HospitalInspections.org

Based on medical record review, staff interview and policy and procedure review, the facility failed to ensure each patients' medical record was complete and accurately documented for two (2) of 30 medical records reviewed, Patient #15 and #17.

Findings Include:

Record review for Patient #15 revealed an admission date of 06/28/17. Further review revealed the "Patient/Family Restraint Education", "Summary of Rights", "Consent for treatment with Psychoactive Medication(s)", "Mini Mental Status Exam", and the "Verbal Information Release/Telephone and Visiting Consent Form" were not complete, did not contain documented evidence of patient identification on each page and/or did not contain documented evidence of the guardian, staff and witness signature(s), dates and/or times of signature(s).


During an interview on 07/11/17 at 1:45 p.m., the Unit Clerk confirmed the medical record findings for Patient #15, and confirmed the admission paperwork should be completed on the day of admission by the nurse. She confirmed the nurse should also place patient stickers on each patient admit form.

Record review for Patient #17 revealed an admission date of 06/26/17. Further record review revealed the "Patient/Family Restraint Education" form was not complete and did not contain documented evidence of staff and witness signature(s), dates and/or times of signature(s).

During an interview on 07/11/17 at 1:50 p.m., the Unit Clerk confirmed the medical record findings for Patient #17, and confirmed the admission paperwork should be completed on the day of admission by the nurse.

During an interview on 07/11/17 at 2:55 p.m., the Social Worker/Behavioral Health Director confirmed that is was the admitting nurse's responsibility to complete the admitting consent forms and paperwork at the time of admission. She confirmed the admitting paperwork findings for Patient #15 and #17 were not complete and said the admit nurse should have completed all the forms.

During an interview on 07/12/17 at 3:30 p.m., the Administrator was asked for a copy of the facility's medical records policy and procedure for completion of a medical record.

During an interview on 07/13/17 at 8:50 a.m., the Director of Nursing (DON) confirmed each page of the medical record should be identifiable, and each page should be stickered. When reviewed the findings for Patient #15 and #17, she confirmed the findings and stated, "The admitting nurse should have completed all the paperwork or documented why she didn't."

During an interview of 07/13/17 at 10:55 a.m., the Assistant Medical Records Director confirmed that each entry into the medical record requires a signature, date and/or time. She also confirmed each page of the medical record should be identifiable. Surveyor requested a copy of the facility P&P for completion of a patient's medical record and identification of each page of a patient's medical record.

Review of the facility's "Nursing Admission Procedure" policy, effective 09/2012, revealed: "1.0 Policy: The R.N. (Registered Nurse) in charge is responsible for overseeing the admission of all patients ...2.0 Procedure: Admission to the Unit: 1. The patient will sign the admission forms, release of information forms (if applicable), patient rights forms and phone consent form prior to or at the time of admission ...3. Forms with appropriate signatures for admission to the hospital are completed ...3.0 Procedure: A. Assessment: 1. An R.N. is responsible for overseeing the admission of all patients to the Unit ...4 ...The following occurs: a. The assigned nurse ensures that the designated program admission forms and consents are signed ...8. If any part of the admission procedure is deferred due to patient's refusal of an assessment by the R.N., a detailed explanation is written in the Interdisciplinary progress notes. Attempts are made to complete the assessment as soon as possible. Interdisciplinary notes reflect these ongoing attempts.

Review of the facility's "Policy for Completion of Medical Records" dated July 2017, revealed: "Facility recognizes the need to have a complete Medical Record therefore; it is a policy ...that any paper form must be signed and dated."

These findings were discussed during the Exit Conference on 07/13/17 at 11:35 a.m. Nothing further was submitted for review.

Based on Organ Procurement Organization (OPO) contract review, OPO Tissue Donation Report review, in-service review, staff interview and policy and procedure review, the facility failed to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, in accordance with the facility OPO policy and procedure and OPO contract for a combined total of 12 times from January 2015 to May 2017.

Findings Include:

Review of the facility's "2017 Tissue Donation Report" revealed the month of January 2017 had one (1) untimely death called in greater than one (1) hour of cardiac death to the OPO. The Summary/Analysis for January revealed " ...One (1) death ...was not called in at all. This counts as a missed tissue referral. Please call all deaths into the referral line within one (1) hour of cardiac death ...".

