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Based on review of Policy/Procedure, clinical record review, and interview with hospital staff, it was determined that the hospital failed to adhere to internal Policy/Procedure for documentation in
the Discharge Nursing Notes.

Findings include:

Six clinical records (#1,#2, #3, #4, #5, #6) for patients (pt) admitted to in-patient care were reviewed. Record review revealed 3 of 6 (#4, #5, and #6) patients signed themselves out of the hospital Against Medical Advice (AMA) within 24 hours of admission.

The clinical records included a form titled: "Cedar Hills Hospital Continuing Care Discharge Plan".

Reviewed the hospital's Policy titled: "Discharge"; Date Issued: 1/2008; Function: Care of Patients; Issued By: Nursing Services, which stated: #6 "Discharge Nursing Notes are to be completed. In the summary the nurse is to document: the patient's condition; any discharge teaching; discharge instructions given, apart from the Aftercare forms; the patient's destination and conveyance; and the responsible person to who discharged."

Review of record for patient #3 revealed a 36 year old female admitted to Cedar Hills Hospital on involuntary hold on 03/07/11. Patient had been evaluated in the Emergency Department of Legacy Emanuel Hospital from 03/06/11 to 03/07/11 where she was placed on a two physician hold. The treating physician at Cedar Hills completed and signed a "Notice of Release from Hospital Detention by a Physician" on 03/08/11 after evaluation of #3. The physician discharge plan stated: "...no meds since pt is to see her assigned prescribing doctor or nurse practitioner in am".

Patient #3's clinical record lacked a "Discharge Nursing Note" as described in the hospital policy referenced above. The record did contain the form "Cedar Hills Hospital Continuing Care Discharge Plan", which lacked documentation of the patient's destination and conveyance and the responsible person to who the patient was discharged.

During an interview with the Chief Operations Officer on 04/20/11 at 1440, s/he stated the hospital had changed to using the "Cedar Hills Continuing Care Discharge Plan" instead of a "Discharge Nursing Note" during 2009. S/he confirmed the hospital's "Discharge" policy had not been revised to address the use of the form "Cedar Hills Hospital Continuing Care Discharge".

Findings were discussed with the hospital Chief Executive Officer, Chief Operations Officer, and Director of Performance Improvement during an exit conference on 04/20/11 at 1500.