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Tag No.: A0132
Based on review of medical records, review of policy and procedures and interview with staff, in 4 of 7 medical records of patients 18 years and older (#1, 5, 7 and 8), out of total 10 records reviewed, the facility failed to ensure Advanced Directives were addressed upon admission with the patient (Pt) and/or their guardian.
Findings include:
Facility policy titled End of Life Decisions: Advance Medical Directives (AMD); Guidelines for Withholding or Limiting Medical Treatment and CPR (Cardiopulmonary Resuscitation) states under A.1. "The nurse completing the nursing admission database shall ask each patient whether he or she has completed an AMD. Documentation of this inquiry shall be noted through use of the Advanced Directive Acknowledgement (ADA)..." Under C. "If the patient has a legally appointed guardian: The unit social worker shall ask the guardian if the patient has an AMD. The guardian shall be asked to sign the ADA form indicating whether the patient has an existing AMD."
Pt #1's medical record review on 1/19/10 at 9:00 AM revealed the ADA completed on 11/10/09 stated "The patient has a guardian of his/her person and is thereby presumed incompetent to understand and sign this document." There is no evidence in the record Pt #1's guardian was contacted regarding an Advanced Directive. This is confirmed in interview with Deputy Administrator C on 1/19/10 at 2:30 PM.
Pt #5's medical record review on 1/20/10 at 7:45 AM revealed there is no ADA in the record. There is no evidence in the record Pt #5 was asked information regarding an Advanced Directive. This is confirmed in interview with Medical Records Supervisor (S) D on 1/20/10 at 10:25 AM.
Pt #7's medical record review on 1/20/10 at 8:30 AM revealed there is no ADA in the record. There is no evidence in the record Pt #5 was asked information regarding an Advanced Directive. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #8's medical record review on 1/20/10 at 9:15 AM revealed there is no ADA in the record. There is no evidence in the record Pt #5 was asked information regarding an Advanced Directive. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Tag No.: A0169
Based on medical record review, review of policy and procedures and interview with staff, in 2 of 10 medical records (#3 and 10) the facility failed to ensure restraint and seclusion orders are not written as "as needed" (PRN).
Findings include:
Facility policy titled Emergency Interventions:Seclusion and Restraint does not include direction to not write restraint or seclusion orders as PRN orders.
Pt #3's medical record review on 1/19/10 at 12:50 PM revealed there is an order written on 1/14/10 at 4:00 PM written as "Renew Medical Restraints PRN x 24 hours..." There are orders for medical restraints written as "Renew 2:1 and 1:1 + medical restraints prn x24 (hours) as per previous order" written on 1/17/10 at 11:00 AM and on 1/18/10 at 9:40 AM. This is confirmed in interview with Deputy Administrator C on 1/19/10 at 2:30 PM.
Pt #10's medical record review on 1/20/10 at 11:00 AM revealed there are restraint orders written between 11/6/09 through 11/28/09 written as PRN orders. This is confirmed in interview with S D on 1/20/10 at 11:15 AM.
Tag No.: A0178
Based on review of medical records, review of policy and procedure and interview with staff, in 3 of 10 medical records that included restraints for aggression (#5, 7 and 9) the facility failed to ensure the 1 hour face to face examination is conducted timely and/or documented in the record including, but not limited to: patient's situation, patient's reaction, patient's medical and behavioral condition and need to continue or terminate the intervention.
Findings include:
Facility policy titled Emergency Interventions: Seclusion and Restraint states under III.G. "Within one hour of authorizing seclusion or restraint, the physician must follow up with a face-to-face assessment. At the time of the assessment, the physician will consult with the patient and staff to identify ways to assist the patient in regaining control. The face-to-face assessment will be accomplished within one hour regardless of whether the episode has ended or not. The results of the assessment will be documented in the patient's yellow progress notes."
