HospitalInspections.org

Based on review of daily census log, observation, interview, and internal documents, it was determined that the hospital failed:

1. to ensure a safe setting for psychiatric patients when multiple numbers of electrical cords were present in the milieu; and

2. unmodified handicapped-assist bars were present in the lobby/Intake waiting room restroom to which patients presented for psychiatric evaluation.

The potential risk of electrical cords in the milieu long enough to be used as a ligature, and unmodified handicapped-assist bars used by patients who present for psychiatric evaluation, and could utilize the bars as a ligature point, posed a serious risk to the health and safety of patients.

Findings include:

1. On 12-27-2016, a copy of the hospital's daily census was provided. The census report revealed that 47 inpatients that day had an Admitting Diagnosis of "Major Depressive Disorder."

Observation during the tour conducted on 12-27-16, revealed multiple electrical cords, one of which was approximately 4-5 feet long, which could be used as ligatures, in the day/recreation room on one of the units.
A water cooler in another patient care area of the unit, which had an electrical cord approximately 3-4 feet long and attached to the water cooler, was also in the milieu.

The Quality Director acknowledged, during interview conducted on 12-27-16, that the cords should not have been in the milieu where patients had access to them. The Director stated that the water coolers with cords were on all patient units.

2. Review of an internal hospital document (Updated November 28, 2016), revealed that the lobby bathrooms, utilized by patients who present to the hospital for psychiatric evaluation, had been identified during a 2015 Risk Assessment as a patient safety risk. The best-practice remedy identified was to make the lobby bathrooms ligature-free.

On 01-04-17, surveyors observed that the lobby/Intake waiting room restroom contained two 3-4 foot horizontal bars, and one 1-2 foot vertical bar. The handicapped-assist bars had not been modified with a solid bottom piece to reduce the risk of a bar being used as a ligature point.

The Quality Director acknowledged, during an interview conducted on 1-04-2017, that the ligature-prevention improvements had not yet been completed for the lobby-Intake restroom.

Based on the Director of Nursing job description, document review, and interview, it was determined that the Director of Nursing failed to be responsible for the operation of the service when instructions on a controlled substance log were not followed by nursing staff for correcting log errors.

Findings include:

The Director of Nursing job description revealed: "...The Director of Nursing is responsible for the clinical practice of nursing which includes directing all services provided by the Nursing Services Department...."

During tour conducted on 12-27-16, surveyors reviewed the "Valley Hospital Controlled Substances Administration Record," dated 12-27-16, for the 1 North medication preparation room. The record contained the following instructions: "...All entries must be...legible...errors must be noted with a line thru the entire row, initials/date and a new entry mode [sic]...."

Review of the Administration Record line labeled "Record Beginning Inventory 2400," revealed the quantity entry for tramadol 50 mg (milligrams) had been overwritten from "35" to "36," the zolpidem 5 mg entry space was overwritten and illegible, and the entry for zolpidem 10 mg was overwritten from "10" to "17." The pre-printed "Nurses Signature" space on the same line contained an illegible signature written over the printed text. None of the above mentioned corrected entries had been crossed out or initialed by staff as required.

The unit Registered Nurse (RN) on duty (#21) confirmed, during an interview conducted on 12-27-16, the illegibility of the aforementioned entries on the unit's daily controlled substances record.

Based on review of policies and procedures, medical record sample prototype of a patient assessment in the Intake/Emergency Department, Medical Staff Rules and Regulations, and interview, it was determined that the hospital's medical record service failed to ensure administrative responsibility for every patient evaluated at the hospital, when the Medical Records Director did not have access to outpatient records in which the patient was not admitted as evidenced by:

(A0438) failure to ensure that the Medical Records Director had direct access to medical records of outpatients not admitted. The potential risk of improperly filed medical records, is that it has the potential to impact the health and safety of patients if appropriate oversight by the Medical Records Director is not maintained;

(A0440) failure to ensure that a system of coding and indexing medical records of outpatients not admitted allowed for retrieval by diagnosis and procedure. The potential risk is to the health and safety of patients should it be determined medically necessary to conduct medical evaluation of the care provided to non-admitted patients; and

(A0450) 1. failure to ensure that medical records of outpatients not admitted were authenticated by the physician/psychiatrist responsible for their care. There lends a high potential risk, that because the medical records are incomplete, with no documenation of the verbal communication between the Registered Nurse (RN) assessing the patient and the psychiatrist who determines the disposition of the outpatient, that patients may be discharged to an unsafe environment, placing their health and safety in an unsafe situation; and

2. failure to ensure that professional staff followed the hospital's policy and procedure for documentation in the medical records of three (3) of three (3) patients, when mark-throughs and other marks made the entries illegible. (Patients # 8, #41 and # 2)

The cumulative effect of this systemic problem resulted in the hospital's failure to meet the requirement for the Condition of Participation for Medical Record Services.

