HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to ensure the social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history for one of 10 medical records reviewed (Patient #1). The facility's census was 101.

Findings include:

Review of the facility policy titled, Discharge Designation and Aftercare Planning Process policy (NSG 13.0, Last Review Date 03/23), revealed the facility coordinates with healthcare professionals and aftercare providers as well as family/guardian to include discharge planning for planned, unscheduled (per patient request), and AMA (against medical advice) discharges to meet the continuing needs of the individual after discharge. Discharge and aftercare planning begins upon admission to the facility and is continually reassessed, updated, and documented to meet the patient/family's needs throughout the patient's length of stay.

Review of Patient #1's medical record revealed he was admitted on 09/04/23 with a primary diagnoses including Psychoses and Schizophrenia and discharged home on 09/18/23.

Staff K was interviewed on 10/23/23 at 8:37 AM. Staff K reported that prior to Patient #1 leaving, "me, the patient and the grandparents talked on the phone the day before he was discharged. I talked to them the day of discharge. Our van took him home. We put him back on the medication that worked for him. We discussed what brought him in. He was doing a lot better on the day of discharge. He just wanted to leave".

The medical record of Patient #1 did not contain documentation by Staff K regarding conversations with Patient #1's grandparents on 09/17/23 and 09/18/23.

Additionally, review of the section on the Discharge Evaluation/Continuing Care Plan for Patient #1 that showed the Patient and/or family's understanding of the discharge plan revealed it was not filled out. A Patient Discharge Note showing Patient #1's discharge paperwork was reviewed, was blank.

The findings were shared in an interview with Staff Q on 10/23/23 at 8:52 AM and confirmed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00146608.

Based on medical record review, review of the facility's Medical Staff Bylaws and interview, the facility failed to ensure the initial psychiatric evaluation included a medical history for one of 10 medical records reviewed (Patient #1). The facility's census was 101.

Findings include:

Review of the facility's Medical Staff Bylaws revealed the Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed, dated and timed and written on the initial psychiatric admission note or dictated within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. The admission note will include a DSM (Diagnostic and Statistical Manual of Mental Disorders) 5 five-axis diagnosis and initial plan of treatment. The Psychiatric Evaluation should include: a. Chief complaint (in patient's own words); b. Mental status evaluation, including description of attitudes and behavior and estimate of intellectual functioning, memory functioning, orientation, and dangerous to self and others (and how tested); c. History of present illness; d. Current and prior psychiatric treatment including substance abuse treatment; e. Medical history; f. Social history; g. Family history of mental substance/substance abuse; h. Developmental history for children and adolescents; i. Education/vocational history; J. Admission diagnoses axis I thru V; k. Patient assets and weaknesses; l. Expected length of stay; m. Contraindications to seclusion and restraint; n. Current medications, and past medications; o. Plan and recommendation for treatment and discharge.

Review of Patient #1's medical record revealed an initial Psychiatric Evaluation by Staff G on 09/05/23 at 9:13 AM. The evaluation did not include a medical history.

The findings were shared in an interview with Staff Q on 10/23/23 at 2:06 PM and confirmed.

Based on medical record review, review of the facility's Medical Staff Bylaws and interview, the facility failed to ensure the initial psychiatric evaluation included the onset of illness and the circumstances leading to admission for one of 10 medical records reviewed (Patient #1). The facility's census was 101.

Findings include:

Review of the facility's Medical Staff Bylaws revealed the Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed, dated and timed and written on the initial psychiatric admission note or dictated within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. The admission note will include a DSM (Diagnostic and Statistical Manual of Mental Disorders) 5 five-axis diagnosis and initial plan of treatment. The Psychiatric Evaluation should include: a. Chief complaint (in patient's own words); b. Mental status evaluation, including description of attitudes and behavior and estimate of intellectual functioning, memory functioning, orientation, and dangerous to self and others (and how tested); c. History of present illness; d. Current and prior psychiatric treatment including substance abuse treatment; e. Medical history; f. Social history; g. Family history of mental substance/substance abuse; h. Developmental history for children and adolescents; i. Education/vocational history; J. Admission diagnoses axis I thru V; k. Patient assets and weaknesses; l. Expected length of stay; m. Contraindications to seclusion and restraint; n. Current medications, and past medications; o. Plan and recommendation for treatment and discharge.

Review of Patient #1's medical record revealed an initial Psychiatric Evaluation by Staff G on 09/05/23 at 9:13 AM. The evaluation did not include onset of illness and the circumstances leading to admission.

The findings were shared in an interview with Staff Q on 10/23/23 at 2:06 PM and confirmed.

Based on medical record review, review of the facility's Medical Staff Bylaws and interview, the facility failed to ensure the initial psychiatric evaluation included an inventory of assets for one of 10 medical records reviewed (Patient #1). The facility's census was 101.

Findings include:

Review of the facility's Medical Staff Bylaws revealed the Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed, dated and timed and written on the initial psychiatric admission note or dictated within 24 hours after admission of the patient and the admission note will be entered in the progress notes at the time of evaluation. The admission note will include a DSM (Diagnostic and Statistical Manual of Mental Disorders) 5 five-axis diagnosis and initial plan of treatment. The Psychiatric Evaluation should include: a. Chief complaint (in patient's own words); b. Mental status evaluation, including description of attitudes and behavior and estimate of intellectual functioning, memory functioning, orientation, and dangerous to self and others (and how tested); c. History of present illness; d. Current and prior psychiatric treatment including substance abuse treatment; e. Medical history; f. Social history; g. Family history of mental substance/substance abuse; h. Developmental history for children and adolescents; i. Education/vocational history; J. Admission diagnoses axis I thru V; k. Patient assets and weaknesses; l. Expected length of stay; m. Contraindications to seclusion and restraint; n. Current medications, and past medications; o. Plan and recommendation for treatment and discharge.

Review of Patient #1's medical record revealed an initial Psychiatric Evaluation by Staff G on 09/05/23 at 9:13 AM. The evaluation did not include an inventory of Patient #1's assets.

The findings were shared in an interview with Staff Q on 10/23/23 at 2:06 PM and confirmed.