Pt #5's medical record review on 1/20/10 at 7:45 AM revealed there is a 1 hour face to face note dated 11/25/09 at 3:00 AM stating "Pt w(with)/loud and semi threatening behavior w/aggressive features. Placed in seclusion for nonredirectable behavior." This note does not include the patient's reaction, medical and behavioral condition and need to continue or terminate the seclusion. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #7's medical record review on 1/20/10 at 8:30 AM revealed there is no 1 hour face to face progress note that corresponds with a restraint order written on 9/18/09 at 04:15 AM. There is a face to face note written on 9/18/09 at 9:44 AM stating "Seclusion-tried to head butt staff-secluded wheelchair". This note does not include the patient's reaction, medical and behavioral condition and need to continue or terminate the seclusion. There is a face to face note written on 10/5/09 without a time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed there is a 1 hour face to face progress note written on 12/4/90 at 5:05 AM stating "Pt aggressive @8:50-Placed in locked seclusion until safe." This note does not include the patient's reaction, medical and behavioral condition and need to continue or terminate the seclusion. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Tag No.: A0450
Based on medical record review, review of policy and procedures, and interview with staff, in 10 of 10 medical records (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) the facility failed to ensure dictated reports including History and Physicals (H &P), Psychiatric Evaluations (PE) and Discharge Summaries (DC) are authenticated by the MD (Medical Doctor) with a date and time. In 5 of 10 medical records (#1, 2, 5, 7 and 9) the facility failed to ensure all orders were complete with a date, time, signed and seclusion/restraint orders included the reason for the order.
Findings include:
Examples of dictations:
Facility policy titled Medical Record Documentation Requirements states under XI. C. "All entries must be dated with month, day and year, while utilizing military time."
Patient (Pt) #1's medical record review on 1/19/10 at 9:00 AM revealed the PE dictated on 11/9/09 is not authenticated by the MD with a date and time. This is confirmed in interview with Deputy Administrator (DA) C on 1/19/10 at 2:30 PM.
Pt #2's medical record review on 1/19/10 at 12:00 PM revealed the PE dictated on 1/7/10 is not authenticated by the MD with a date and time. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #3's medical record review on 1/19/10 at 12:50 PM revealed the H & P dictated on 4/3/09 and the PE dictated on 4/3/09 are not authenticated by the MD with a date and time. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #4's medical record review on 1/19/10 at 1:34 PM revealed the annual H & P dictated on 2/16/09 and the most recent PE dictated on 2/15/09 is not authenticated by the MD with a date and time. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #5's medical record review on 1/20/10 at 7:45 AM revealed the H & P dictated on 11/23/09 and the PE dictated on 11/20/09 are not authenticated by the MD with a date and time This is confirmed in interview with Medical Records Supervisor (S) D on 1/20/10 at 10:25 AM.
Pt #6's medical record review on 1/19/10 at 3:30 PM revealed the H & P dictated on 12/2/09 and the PE dictated on 12/2/09 are not authenticated by the MD with a date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #7's medical record review on 1/20/10 at 8:30 AM revealed the PE dictated on 9/16/09 and the DS dictated on 10/29/09 are not authenticated by the MD with a date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #8's medical record review on 1/20/10 at 9:15 AM revealed the H & P dictated on 11/12/09, the PE dictated on 11/12/09 and the DS dictated on 12/3/09 are not authenticated by the MD with a date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed the H & P dictated on 12/4/09 and the PE dictated on 12/4/09 are not authenticated by the MD with a date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #10's medical record review on 1/20/10 at 11:00 AM revealed the H & P dictated on 11/14/09 and the PE dictated on 11/12/09 are not authenticated by the MD with a date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Examples of orders:
Facility policy titled Emergency Interventions: Seclusion and Restraint states under IV.C "The physician order must: 1. include a specific description of the behavior necessitating seclusion or restraint 2. be time limited."
Pt #1's medical record review on 1/19/10 at 9:00 AM revealed there is a seclusion order written on 11/8/09 at 4:30 PM states "May continue locked seclusion for up to 4 more hours per above order, " and does not include a reason why. There are orders written on 11/16/10 at 6:15 PM and 11/13/09 at 5:47 AM that do not include the reason why. An order written on 11/13/09 at 6:00 AM states "Extend up to 4 (hours)" (illegible) and is not complete including extending what, and why. A Telephone seclusion order written on 11/13/09 at 4:20 PM does not include a time limit. A seclusion order written on 11/13/09 at 9:20 PM does not include a reason why. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #2's medical record review on 1/19/10 at 12:00 PM revealed there is a seclusion order written on 1/9/10 at 1:15 PM that does not include the reason why. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #5's medical record review on 1/20/10 at 7:45 AM revealed there is a note regarding an allergy to Ritalin written on the order sheet on 11/23/09 at 8:50 AM that is not signed by the author; and an order for seclusion written without a date. There are an orders for seclusion written on 11/25/09, not timed by the MD, and on 11/24/09 at 12:10 PM do not include a reason why. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #7's medical record review on 1/20/10 at 8:30 AM revealed there is an order written on 9/27/09 at 2:40 PM that is not written by the MD, and is not written as a Verbal or Telephone order and signed by the staff that wrote the order. There is an involuntary seclusion order written on 9/18/09 at 5:15 AM that does not include a reason why. There is a Verbal order written on 9/16/09 at 9:40 AM to continue restraints that does not include a reason why. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed there is a written order on 12/6/09 at 6:30 AM to extend locked seclusion without a reason why. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Tag No.: A0457
Based on review of medical records, review of Medical Staff Rules and Regulations and interview with staff, in 7 of 10 records (#1, 2, 3, 5, 7, 9 and 10) the facility failed to ensure verbal (VO) and telephone orders (TO) are authenticated by a Medical Doctor (MD) with a signature, date and time.