Based on review of policies and procedures, medical record, and interview, it was determined that the hospital failed to appropriately file a medical record consistent with the hospital's formal medical record system for each outpatient who presented to the facility for an assessment. The Medical Records Director did not have direct access to the outpatient records of patients not admitted. The potential risk of improperly filed medical records, is that it has the potential to impact the health and safety of patients if appropriate oversight by the Medical Records Director is not maintained.

Findings include:

The "Medical Record Purpose and Goals" policy revealed: "Purpose: To establish responsibility, authority, standards and interrelationships for the Medical Records Department. Policy: It is the policy of the (hospital) to maintain an adequate medical record for each individual who is evaluated and treated in our facility. The medical records are documented...are readily accessible and permit prompt retrieval of information...Purpose: The purpose of the medical record are as follows: 1. To serve as a basis for planning patient care and for continuity in the evaluation of the patient's condition and treatment... 3. To document communication between the provider and the patient; also any other healthcare professionals who contribute to the patient's care...."

The "Documentation in the Patient's Medical Record" policy revealed: "...Identifying information Each page in the medical record, must have the patient's name and MR# (Medical record number)...."

During surveyor review, in an attempt to follow the flow of patient documentation from presentation through decision to admit, then through Initial unit nursing assessment, and through hospitalization, a request was made of the Quality Director for a prototype of a record of a patient presenting to the Emergency Department, but not subsequently admitted.

Review was conducted of the medical record of Patient #7, a patient who presented to the Intake/Emergency Department, but was not admitted. There was no patient identifying sticker with the date of admission or a medical record number.

The Medical Records Director was not available for interview at the time during the survey when medical record review of the Intake (Emergency Department) review was conducted.

The Chief Executive Officer (CEO) acknowledged, during interview conducted on 12-28-16, that the medical records of patients evaluated in the Intake/Emergency Department, but not admitted to the hospital, are maintained in a hospital drive file, separate from the paper and electronic medical records of admitted patients. The CEO, when asked how the Director of Medical Records would access such a record, contained in a file on a hospital drive, acknowledged that the Medical Records Director would have to have an Intake Specialist, CEO, or other specially designated person access the record.

Based on review of policy and procedure, Intake/Emergency Department record, and interview, it was determined that the hospital failed to implement a system of coding and indexing the medical records of patients assessed in the Intake/Emergency Department but not admitted, by using a medical record number consistent with the medical record system in place for admitted patients. The system used for non-admitted outpatients failed to allow for retrieval by diagnosis and procedure in an effort to support medical care evaluation studies. The potential risk is to the health and safety of patients should it be determined medically necessary to conduct medical evaluation of the care provided to non-admitted patients.

Findings include:

The "Documentation in the Patient's Medical Record" policy revealed: "...Identifying information Each page in the medical record, must have the patient's name and MR# (Medical record number)...."

The "Maintaining Assessment Records" policy for the Intake Department revealed: "...Procedure...2. The scanned assessment records will be filed electronically by year, month, day, patient name, and patient's last initial...."

Review of 1 of 1 Intake/Emergency Department medical records (Patient #7) in which the patient was not admitted, revealed there was no diagnosis on the assessment paper documenation provided. The record, documented on "Care Center Nurses Notes" (Intake/Emergency Department) had a typed annotation on the right side of the paper at the bottom of the page which read: "Patient Label." There was no label on the patients "Care Center Nurses Notes," and no medical record number, in which the record was coded and indexed in a manner which supported retrieval by diagnosis.

The Chief Executive Officer acknowledged, during interview conducted on 12-28-16, that the medical records of patients presenting to the Intake/Emergency Department, but not admitted to the hospital, contained no medical record numbers consistent with the medical records of patients admitted to the hospital.

