HospitalInspections.org

Based on a review of medical records and interview with the Administrator it was determined the hospital failed to ensure a psychiatric evaluation was completed within 60 hours of admission and filed in the medical record in 2 of 9 medical records reviewed. This affected Patient Identifier (PI) # 1 and PI #3.

Findings include:

1. Patient Identifier (PI) # 1 was admitted to the hospital 9/3/09 with a diagnosis of Major depressive Disorder.

A review of the medical record failed to provide a psychiatric evaluation.

On 8/11/10 at 8:30 AM, Employee Identifier (EI) # 1, the Director, provided to the surveyor a copy of a psychiatric evaluation that had the title of the form marked through. The form was titled Discharge Summary. The form was printed out and signed by the Psychiatrist 8/10/10 for 9/4/09. EI # 1 continued and said that the Psychiatrist had it in his computer and printed it out.

2. PI # 3 was admitted to the hospital 10/29/09 with a diagnosis of Schizophrenia Paranoid Type.

A review of the medical record provided a psychiatric evaluation for 8/26/09 signed by the Psychiatrist 11/3/09 3:30 PM.

On 8/11/10 at 8:40 AM, EI # 1 provided to the surveyor a copy of a psychiatric evaluation that had been dictated by the Psychiatrist 10/29/09 and was signed 8/10/10 at 9:30 PM for 11/2/09 at 11:00 AM. Employee Identifier # 1 stated that she met with the Psychiatrist and the evaluation was in his computer and he must have printed out the wrong one before that he had signed for 11/3/09.

Based on review of medical records and interview with Employee Identifier # 1, the Director, it was determined in medical record # 1 that the discharge instructions failed to document when and where the patient was to follow up for outpatient care. This had the potential to affect all patients discharged from the hospital and did affect Patient Identifier (PI) # 1.

Findings include:

1. PI # 1 was admitted to the hospital with a diagnosis of Major Depressive Disorder.

The hospital Discharge and Continuity of Care Instructions documented the follow-up appointment: "Appt (appointment) with AOP (AltaPointe outpatient) for psychiatry. "Discharge: "Other."

There was no date or time to follow-up or where the patient was discharged to. The Discharge assessment documented, "Consumer is alert, oriented and in no apparent distress. States understanding of discharge instructions."

In response to written questions on 8/11/10 at 8:30 AM, EI # 1 in an interview, stated that it's not documented but they always make sure the patient knows where to go; he was going to a group home and they would make sure he kept his appointment.