HospitalInspections.org

Based on medical record review, interviews with staff, and a review of policy and procedures, it was determined that the facility failed to maintain a complete medical record for one out of five sampled patients (P) (P#1).

Findings:

A medical record (MR) review revealed that Patient (P) P#1 was a 22-year-old who presented to the facility on a 1013 (a legal document for an involuntarily hold) from the Emergency Department (ED) of a local hospital.

An ED Note revealed that P #1 was transferred to the ED via Emergency Medical Services (EMS) for psychiatric problems and suicidal ideation on 7/25/22 at 9:15 p.m. ED notes indicated P #1 had multiple prior ED visits. ED notes revealed that P#1 was eligible for a legal hold after receiving history. P#1 reported that she drank two bottles of alcohol. In addition, P #1 admitted to illicit drug use.

P #1 reported to ED doctors she was raped the day before and the same day she came to the ED. P#1 was too intoxicated to consent to a forensic examination. The exam was deferred to the next day when she was sober. P #1 was diagnosed with: depression, anxiety, bipolar disorder, suicide risk, drug abuse, and alcohol intoxication.

On 7/26/22, SANE (a forensic nursing service provider that collected evidence of rape on the victim) came to examine and collect evidence, but P #1 refused the examination. P#1 was kept in the hospital and transferred to the facility for further psychiatric treatment on a 1013 on 7/26/22. P#1 was admitted by a physician's order on 7/26/22 at 3:45 p.m. A history and physical exam was completed on 7/27/22 at 8:00 a.m. A psychiatric evaluation was completed on 7/27/22 at 2:30 p.m. P#1 was diagnosed with Cocaine and Cannabis (marijuana) use.

An initial treatment plan consisted of Seroquel (an antipsychotic medication) 200 milligram (mg), every 15 minutes supervision, group therapy, and detox. P#1's initial discharge plan was between seven and ten days.

Psychiatric progress notes were completed on 7/28/22, 7/29/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, and 8/3/22.

A review of a 'Progress Note' documented on 8/2/22 at 2:34 p.m. revealed the facility contacted P#1's family to report an allegation of rape by the patient. P#1's family stated that P #1 had made such allegations in the past that when she "does not get her way, she will yell out the R-word."

A Nursing Assessment was completed on 7/26/22 at 9:50 p.m. when the patient arrived on the unit. Nursing Assessments were completed twice a day on 7/27/22, 7/28/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, 8/3/22/ 8/4/22.

On 8/2/22 at 12:45 p.m., a patient on the unit reported to Registered Nurse (RN) LL that "P #1 was taken advantage of". P #1 met with RN LL to discuss what happened. P #1 did not want to talk about what happened. RN LL got an order and moved P #1 to another unit, and P#1 was placed on an every five minutes level of surveillance. P #1 agreed to call a forensic agency that dealt with sexual violence and investigation by collecting physical evidence. A staff nurse from the agency came with the law enforcement. The result of the examination was not disclosed to the facility.

A review of the 'Observation Sheet' revealed that P #1 was on every 15 minutes surveillance and suicide precautions on 7/26/22, 7/27/22, 7/28/22, 7/29/22, 7/30/22, 7/31/22.

P #1's observation level changed from every 15 minutes to every five minutes on 8/2/22 at approximately 6:30 p.m. and was in effect for 8/3/22 and 8/4/22.

Further review of P #1's medical record showed no 'Patient Observation Record Q (every) 5 and Q15' for 8/1/22.

Patient #1 was discharged home on 8/4/22 at 8:00 a.m. with instructions to follow up with P#1's primary care provider and outpatient treatment.



During a joint interview with Director of Nursing (DON) KK and Risk Manager (RM) MM on 8/31/22 at 2:30 p.m. in the facility's conference room, both administrators were informed that while reviewing P#1's MR, the 'Patient Observation Record Q5 and Q15' for 8/1/2022 could not be located. DON KK reviewed P #1's MR but could not find the document. DON KK said she was going to the unit and other places where the MR was and continued the search for the document. DON KK left the room, returned an hour later, and said she was still looking for the document. On the same date, by 4:30 p.m., DON KK came back into the room and ascertained that the document was there because she saw it when the allegation was made; however, she could not locate it. DON KK and RM MM agreed that P #1's medical record did not have a 'Patient Observation Record Q5 and Q15' for 8/1/22.


A review of a policy titled "Documentation Protocol", policy #IM-009 issued date: 1/15, last revised: 3/18, revealed that facility records, charts, and documents were to be accurate, truthful, and complete. The policy noted that staff was to document accurate services provided and patient interactions. The policy further stated every staff who created or reviewed documentation in a MR or responded to or implemented orders or directives contained in a MR complied with the protocol. This duty was to ensure the accuracy of MRs applied to the entire MR, not just documentation a staff individually created, reviewed, or acted upon. Further review of the policy indicated the purpose was to ensure accurate and timely documentation; to provide a means of communication between healthcare providers; to provide a legal record to protect the patient, the facility and health care team; and to provide information in the medical record for performance improvement.

A review of a policy titled " Levels of Observation", policy # CTS-113, issued 4/2020, and last revised date: 1/2/2022 revealed:
POLICY: In order to maintain patient safety, the hospital staff made and documented routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observation could be increased by the RN any time there was a concern but only a psychiatric practitioner may decrease the level.
PROCEDURE:
1.The psychiatric practitioner ordered one of three levels of observation at time of admission and as the patient's condition warranted a change:
a. 15 minute
b. 5 minute
c. One-to-one

2. The psychiatric practitioner may also order a precaution level of observation for:
a. Suicide
b. Assault
c. Elopement
d. Seizure
e. Fall
f. Sexual Acting Out

3.Documentation of Observations
a. Staff documented all levels of observation on each patient's observation form which became a part of the patient record. Each entry was to include the following:
i. Level of observation
ii. Precaution
iii. Location
iv. Behavior
v. Activity
vi. Time
vii. Staff Initial and Signature
b. Documentation of the observation was to be completed once the patient had been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner.