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Based on document review and interview, it was determined the Hospital failed to ensure patients rights were maintained. As a result, the Condition of Patient Rights (42 CFR 482.13) was not met. This has the potential to affect 100% of the patients serviced by the Hospital.

Findings include:

1. The Hospital failed to ensure that patients were notified of their rights. (A-116)

2. The Hospital failed to ensure that patients received care in a a safe setting. (A-144)

3. The Hospital failed to ensure staff were aware medications can be considered a form of a restraint. (A-161)

4. The Hospital failed to ensure the least restrictive type of restraint was utilitzed. (A-165)

5. The Hospital failed to ensure the use of restraint was in accordance with hospital policy. (A-167)

6. The Hospital failed to ensure a physician order was obtained for the use of a restraint. (A-168)

Based on document review and interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure that a Restriction of Rights Notification was given to the patient.

Findings include:

1. On 7/10/15 at 9:00 AM the policy titled "Patient Rights-Behavioral Health." (reviewed 1/1/15) was reviewed. The policy required "These rights are specific to behavioral health patients, and are in addition to those spelled out in the hospital policy, patient rights and responsibilities ...Whenever a patient's rights are restricted, the patient the family, facility director, and anyone the patient designates shall be informed in writing. (Restriction of Rights) form."

2. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic) by E#7 via injection per MD#2's order. The clinical record lacked a "Restriction of Rights" form.

3. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated, "I remember Pt #1. Pt. #1 came in complaining of a shrinking brain and wanted test done. Pt #1 was anxious, paranoid and labile. A petitition and certificate for involuntary admission was completed. Pt #1 became agitated and threatening to staff, so MD #2 ordered a shot of medication. Pt #1 refused to take it even after I tried to convince Pt. #1 to take it. Security guards did a physical hold and I gave the shot. I don't remember if any documentation was filled out on that. I documented the shot given."

4. During an interview conducted with Director of Emergency Services (E #4) on 7/8/15 at approximately 2:45 PM, E#4 stated, "If the patient is here on a petition and certificate and we didn't feel the forced medications and physical hold were a restraint. We don't do any documentation for the physical hold other then medication which was given."

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Based on document review and staff interview, it was determined of 5 of 6 (Pt's #3, #4, #5, #9, #10) records reviewed, the Hospital failed to ensure a safe environment when a patient with a behavioral health diagnosis presented to the Emergency Department per policy. This has the potential to affect all staff, visitors and patients being treated by the Emergency Department (ED).

Findings include:

1. The policy titled "BH (Behavioral Health) Search of Person" (revised 5/11) was reviewed on 7/10/15. The policy required "Searches will be done in the ED and on arrival... Check all belongings and person to verify absence of hazardous items... Patients will be asked to remove clothing down to underclothes in the presence of staff and change into hospital gown/greens for the purpose of the search..." The ED document titled "Behavioral Health Safety Standards" required "2. Behavioral patients must always change into scrubs immediately upon arrival... placed in a patient's belonging bag... placed in a secure trunk located at the nurse's desk..."

2. The clinical record of Pt #3 was reviewed on 7/7/15 at approximately 2:00 PM. Pt #3 presented to the ED on 5/22/15 with a diagnosis of Depression and Suicidal Ideation. On 5/22/15 at approximately 5:17 PM, Pt #3 was admitted to a psychiatric unit and admission psychiatric nursing documentation stated "Searched by: er." ED documentation lacked as to when/if Pt #3 was changed into scrubs and if/when Pt #3 was searched for contraband.

3. The clinical record of Pt #4 was reviewed on 7/8/15 at approximately 1:20 PM. Pt #4 was brought to the ED on 5/22/15 at 6:18 PM by law enforcement with a diagnosis of suicide attempt and alcohol intoxication. A provider note dated 5/22/15 at 8:47 PM noted "Transported to Receiving Unit... by security... personal belongings taken to floor with patient." The record lacked documentation of Pt #9 being searched for contraband or that clothing was removed by the ED.

4. The clinical record of Pt #5 was reviewed on 7/9/15 at approximately 9:45 AM. Pt #5 presented to the ED via police and ambulance personnel on 5/22/15 at 8:57 PM with the CC (Chief Complaint) Overdose and Psychotic Behavior. At 10:14 PM, ED nursing documentation stated Pt #5's belongings were at the nursing station. The ED documentation lacked as to when Pt #5 was changed into scrubs, and belongings were not removed upon admission, as per Hospital policy.