Findings include:
Facility Medical Staff Rules and Regulations state under B. 5. "Orders dictated over the telephone shall be signed by the person who dictated, with the name of the physician or physician assistant, per his or her name. These orders shall be signed, timed and dated by a physician within 48 hours."
Patient (Pt) #1's medical record review on 1/19/10 at 9:00 AM revealed there are VOs and TOs written between 11/6/09 and 11/15/09 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with Deputy Administrator (DA) C on 1/19/10 at 2:30 PM.
Pt #2's medical record review on 1/19/10 at 12:00 PM revealed there are VOs and TOs written between 1/5/10 and 1/19/10 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #3's medical record review on 1/19/10 at 12:50 PM revealed there are VOs and TOs written between 1/11/10 and 1/19/10 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with DA C on 1/19/10 at 2:30 PM.
Pt #5's medical record review on 1/20/10 at 7:45 AM revealed there are VOs and TOs written between 11/21/09 and 11/24/09 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with Medical Records Supervisor (S) D on 1/20/10 at 10:25 AM.
Pt #7's medical record review on 1/20/10 at 8:30 AM revealed there are VO and TOs written between 9/15/09 and 9/26/09 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed there are VOs and TOs written between 12/5/09 and 12/10/09 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Pt #10's medical record review on 1/20/10 at 11:00 AM revealed there are VOs and TOs written between 11/13/09 and 11/20/09 that are not authenticated by an MD with a signature and/or date and time. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Tag No.: A0468
Based on review of medical records, review of Medical Staff Rules and Regulations, review of policy and procedures, and interview with staff, in 3 of 7 closed medical records (#1, 9 and 10) out of a total of 10 records reviewed, the facility failed to ensure the record is complete within 15 days per policy.
Findings include:
Facility policy titled Medical Record Documentation Requirements under X. states "Discharge Summary (DS)Completed within 15 days of discharge."
Facility Medical Staff Rules and Regulations state under B. 8. "A discharge summary shall be dictated within one working day of a patient's discharge and placed in the record within 15 days after discharge."
Patient (Pt) #1's medical record review on 1/19/09 at 9:00 AM revealed he was discharged on 1/15/09. The record is not complete with a DS per policy. This is confirmed in interview with Deputy Administrator C on 1/19/10 at 2:30 PM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed he was discharged on 12/10/09. The record is not complete with a DS per policy. This is confirmed in interview with Medical Records Supervisor (S) D on 1/20/10 at 10:25 AM.
Pt #10's medical record review on 1/20/10 at 9:30 AM revealed he was discharged on 11/30/09. The record is not complete with a DS per policy. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.
Tag No.: A0469
Based on review of medical records, review of Medical Staff Rules and Regulations, review of policy and procdure, and interview with staff, in 3 of 7 closed medical records (#1, 9 and 10) out of a total of 10 records reviewed, the facility failed to ensure the record is complete within 15 days per policy.
Findings include:
Facility policy titled Medical Record Documentation Requirements under X. states "Discharge Summary (DS)Completed within 15 days of discharge."
Facility Medical Staff Rules and Regulations state under B. 8. "A discharge summary shall be dictated within one working day of a patient's discharge and placed in the record within 15 days after discharge."
Patient (Pt) #1's medical record review on 1/19/09 at 9:00 AM revealed he was discharged on 1/15/09. The record is not complete with a DS per policy. This is confirmed in interview with Deputy Administrator C on 1/19/10 at 2:30 PM.
Pt #9's medical record review on 1/20/10 at 9:30 AM revealed he was discharged on 12/10/09. The record is not complete with a DS per policy. This is confirmed in interview with Medical Records Supervisor (S) D on 1/20/10 at 10:25 AM.
Pt #10's medical record review on 1/20/10 at 9:30 AM revealed he was discharged on 11/30/09. The record is not complete with a DS per policy. This is confirmed in interview with S D on 1/20/10 at 10:25 AM.