedicine assessment began:" was 2002 hours and the "Name of the person performing telemed assessment:" was (first name only/no title) "C1". The MR lacked documentation of results of a psychiatric evaluation.

The MR of patient P2 indicated the patient indicated the following: On 7/10/21 at 0752 hours the patient arrived in the ED via EMS (Emergency Medical Services) and was subsequently admitted. The Discharge Summary indicated the following: Date of discharge: 7/13/21. He/she was discharged via police escort to PH1 for psychiatric evaluation. The MR lacked documentation of an order for discharge/transfer and lacked documentation of transfer form.

4. On 9/15/21, beginning at approximately 1:00 PM, A2, IT (Information Technology) Analyst RN, verified the MR of patient P1 lacked documentation of results from the telepsychiatric consult. A2 verified the MR findings of patient P2; including lack of documentation of a physician's order for discharge/transfer and/or a completed transfer form.