5. The clinical record of Pt #9 was reviewed on 7/8/15 at approximately 10:00 AM. Pt #9 was admitted to the ED on 6/2/15 at 3:23 PM with a diagnosis of Paranoid Psychosis. A provider note dated 6/2/15 at 6:34 PM noted "Pt was taken up to 786 by 2 security guards after making multiple threats that he/she was going to leave and if he/she could not he/she would hurt the staff." The record lacked documentation of Pt #9 being searched for contraband or that clothing was removed by the ED.

6. The clinical record of Pt #10 was reviewed on 7/8/15 at approximately 2:00 PM. Pt #10 was admitted to the ED on 6/21/15 at 11:27 AM with a diagnosis of a Psychotic Episode. The triage assessment noted "...Pt has been threatening other residents that he/she will slit their throats...." The record noted at 2:53 PM that Pt's belongings were itemized, bagged and placed at the nurses station, nearly 3 hours after admission to the ED.

7. An interview was conducted with the Director of Emergency Department (E#4) on 7/7/15 at approximately 11:25 AM. The Quality Nurse (E#3) was present. When asked what their policy was for the care of psychiatric patients upon arrival, and during, the ED stay specifically related to changing into scrubs and checking for contraband, E#4 stated all psychiatric patients have the ED document "Behavioral Health Safety Standards" explained to them, change into scrubs, and are asked to remove all clothing and belongings which are then inventoried and placed into bags and placed in a box at the ED nursing station. E#4 stated if a patient refuses, the staff are to call Security for assistance and that "them just showing up and walking through is usually enough to have the patient comply with this."

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure staff was aware that a physical hold/forced medications was a type of restraint.

Findings include:

1. On 7/9/15 at 8:00 AM the policy titled "Restraint and Seclusion" (reviewed 11/14) was reviewed. The policy required "Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely... Behavioral Health Restraint and Seclusion: 1. Requirements for all Settings. A. Initiation of restraints or seclusion: A registered nurse may initiate a restraint or seclusion in advance of the physicians' orders. i. As soon as possible but no longer than one hour after the initiation of the restraint or seclusion.... and obtain a physicians order. B. One hour face to face assessment: the licensed practitioner or an appropriately trained registered nurse... type and location of restraining device shall be documented... rationale of restraint."

2. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic) by E#7 via injection per MD#2's order. The clinical record lacked an order for forced medications or physical hold.

3. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated "I remember Pt #1. Pt #1 came in complaining of a shrinking brain and wanted test done. Pt #1 was anxious, paranoid and labile. A petition and certificate for involuntary admission was completed. Pt #1 became agitated and threatening to staff, so MD #2 ordered a shot of medication. Pt #1 refused to take it even after I tried to convince Pt. #1 to take it. Security guards did a physical hold and I gave the shot. I don't remember if any documentation was filled out on that. I documented the shot given."

4. During an interview conducted with Director of Emergency Services (E#4) on 7/8/15 at approximately 2:45 PM, E#4 stated "If the patient is here on a petition and certificate and we didn't feel the forced medications and physical hold were a restraint. We don't do any documentation for the physical hold other then medication which was given."

5. During an interview conducted with Coordinator of Quality Management (E#8) on 7/8/15 at approximately 8:15 AM, E#8 stated "There is no adverse report or documentation that Pt. #1 was given forced medication in the ED or had a physical hold or eloped. A physical hold and forced medications are restraints. An adverse report and nursing documentation should have been completed for the physical hold and elopement."

Based on record review and interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure alternative interventions and least restrictive interventions were used prior to performing a physical hold.

Findings include:

1. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic) by E#7 via injection per MD#2's order. The clinical record lacked documentation alternative interventions and least restrictive interventions were used prior to performing a physical hold.

2. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated "Pt #1 refused to take it even after I tried to convince Pt #1 to take it. Security guards did a physical hold and I gave the shot. I don't remember if any documentation was filled out on that. I documented the shot given." E#7 verbally agreed the only interventions offered prior to administration of the injections was verbal.

Based on document review and staff interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure the restraint and seclusion process was in accordance with policy.

Findings include:

1. On 7/9/15 at 8:00 AM the policy titled "Restraint and Seclusion" (reviewed 11/14) was reviewed. The policy required "Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely... Behavioral Health Restraint and Seclusion: 1. Requirements for all Settings. A. Initiation of restraints or seclusion: A registered nurse may initiate a restraint or seclusion in advance of the physicians' orders. i. As soon as possible but no longer than one hour after the initiation of the restraint or seclusion.... and obtain a physicians order. B. One hour face to face assessment: the licensed practitioner or an appropriately trained registered nurse... type and location of restraining device shall be documented... rationale of restraint."

2. On 7/9/15 at 10:00 AM the document titled "Restraints-Intervention Changes" used for staff education was reviewed. The document required "Complete (electronic documentation) every time restraints are initiated... A face to face encounter must occur for violent restraint application."

3. On 7/10/15 at 9:00 AM the policy titled "Patient Rights-Behavioral Health." (reviewed 1/1/15) was reviewed. The policy required "These rights are specific to behavioral health patients, and are in addition to those spelled out in the hospital policy, patient rights and responsibilities ...Whenever a patient's rights are restricted, the patient the family, facility director, and anyone the patient designates shall be informed in writing. (Restriction of Rights) form."

4. On 7/9/15 at 7:30 AM the policy titled "Incident Report/Safety Issues" (reviewed 4/8/15) was reviewed. The policy required "employees, volunteers and members of the medical staff are instructed to complete incident reports... on any event that is not consistent with the routine operation of the hospital or the routine care of a particular patient."

5. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic) by E#7 via injection per MD#2's order. The clinical record lacked a "Restriction of Rights" form. The clinical record lacked an order for forced medications or physical hold. The clinical record lacked a face to face assessment within one hour by a qualified staff practitioner. There were no adverse reports completed for the physical hold and forced medications.

6. During an interview conducted with Coordinator of Quality Management (E#8) on 7/8/15 at 8:15 AM-8:30 AM, E#8 stated, "There is no adverse report or documentation that Pt #1 was given forced medication in the emergency department or had a physical hold or eloped. A physical hold and forced medications are restraints. An adverse report and nursing documentation should have been completed for the physical hold and elopement."

7. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated, "Security guards did a physical hold and I gave the shot. I don't remember if any documentation was filled out on that. I documented the shot given."

8. During an interview conducted with Director of Emergency Services (E#4) on 7/8/15 at approximately 2:45 PM, E#4 stated, "If the patient is here on a petition and certificate and we didn't feel the forced medications and physical hold was a restraint, we don't do any documentation for the physical hold other then medication which was given."

Based on record review and interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure a physician's order was obtained for the restraint/physical hold.

Findings include:

1. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic). The record lacked documentation of an order for a restraint/physical hold.

2. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated, "I remember Pt #1. Pt #1 came in complaining of a shrinking brain and wanted test done. Pt #1 was anxious, paranoid and labile. A petition and certificate for involuntary admission was completed. Pt #1 became agitated and threatening to staff, so MD #2 ordered a shot of medication. Pt #1 refused to take it even after I tried to convince Pt. #1 to take it. Security guards did a physical hold and I gave the shot. I don't remember if any documentation was filled out on that. I documented the shot given."

3. During an interview conducted with Director of Emergency Services (E #4) on 7/8/15 at approximately 2:45 PM, E#4 stated, "If the patient is here on a petition and certificate and we didn't feel the forced medications and physical hold were a restraint. We don't do any documentation for the physical hold other then medication which was given." E#4 verbally agreed the record did not have a physicians order for the restraint/physical hold and should have.

Based on record review and interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required a physical hold/forced medication in the Emergency Department (ED), the Hospital failed to ensure a face to face assessment within one hour by a qualified staff practitioner was conducted.

Findings include:

1. On 7/9/15 at 8:00 AM the policy titled "Restraint and Seclusion" (reviewed 11/14) was reviewed. The policy required "B. One hour face to face assessment: the licensed practitioner or an appropriately trained registered nurse... type and location of restraining device shall be documented... rationale of restraint."

2. On 7/7/15-7/8/15 Pt #1's clinical record was reviewed. Pt #1 was admitted to the ED on 5/23/15 at 12:30 AM with complaints of "My brain is shrinking." and diagnosed with Paranoia, Depressive Disorder, Anxiety, Delusional Disorder and Psychosis. The ED mental exam dated 5/23/15 noted Pt #1 was hyper-talkative-nonsensical, agitated, uncooperative and hostile with staff. Pt #1 was given Lorazepam 2 milligrams (sedative) and Haloperidol 10 milligrams (anti psychotic) by E#7 via injection per MD#2's order. The clinical record lacked a face to face assessment within one hour by a qualified staff practitioner.

3. During an interview conducted with Registered Nurse (E#7) on 7/8/15 at approximately 2:00 PM, E#7 stated "Pt #1 became agitated and threatening to staff, so MD #2 ordered a shot of medication. Pt #1 refused to take it even after I tried to convince Pt. #1 to take it. Security guards did a physical hold and I gave the shot."

4. During an interview conducted with Director of Emergency Services (E#4) on 7/8/15 at approximately 2:45 PM, E#4 verbally agreed the record lacked documentation of a face to face assessment being conducted within one hour of the restraint/physical hold and there should have been.

A. Based on record review and staff interview, it was determined in 5 of 10 (Pt's #2, #7, #8, #9, #10) records reviewed, the Hospital failed to ensure clinical documentation described the patient's progress and response to treatments.

Findings include:

1. The clinical record of Pt #2 was reviewed on 7/7/15 at approximately 12:15 PM. Pt #2 was admitted on 6/25/15 with a diagnosis of Schizoaffective Disorder. The Physician's Progress Notes scribed by MD#1 lacked documentation of progress towards goals, response to medications and effectiveness of therapy services

2. The clinical record of Pt #7 was reviewed on 7/7/15 at approximately 2:00 PM. Pt #7 was admitted on 7/1/15 with a diagnosis of Paranoia. The Physician's Progress Notes scribed by MD#1 lacked documentation of progress towards goals, response to medications and effectiveness of therapy services.

3. The clinical record of Pt #8 was reviewed on 7/7/15 at approximately 2:30 PM. Pt #8 was admitted on 6/27/15 with a diagnosis of Paranoia. The Physician's Progress Notes scribed by MD#1 and MD #3 lacked documentation of progress towards goals, response to medications and effectiveness of therapy services.

4. The clinical record of Pt #9 was reviewed on 7/8/15 at approximately 10:00 AM. Pt #9 was admitted on 6/2/15 with a diagnosis of a Psychotic Episode. The Physician's Progress Notes scribed by MD#1 lacked documentation of progress towards goals, response to medications and effectiveness of therapy services.

5. The clinical record of Pt #10 was reviewed on 7/8/15 at approximately 3:00 PM. Pt #10 was admitted on 6/21/15 with a diagnosis of Paranoid Schizophrenia. The Physician's Progress Notes scribed by MD#1 and MD#3 lacked documentation of progress towards goals, response to medications and effectiveness of therapy services.

6. During an interview on 7/8/15 at approximately 3:15 PM, E#6 (Manager of Behavioral Health) verbally agreed the progress notes lacked documentation of progress towards goals, response to medications and effectiveness of therapy services. E#6 stated each morning a team meeting is held and the patients progress is discussed but it was not documented.


B. Based on record review and staff interview, it was determined in 1 of 10 (Pt #2) record reviewed, the Hospital failed to ensure the record contained accurate treatments orders which were specific to the patient's assessments and diagnosis.

Findings include:

1. The clinical record of Pt #2 was reviewed on 7/7/15 at approximately 12:15 PM. Pt #2 was admitted on 6/25/15 with a diagnosis of Schizoaffective Disorder. The comprehensive nursing assessment conducted on 6/25/15 noted Pt #2 had never smoked. The social workers behavioral assessment conducted on 6/27/15 noted patient denies the use of cigarettes. Nicotine patches were ordered daily on 6/25/15 and were discontinued at discharge on 7/7/15. The Medication Administration Record noted the Nicotine patches were not administered during the admission although on 6/30/15 it was noted "old medication patch removed....left upper shoulder..." The record lacked documentation the physician was contacted to clarify the Nicotine patch order or that the order was not being followed.

2. During an interview on 7/7/15 at approximately 2:00 PM, E#6 stated Pt #2 did not smoke and the order was inappropriate. E#6 stated "The old medication patch removed must have been charted on the wrong person." E#6 stated "It (the nicotine patch order) should have been discontinued."

A. Based on record review and staff interview, it was determined in 6 of 10 (Pt's #2,#3, #7, #8, #9, #10) records reviewed, the Hospital failed to ensure clinical documentation was legible.

Findings include:

1. The clinical record of Pt #2 was reviewed on 7/7/15 at approximately 12:15 PM. Pt #2 was admitted on 6/25/15 with a diagnosis of Schizoaffective Disorder. The Progress Notes dated 6/25, 6/26, 6/27, 6/28, 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, 7/5, 7/6 and 7/7/15 scribed by MD#1 were illegible.

2. The clinical record of Pt #3's was reviewed on 7/7/15 at approximately 2:00 PM. Pt #3 was admitted on 5/22/15 with a diagnosis of Depression and Suicidal Ideation. The daily provider progress notes dated 5/24/15 thru 5/29/15 were reviewed with the Quality Nurse (E#16) on 7/8/15 at approximately 12:30 PM. E#16 was unable to determine what all the entries stated, due to illegibility of entries, and contacted the Behavioral Health Clerk (E#14). E#14 reviewed the provider progress notes on 7/8/15 at approximately 1:00 PM and was unable to determine what all the entries stated.

3. The clinical record of Pt #7 was reviewed on 7/7/15 at approximately 2:00 PM. Pt #7 was admitted on 7/1/15 with a diagnosis of Paranoia. The Progress Notes scribed by MD#1 were illegible.

4. The clinical record of Pt #8 was reviewed on 7/7/15 at approximately 2:30 PM. Pt #8 was admitted on 6/27/15 with a diagnosis of Paranoia. The Progress Notes scribed by MD#1 and MD #3 were illegible.

5. The clinical record of Pt #9 was reviewed on 7/8/15 at approximately 10:00 AM. Pt #9 was admitted on 6/2/15 with a diagnosis of Paranoid Schizophrenia. The Progress Notes dated 6/3/15 and 6/4/15 scribed by MD#1 were illegible.

6. The clinical record of Pt #10 was reviewed on 7/8/15 at approximately 3:00 PM. Pt #10 was admitted on 6/21/15 with a diagnosis of Paranoid Schizophrenia. The Progress Notes scribed by MD#1 and MD#3 were illegible.

7. During an interview on 7/8/15 at approximately 2:00 PM, E#6 (Manager of Behavioral Health) verbally agreed the progress notes were not legible and should be.

8. An interview was conducted with the Quality Nurse (E#16) on 7/8/15 at approximately 1:30 PM. E#16 reviewed Pt #3's record and verbally agreed the physician entries were not legible and should be.


B. Based on document/record review and staff interview, it was determined in 6 of 10 (Pt's #3, #4, #7, #8, #9, #10) records reviewed, the Hospital failed to ensure telephone/verbal orders were authenticated within 48 hours per policy.

Findings include:

1. The policy titled "Physician's Order" (revised 12/9/14) was reviewed on 7/8/15. The policy required the physician to sign telephone/verbal orders within 48 hours.

2. The clinical record of Pt #3's was reviewed on 7/7/15 at approximately 2:00 PM. Pt #3 was admitted on 5/22/15 with a diagnosis of Depression and Suicidal Ideation.
a. On 5/22/15 at 5:59 PM, four medication orders were entered into the computer by the clerk. Four out of four medication orders were E-signed by the physician on 5/29/15 at 8:10 AM, beyond the Hospital's required 48 hour timeframe.
b. On 5/23/15 at 7:50 PM, a clerk transcribed a written telephone order "Consult Hospitalist" into the computer system. The order was E-signed by the physician on 5/27/15 at 8:10 AM, beyond the Hospital's required 48 hour timeframe.

3. The clinical record of Pt #4 was reviewed on 7/8/15 at approximately 1:20 PM. Pt #4 was admitted with a diagnosis of suicide attempt and alcohol intoxication on 5/22/15. A telephone order for Desyrel, Catapress, Malox, Milk of Magnesia, Cogentin and Precautions dated 5/22/15 was authenticated by the physician on 5/27/15, greater than 48 hours. A telephone order for Motrin dated 5/24/15 was authenticated by the physician on 5/27/15, greater than 48 hours. A telephone order for Lithium dated 5/23/15 was authenticated by the physician on 5/27/15, greater than 48 hours.

4. The clinical record of Pt #7 was reviewed on 7/7/15 at approximately 2:00 PM. Pt #7 was admitted on 7/1/15 with a diagnosis of Paranoia. A telephone order for Desyrel and Haldol dated 7/1/15 had not been authenticated as of 7/9/15, greater than 48 hours.

5. The clinical record of Pt #8 was reviewed on 7/7/15 at approximately 2:30 PM. Pt #8 was admitted on 6/27/15 with a diagnosis of Paranoia. A telephone order for admission dated 6/27/15, Desyrel dated 6/27/15 and a Nicotrol Patch dated 6/28/15 had not been authenticated as of 7/9/15, greater than 48 hours.

