HospitalInspections.org

Based on review of policies and procedures, hospital documents, medical record review, and staff interview the hospital staff failed to monitor and track the patient data related to the guardianship documentation process for 7 of 7 patients reviewed (#1, #2, #3, #4, #5, #6, and #7).

The findings include:

Review the hospital's policies and procedures revealed no policy nor procedure had been developed related to the guardianship documentation process.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA (Durable Power of Attorney)' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

1. Closed medical record review revealed patient #3 was admitted on 03/01/2013. Further review revealed the named patient was IVC (involuntary committed). Further review revealed "Guardian or DPOA (Durable Power of Attorney) was "blank" (not completed)on the "intake" form. Further record review revealed the named patient was discharged from hospital and the guardian was not notified of the discharge.

Record review revealed "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed the named patient was declared an "Incompetent Person" and the named family member had guardianship of the named patient since 11/03/2005 (8 years and 9 months).

Review of complaint response letter dated 04/26/2013 revealed, "...The documentation process for situations such as this (guardian notification of discharge) is being reviewed to better accommodate the patient and the patient's guardian."

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

2. Closed medical record review revealed patient #1 was admitted on 06/15/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

3. Closed medical record review revealed patient #2 was admitted on 05/30/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

4. Closed medical record review revealed patient #4 was admitted on 04/03/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

5. Closed medical record review revealed patient #5 was admitted on 04/30/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."


6. Open medical record review revealed patient #6 was admitted on 06/22/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

7. Open medical record review revealed patient #7 was admitted on 06/22/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake"form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

Based upon review of hospital policies and procedures, hospital documents, medical record, and staff interviews, the hospital staff failed to ensure a safe discharge by failing to notify patient's guardian of discharge for 1of 10 patients reviewed (#3).

The findings include:

Review of the hospital's policy, "Consent for Psychiatric Treatment", revised on 09/10 revealed, "...GENERAL INFORMATION A. Consent forms and other legal forms (e.g durable power of attorney, guardianship papers, etc.) will become part of the patient's medical record regardless of legal status."

Review of the hospital's policy, "Discharge Planning Process", revised on 05/05/11 revealed, "...IMPLEMENTATION OF THE DISCHARGE PLAN...Prior to discharge, the nursing staff ensures that patients and caregivers, as appropriate, receive and understand instructions ..."

Closed Medical record review conducted on 06/25/2013 revealed patient #3 was admitted on 03/01/2013. Further review revealed patient #3 was IVC (involuntary committed). Further review revealed "Guardian or DPOA (Durable Power of Attorney) was "blank" (not completed). Record review revealed a form, "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed patient #3 was declared an "Incompetent Person". Further review revealed the identified family member had guardianship of patient #3 since 11/03/2005 (8 years and 9 months). Record review revealed a "HISTORY AND PHYSICAL" dictated on 03/01/2013 by the admitting physician that the identified family member was "legal guardian." Further review revealed the "...PATIENT DISCHARGE PLAN: ...that patient #3 will discharge home with (the named family member-guardian)..." Further record review revealed patient #3 was discharged from hospital 03/25/2013 and the record revealed no documentation that the patient's guardian was notified of discharge.

Interview conducted on 06/26/2013 at 1000 with the discharge nurse revealed the patient #3 was discharged without the guardian being notified. Interview confirmed the hospital's discharge policy was not followed.

NC00089494

Based on review of policies and procedures, hospital documents, medical record review, and staff interview the hospital staff failed to monitor and track the patient data related to the guardianship documentation process for 7 of 7 patients reviewed (#1, #2, #3, #4, #5, #6, and #7).

The findings include:

Review the hospital's policies and procedures revealed no policy nor procedure had been developed related to the guardianship documentation process.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA (Durable Power of Attorney)' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

1. Closed medical record review revealed patient #3 was admitted on 03/01/2013. Further review revealed the named patient was IVC (involuntary committed). Further review revealed "Guardian or DPOA (Durable Power of Attorney) was "blank" (not completed)on the "intake" form. Further record review revealed the named patient was discharged from hospital and the guardian was not notified of the discharge.

Record review revealed "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed the named patient was declared an "Incompetent Person" and the named family member had guardianship of the named patient since 11/03/2005 (8 years and 9 months).

Review of complaint response letter dated 04/26/2013 revealed, "...The documentation process for situations such as this (guardian notification of discharge) is being reviewed to better accommodate the patient and the patient's guardian."

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

2. Closed medical record review revealed patient #1 was admitted on 06/15/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

3. Closed medical record review revealed patient #2 was admitted on 05/30/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."

4. Closed medical record review revealed patient #4 was admitted on 04/03/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

5. Closed medical record review revealed patient #5 was admitted on 04/30/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIENT PROGRAM INQUIRY WORKSHEET) every portion of the intake form is to be filled out...this is an expectation..."

Staff interview conducted with RN #3 on 06/26/2013 at 1423 revealed, "On the intake form everything is addressed if they (patients) can tell you...would not leave anything blank...if anything is left blank means you did not address and possible you did not ask...any nurse can do intake."

Staff interview conducted with RN #4 on 06/26/2013 at 1430 revealed, "On the intake form everything needs to be filled out...guardian needs to be addressed..."


6. Open medical record review revealed patient #6 was admitted on 06/22/2013. Further review revealed the "Guardian or DPOA" was not completed on the "intake" form.

Interview conducted on 06/26/2013 at 1400 with the administrative personnel revealed, "we were made aware, when a complaint was filed, that the 'Guardian or DPOA' was not being completed." At the present time no documentation processes have been changed and no monitoring, no tracking, and no staff education has been implemented." The interview confirmed that no performance improvement had been made to the guardianship documentation process.

Staff interview conducted with RN #2 on 06/26/2013 at 1421 revealed, "...on the 'intake' (the named unit INPATIE