HospitalInspections.org

Based on record review and interview the facility failed to ensure the patient's medical record contained complete information/documentation for (3) three of (3) patients requesting to be released when the contacting of the physician and the physician's response were not documented. (Patients #1, 11, and 9)

Findings Include:

Review of Patient #1's Medical Records reflected:
Request for discharge signed on 12/13/15 at 6:48 p.m.
Review of Nurse's Notes dated 12/13/15 did not reflect the communication with the physician with instructions to hold after the 4 hours.

Review of Patient #11's Medical records dated 12/6/15 reflected a signed request for release from Voluntary Care on 12/6/15 at 11:52 a.m.
Review of nurse's note dated 12/6/15 at 9:21 a.m. did not reflect a discussion with the physician or a physician's order to release or hold the patient.

Review of Patient #9"s dated 12/3/15 reflected a signed request for release from Voluntary Care on 12/3/15 at 4:12 p.m., physician notified at 4:17 p.m.
The record did not reflect a discussion with the physician or a physician's order to release or hold the patient.

During an interview on 4/4/16 in the conference room Staff #10, RN nurse supervisor was asked if the facility has a policy and procedure for documenting the interaction with the physician she stated, "I'm not aware of a procedure."

Review of the facility provided policy titled Rights of Voluntary Patients Seeking Discharge (dated 6/17/15) reflected: " ...1. A voluntarily patient may request to be discharged from the hospital at any time by telling staff or writing a letter requesting release ....6. Immediately upon receiving a request for release, the nurse shall notify the patient's physician ...to determine the course of action ....Documentation: ...2. The request for release, and if submitted, the retraction of the request for release; shall be documented in the progress notes section of the medical record .... 3. The physician's order shall be documented and shall include the clinical justification for detaining the patient when the request for release is filed and denied ...."

During an interview in the afternoon on 4/5/16 in the conference room, "Staff #2, Risk Manager, confirmed the finding.

Based on interview and record review the facility failed to ensure the medical record contained all practitioner's orders when (3) three out of (3) three patient's, requesting to be released from the facility, did not have physician's orders to release or hold the patients. (Patients #1, 11, and 9)

Findings Include:

Review of Patient #1's Medical Records dated 12/13/15 reflected a signed request for release from Voluntary care at 6:48 p.m.
Review of the Physician's Orders dated 12/13/15 did not reflect an order to release or hold for 24 hours.

Review of Patient #11's Medical records dated 12/6/15 reflected a signed request for release from Voluntary Care at 11:52 a.m.
Review of Physician's Orders dated 12/6/15 did not reflect physician's order to release or hold the patient for 24 hours.

Review of Patient #9's Medical Records dated 12/3/15 reflected a signed request for release from Voluntary Care at 4:12 p.m.
Review of Physician's Orders dated 12/13/15 did not reflect physician's order to release or hold the patient for 24 hours.

During an interview on the afternoon on 4/5/16 in the conference room, Staff #2, Risk Manager stated, "We have a policy and procedure for patients seeking discharge. The nurse calls the physician and gets an order." When asked if it is a written order, Staff #2 stated, "Yes."


Review of the facility provided policy titled Rights of Voluntary Patients Seeking Discharge (dated 6/17/15) reflected: " ...1. A voluntarily patient may request to be discharged from the hospital at any time by telling staff or writing a letter requesting release ....6. Immediately upon receiving a request for release, the nurse shall notify the patient's physician ...to determine the course of action ....9. The physician must give the nurse an order to hold the patient, for a period not to exceed 24-hurs, pending a fact-to-face evaluation by the physician ..."
Documentation: ...2. The request for release, and if submitted, the retraction of the request for release; shall be documented in the progress notes section of the medical record .... 3. The physician's order shall be documented and shall include the clinical justification for detaining the patient when the request for release is filed and denied ...."


During an interview in the afternoon on 4/5/16 in the conference room, "Staff #2, Risk Manager, confirmed the finding.