6. The clinical record of Pt #9 was reviewed on 7/8/15 at approximately 10:00 AM. Pt #9 was admitted on 6/2/15 with a diagnosis of Paranoid Schizophrenia. A telephone order for discharge dated 6/4/15 had not been authenticated as of 7/9/15, greater than 48 hours. A written telephone order dated 6/4/15 for Restraint/Seclusion, Haldol and Ativan was electronically signed on 6/25/15, greater than 48 hours. The written telephone orders for Restraint/Seclusion, Haldol and Ativan were not entered into the medical record. A telephone order for Precautions and activity stated "no signature necessary for entry..." dated 6/2/15 had not been authenticated as of 7/9/15, greater than 48 hours.

7. The clinical record of Pt #10 was reviewed on 7/8/15 at approximately 3:00 PM. Pt #10 was admitted on 6/21/15 with a diagnosis of Paranoid Schizophrenia. A telephone order for Physical Therapy to evaluate and treat dated 6/21/15, for Timoptic eye drops dated 6/21/15, for Prolixin dated 6/24/15 and a urine culture dated 7/1/15 had not been authenticated as of 7/9/15, greater than 48 hours.

8. During an interview on 7/8/15 at approximately 2:00 PM, E#6 stated the nurses enter telephone/verbal orders and written orders into the electronic medical record but the physicians should be signing all orders electronically. E#6 stated the nurses should not state that an order does not need signed.

9. An interview was conducted with E#16 on 7/8/15 at approximately 1:30 PM. E#16 reviewed Pt #3's record and verbally agreed the physician orders were not signed within 48 hours and should have been.


C. Based on record review and staff interview, it was determined in 4 of 10 (Pts #4, #8, #9, #10) records reviewed, the Hospital failed to ensure records were completed.

Findings include:

1. The clinical record of Pt #4 was reviewed on 7/8/15 at approximately 1:20 PM. Pt #4 was admitted with a diagnosis of suicide attempt and alcohol intoxication on 5/22/15. The discharge summary dictated by MD#1 on 5/25/15 and electronically signed as completed on 5/27/15 had multiple blanks that had not been filled in.

2. The clinical record of Pt #8 was reviewed on 7/7/15 at approximately 2:30 PM. Pt #8 was admitted on 6/27/15 with a diagnosis of Paranoia. The history and physical dictated by MD#3 on 6/28/15 was incomplete and unsigned as of 7/9/15.

3. The clinical record of Pt #9 was reviewed on 7/8/15 at approximately 10:00 AM. Pt #9 was admitted on 6/2/15 with a diagnosis of Paranoid Schizophrenia. The history and physical dictated by MD#1 on 6/2/15 and electronically signed as completed on 6/13/15 had blanks that had not been filled in.

4. The clinical record of Pt #10 was reviewed on 7/8/15 at approximately 3:00 PM. Pt #10 was admitted on 6/21/15 with a diagnosis of Paranoid Schizophrenia. The history and physical dictated by MD#3 on 6/21/15 was incomplete and unsigned as of 7/9/15.

5. During an interview on 7/8/15 at approximately 1:00 PM, E#8 (Coordinator of Quality Management) verbally agreed that Pts #4, #8, Pt #9 and Pt #10 records were not completed and should have been.


D. Based on document review and interview, it was determined for 1 of 10 (Pts #3) patient, the Hospital failed to ensure entries into the medical record were dated, timed, and authenticated.

Findings include:

1. The clinical record of Pt #3 was reviewed on 7/7/15 at approximately 2:00 PM. Pt #3 admitted on 5/22/15 with a diagnosis of Depression and Suicidal Ideation.
a. On 5/23/15 at 7:30 PM, there was a written telephone order "Consult Hospitalist". There was no date or time as to when the physician signed the written order. On 5/22/15 at 2:36 PM, the printed "Medication Reconciliation ADMISSION" lacked a date/time as to when the physician gave the order and lacked date/time as to when the physician signed the printed order.
b. On 5/23/15 at 7:35 PM, there was a written order for "Place on my list. Chest X-ray. Guafenesin 200 mg (milligrams) po (by mouth) q (every) 6 h (hour) prn (as needed) cough." The order lacked who the provider was that gave the order and who the recipient of the order was .
c. On 5/25/15, there was a written physician order which lacked the time as to when the order was written.

2. An interview was conducted on 7/8/15 at approximately 1:15 PM with E#16. E#16 reviewed Pt #3's record and verbally agreed the orders lacked dates, times, and/or who gave or received the order and should have.






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