HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 13 medical records reviewed, it was determined the staff failed to document a psychiatric patient's collateral information regarding the patient's mental state and behavioral symptoms. This was evident for MR #1.

Findings include:

The policy titled "Emergency Department Documentation," last revised 11/20 states, "the ED staff will chart both subjective and objective data and any other information that is pertinent to the complaint (s) the patient wishes to have addressed."

Review of MR #1 identified a 77-year-old patient who presented to the Emergency Department (ED) on 2/8/23 at 10:38 AM where Staff C, Nurse Practitioner saw the patient and documented at 3:48 PM, "patient complained of severe anxiety and that EMS had brought her to this hospital because the patient was hypertensive. The patient reports an extensive history of mental health treatment and concerns and was hospitalized 2/2022 - 4/2022 (8 weeks) for similar complaints. The patient reports the psychiatrist had increased her medication recently and that she had moved in with her daughter." The patient's appearance was anxious, alert, and disheveled. All other assessments and review of systems were normal.
The provider also documented that she "spoke to the patient's psychiatrist for his recommendations for her to receive a mental health evaluation. Patient's family has provided conflicting information and then patient's report and have expressed significant frustration with patient's current situation. Patient was here one (1) week ago for similar symptoms, treated with sedative and antipsychotic for agitation which was effective. The patient was given 10 mg Olanzapine (used to treat the symptoms of schizophrenia) intramuscularly at 12:51 PM, during this visit, with positive affect on anxiety. Patient initially wanting to return home and throughout multiple discussions with her family including her daughter and granddaughter it was determined that the patient could be referred for mental health evaluation and she became agreeable."

The patient was transferred to another hospital at 5:09 PM that day for further management of her symptoms.

Staff C, Nurse Practitioner stated during an interview conducted on 6/30/23 at 11:17 AM that she could not recall what was the patient's psychiatrist recommendation and that she only spoke to the patient's family on one (1) occasion, however Staff C, Nurse Practitioner documented in the medical record that she had "multiple discussions" with the family. During the interview Staff C, Nurse Practitioner stated she could not provide any information of the patient's behavior prior to the patient's arrival to the ED.

There was no documentation in the medical record of the patient's collateral information to support the justification for administration of the medication that was given for this visit and the reason for transferring the patient to a higher level of care.

This finding was shared with Staff A, Chief Nursing Officer on 6/30/23 at 2:30 PM.