Based on review of Medical Staff Rules and Regulations, policies and procedures, medical records, and interviews, it was determined that the hospital failed:

1. to ensure that medical records of patients assessed in the Intake/Emergency Department, but not admitted to the hospital, were authenticated by the physician/psychiatrist responsible for the care/disposition of the patient. There is high potential risk, that because the medical records are incomplete, with no documenation of the verbal communication between the Registered Nurse (RN) assessing the patient and the psychiatrist who determines the disposition of the outpatient, that patients may be discharged to an unsafe environment, placing their health and safety in peril.

2. to ensure that professional staff followed the hospital's policy and procedure for documentation in the medical records of three (3) of three (3) patients, when mark-throughs and other marks made the entries illegible. (Patients # 8, #41 and # 2)

Findings include:

1. The Medical Staff Rules and Regulations revealed: "...5. MEDICAL RECORDS..5.3 Member Responsibility for Medical record. 5.3.1 Attending members are responsible for ensuring that the medical record contains all such information as may be necessary to prevent harm to patients in the Facility or to others...."

The "Telephone Order read-Back" policy revealed: "Purpose To ensure clear understanding by nursing of all physician's telephone orders....Procedure 1. When receiving a telephone order for a patient, the nurse will write the order(s)...."

A copy of Emergency Department medical record of Patient #7, a patient who presented to Intake/ED, but was not admitted, was provided as a prototype. Review of the record revealed that the patient presented in early December, 2016, and was not admitted to the hospital. The record revealed: "I, (Patient #7), have been evaluated by a team member of (Hospital's) Assessment Team on (date). The following recommendations have been made to help me better cope with my situation: 1. To go to (Recovery Clinic) at 7:00 A.M. 2. (Team named) will see you in A.M. 3. Will ride bike to friend (name) house tonight... The "Crisis Response Plan" revealed: "Called Crisis Line- XXX-XXX-XXXX... "Actions Taken (if not admitted to in-patient care) 'X' Family/MHP (medical healthcare professional)..."Staffed c (with) (Physician #7)." The author was Staff, #20, an RN.

Patient #7's medical record did not contain documenation of the conversation between the RN and the Psychiatrist, an order for discharge, and did not contain a physician signature as required, attesting that he/she was aware of the patient's condition prior to discharge.

The Quality Director acknowledged, during interview conducted on 12-27-16, that the Emergency Department RNs who conduct the patient assessment, call the appropriate physician. The Director acknowledged that no physician signs the RN assessment, and that the documenation does not reveal what information about the patient assessment/condition was imparted to the physician, and what physician communication was imparted back to the RN.

The Medical Director acknowledged, during interview conducted on 12-27-16, that it was a risk to send patients back to an environment outside of inpatient care without the physician/psychiatrist knowing what the documentation revealed. The Director stated that without signing the actual nursing documentation, the physician/psychiatrist would only know what the RN presented verbally about the patient. The Medical Director acknowledged that physicians/psychiatrists should be signing the outpatient documentation on the medical record.

2. (Hospital) policy and procedure titled, "Documentation in the Patient's Medical Record," revealed: "...Correcting Errors...Acceptable...Corrections must be made be drawing a single line through the incorrect entry, with initials with and date...Unacceptable...Scribbling through documentation..."Legibility...Acceptable...Write legibly...."

Review of the "High Risk Notification Alert Internal Nurse-to-Nurse Report" for Patient #8, dated 11-16-2016, revealed that on the line for "Patient Name," a different patient's name had been written, crossed out, and Patient #8's name was written above it. On the line labeled "Suicidal: Indicators," the originally entered text was crossed out and another entry was written above it. The corrected entry contained no initials or date.

Within the column labeled "7:00 PM-7:30 AM Shift," the "24 Hour Nursing Progress Note" for Patient #41, dated 1-3-17, contained an overwritten, not initialed, and illegible notation of the patient's self-rated depression level.

The "High Risk Notification Alert Internal Nurse-to-Nurse Report for Patient #2, dated 11/7/16, contained heavily scribbled-over entries under sections labeled "Unit," "Physician," and "Detox: Indicator(s)." Patient #2's "Initial Assessment-Care Center...Psychiatric Screening" document dated 11-7-16, contained two overwritten, not initialed corrected entries in the paragraph describing the patient's Presenting Problem, Symptoms and Significant History, and one overwritten, not initialed entry in the Substance Abuse History Section related to first use of alcohol.