HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patient signed informed consent for psychotropic medications for three of 20 (Patient # 12, 13, & 14) records reviewed.

This failed practice had the potential for patients not to exercise his/her rights to refuse or receive education about psychotropic medications.

Findings:

A policy titled "Informed Consent for Psychotropic Medications" states the hospital will obtain consent for treatment with psychotropic medication.

Patients # 12 and 13

A review of patients record showed no documentation of psychotropic medication consent form.

Surveyor requested psychotropic medication consent form for patients # 12 and 13. No documentation provided.

Patient # 14

A review of patient record showed psychotropic medication consent form without signature of patient and nurse.

On 05/04/18 at 11:30 am, Staff A stated his/her expectation would be for psychotropic medication consent form to be completed and signed with patient and nurse signature.

Based on record review and interview, the hospital failed to ensure registered nurse obtained informed consent for psychotropic medications for three of 20 (Patient # 12, 13, & 14) records reviewed.

This failed practice had the potential for patients not to exercise his/her rights to refuse or receive education about psychotropic medications.

Findings:

A policy titled "Informed Consent for Psychotropic Medications" states the RN will assist the physician in obtaining informed consent for medications.

See Tag A - 0131.

Based on record review and interview, the hospital failed to ensure nursing shift assessment was placed in patient chart for one of 20 (Patient # 12) records reviewed.

This failed practice had the potential for patients medical record to be incomplete.

Findings:

A review of document titled "Shift Nursing Assessment/Reassessment" says the shift nursing assessment will be completed on all patients for each shift of stay.

Patient # 12

Surveyor was not able to find documentation of shift nursing assessment/reassessment for the 7 PM - 7 AM shift on 02/26/18 for patient # 12 during patient record review.

Surveyor asked Staff A for and allowed time to locate document. Shift Nursing Assessment/Reassessment was not given to surveyor.

On 05/04/18 at 11:30 am, Staff A stated the nurses should do shift nursing assessment every shift and each shift does their own filing.

Based on record review and interview, the hospital failed to ensure the physician completed the the history and physical with 24 hours according to medical staff rules and regulation for one of 20 (Patient # 3) records reviewed.

This failed practice had the potential to cause harm or improper treatment for patient # 3 who was admitted to the hospital.

Findings:

A policy titled "Medical Staff Rules and Regulations" says a complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission.

Patient # 3

A review of record titled "History and Physical" completed by Staff I shows admission date as 02/28/18 and the date dictated was 03/01/18.

On 05/04/18 at 11:00 am, Staff A stated the history and physical should be dictated within 24 hours of patients admission.

Based on record review and interview, the hospital failed to ensure the physician completed the discharge summary according to medical staff rules and regulation for three of 20 (Patient # 15, 18 & 20) patient records.

This failed practice resulted in delinquent patient records for patient # 15, 18 & 20.

Findings:

A policy titled "Medical Staff Rules and Regulations" says if the discharge summary is not completed within thirty (30) days after the discharge, the medical record will be deemed delinquent.

Patient # 15

Patient was admitted on 03/15/18 and discharged on 03/23/18.

A review of document titled "Discharge Summary" shows document was physically signed by Staff H on 05/02/18 (42 days later).

A e-mail confirmation was provided by Staff A showing Staff H emailed discharge summary to medical records department on 04/18/18.

Patient # 18

Patient was admitted on 03/07/18 and discharged on 03/09/18.

On 05/04/18 (56 days later), surveyor was not able to find documentation of discharge summary for patient # 18 during patient record review.

Surveyor asked Staff A for and allowed time to locate document. Discharge summary was not given to surveyor.

Patient # 20

Patient was admitted on 02/15/18 and discharged on 02/21/18.

On 05/04/18 (72 days later), surveyor was not able to find documentation of discharge summary for patient # 20 during patient record review.

Surveyor asked Staff A for and allowed time to locate document. Discharge summary was not given to surveyor.

On 05/04/18 at 11:15 am, Staff A stated the expectation for discharge summary is to be completed within 30 days after discharge per policy.