HospitalInspections.org

Based on medical record reviews, document reviews, and staff interviews, it was revealed the facility failed to ensure an accurate and complete medical record per policy in two (2) out of ten (10) patients, patient #1, and #9. This failure has the potential to negatively impact all patients being discharged or transferred from the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was transferred to the facility on 04/29/22 after being incarcerated for property destruction at a local regional jail facility. The patient was alleged to have increased erratic behaviors. The patient was diagnosed with severe manic bipolar disorder. The patient was found to lack capacity. A second capacity assessment was conducted on 05/04/22 by the assistant medical director at the time, which also stated the patient does not possess capacity, and a healthcare surrogate was established through the department of health and human resources (DHHR). The patient was transferred to another inpatient psychiatric facility on 07/28/23. A discharge summary was dictated by Emp #2 on 09/04/23 at 11:32 a.m. The discharge summary stated a discharge date of 08/11/23 at 9:37 a.m. (Actual discharge date 07/28/23).

A "Report of Discharge of Involuntarily Hospitalized Patient" form was reviewed for patient #1. The form was completed on 07/28/23 and signed by the facility's medical director at the time. The form states in part, "Respondent can no longer benefit from hospitalization and has been discharged from involuntary commitment ..."

May it be noted that the above document was not contained within patient #1's medical record and was provided by the complainant.

A record review was conducted for patient #9. The patient was involuntarily admitted on 8/1/23 at 11:55a.m. The patient was discharged on 09/18/23. A section titled "Discharge Summary" entered by emp #12 and 14 on 9/27/23 states, in part, "Discharge Date: 9/18/23."

A review was conducted of the policy titled "Discharge Plans," effective date 09/07/23. A section of the policy, titled "Purpose of Policy'' states, "To provide each patient a discharge plan that addresses continuity of care from an inpatient to an outpatient setting." A section of the policy, titled "Clinical Services'' states, in part, "a. The provider is responsible for the legal discharge of the patient. He or she will consult with Nursing, Social Work, the ITT (Interdisciplinary Treatment Team), and the Director of Admissions regarding the circumstances/benefits of releasing a patient on trial visit or discharge. f. The Provider will subsequently complete a Discharge Summary to be included into the patient's medical record within 7 [seven] days of the date the patient is placed on Trial Visit or discharged."

A review was conducted of a document, titled "Medical Staff Bylaws, Rules, and Regulations Adopted and Approved", signed April 25, 2023. The document states, in part, "... Appendix D: Medical Staff Rules and Regulations ... Article I Admission and Discharge of Patients ...1.15 Discharge of Patients ... A final dictated Discharge Summary will be completed within seven (7) days after the date of the discharge or release on Trial Visit Status by the attending provider or his/her designee ..." A section of this document, titled "2.12 Completion of Medical Records/Discharge Summary" states, in part, "The medical record, including the final discharge summary shall be completed before seven (7) days of discharge. The Medical Record shall be considered delinquent after seven (7) days of discharge, if the discharge summary has not been completed. When final laboratory or other essential reports are not received at the time of discharge, a notation shall be written or dictated that this information is pending." A section of this document, titled "2.13 Delinquent Medical Records" states, in part, "The Health Information Management Department will provide each provider with a list of his/her incomplete medical records every seven (7) days."

A review was conducted of emails sent from emp #5. The first email was dated 08/01/23 at 8:18 a.m. from emp #5 to emp #2 and states, "Following patient have DC (Discharge) summaries due: [Patient #1] DC date 7/28 due 8/4." The second email was dated 08/18/23 at 8:03 a.m. from [emp #5] to [Medical Director's secretary] and states, "Hey [emp #2] still has not completed DC summary on [patient #1] for 7/28. [Other psychiatric facility] has already discharged and completed their summary. Just wanted to let you know."

An interview was conducted with emp #1 on 10/23/23 at 2:20 p.m. Regarding patient #1, emp #1 states in part, "... When [patient #1] was transferred, the intent would not have been to release [patient #1] from [patient #1]'s involuntary commitment. The patient had shown up on a discharge census which is why the paper was completed and sent to the courts. I knew [emp #2] was late on the discharge summary but I do not know why it wasn't completed until September 4th."

An interview was conducted with emp #3 on 10/23/23 at 3:10 p.m. Regarding patient #1 being discharged from their involuntary commitment, emp #3 states in part, "In this case the notice of discharge was inadvertently filled out and sent to the court. After discharge of patients, this document goes to the court of record as mandated by code. All discharge patients get that form. We would not do this form in terms of a transfer. We should not send it for transferred patients. This patient was swapped out with another patient at [Other psychiatric facility]. The notice of final commitment should cover the patient until they are discharged from the hospital completely. I did not know that this paper was inadvertently filled out until the Ombudsman contacted us. I found out that the notice of discharge was sent to the court. We should not have sent this document. I found out when the Ombudsman called me about a month ago. We do not keep a copy of this document in the medical record; it is strictly for the courts ... Normally, this document is not kept in the medical record since it is just a court document. You wouldn't know if the paper had been completed or not, since it's not kept in the medical record. We would not know if one was done inadvertently on a patient from somewhere else either, since it is not part of the medical record."

An interview was conducted with emp #5 on 10/24/23 at 9:00 a.m. Regarding the "Report of Discharge of Involuntarily Hospitalized Patient" form for patient #1, emp #5 states in part, "The process of not keeping that form in the medical record was implemented before I got here ...." Regarding patient #1's discharge summary emp #5 states, "I keep track of the discharge summaries which are late and send an email to the physician responsible for completing the discharge summary. I also call the Medical Director's secretary and let [secretary] know of the incomplete discharge summaries. In this case, I emailed the physician and when it still wasn't completed I emailed the medical director's secretary."

A telephone interview was conducted on 10/24/23 at 10:15 a.m. with emp #2. Regarding the discharge summary not being completed until September 4th, emp #2 states, "I was ill at the time, and it took longer than it should have."

An interview was conducted with emp #7 on 10/24/23 at 3:03 p.m. Regarding patient #1 and the "Report of Discharge of Involuntarily Hospitalized Patient" form for patient #1, emp #7 states in part, "It was not anyone's intent to discharge the patient from their involuntary commitment that day. Even though there is no obligation for us to keep that document in the patient's medical record, we can do that from now on ..."