Review of the facility's "2016 Tissue Donation Report" revealed the months of January, February, March, June, September and November 2016 each had one (1) untimely death called in greater than one (1) hour of cardiac death to the OPO. The Summary/Analysis revealed: "January: ...There was one (1) late referral ...called into the referral line over one (1) hour after cardiac death. Please call in ALL deaths within one (1) hour after cardiac death ...February: ...Please call in ALL referrals within one (1) hour after cardiac death ...March: ...there was one (1) late referral ...called into the referral line over one (1) hour past time of cardiac death. Please call in all referrals within one (1) hour of cardiac time of death ...June: ...There was one (1) late referral ...called in past the one (1) hour time of cardiac death. Please call in all referrals with one (1) hour of cardiac death ...September: ...One (1) death ...was not called in within the hours of cardiac death ...Please call all deaths into the referral line within one (1) hour of cardiac death ...November: ...One (1) death from ...was not called in within one (1) hour of cardiac death ...Please remember to call all deaths into the referral line within one (1) hour of cardiac death ..."

Review of the facility's "2015 Tissue Donation Report" revealed the months of January, February, May, July and October 2015 each had one (1) untimely death called in greater than one (1) hour of cardiac death to the OPO. The Summary/Analysis revealed: "January: ...there was one (1) untimely referral ...Please call in all deaths within one (1) hour after cardiac death ...February: ...there was one (1) untimely referral ...Please call in all deaths within one (1) hour after cardiac death ...May: ...There was one (1) untimely death ...Please call in ALL deaths with one (1) hour ...July: ...there was one (1) late tissue referral ...please call in all deaths within one (1) hour of cardiac death ...October: ...there was one (1) late referral ...called into the referral line over one (1) hour after cardiac death. Please call in All deaths ...".

Review of the facility in-service, dated: April 20, 2017, revealed: "Program Title: MORA (MS Organ Recovery Agency) ...Dept. Represented: Hospital-wide ...Objectives: ...4. Know guidelines for reporting ...".

During an interview on 07/12/17 at 11:15 a.m., the OPO findings were discussed with the Risk Manager concerning the untimely reporting of deaths called into the OPO from January 2015 thru May 2017. She confirmed all the data findings and said she did not realize there were untimely deaths being called in. She confirmed the OPO had completed an in-service in April 2017 for the staff.

During an interview on 07/13/17 at 8:40 a.m. Registered Nurse (RN) #1 confirmed that staff notify MORA as soon as a patient expires. When RN #1 was asked what the time frame was for reporting a death to the OPO, she stated that she was unable to recall a specific timeframe.

During an interview on 07/13/17 at 8:50 a.m. the Director of Nurses (DON) confirmed the staff has to call the OPO within one (1) hour of a patient's death.

Review of the facility's "Organ and Tissue Donation" policy, revised December 2009, revealed: "Purpose: ...To comply with federal ...guidelines ...Policy/Standard of Care:...Recovery Coordinators ...are available around the clock to assist with implementation of this policy and process ...Procedure: ...C. Donor Referral Procedure: ...1. Organ Donor Referral: The hospital's representative for referring potential organs or tissues will be a licensed nurse who is familiar with the patient's condition ...2. Tissue Donor Referral: a. Potential tissue donor should be referred within one (1) hour of death and prior to funeral home notification ..."

Review of the facility's "Organ and Tissue Donation Cooperative Agreement entered into ...03/21/14" revealed: "Timely Notification for Tissue Donation: For individuals who have died a cardiac death, notification is timely if the referral is made as soon as possible, ideally within one (1) hour of the cardiac death ...Section 1. Hospital Obligations ...1.2 Provide ...a Timely Notification for Tissue Donation ..."

These findings were discussed during the Exit Conference on 07/13/17 at 11:35 a.m. Nothing further was submitted for review.

Based on Organ Procurement Organization (OPO) contract review, OPO Tissue Donation Report review, in-service review, staff interview and policy and procedure review, the facility failed to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, in accordance with the facility OPO policy and procedure and OPO contract for a combined total of 12 times from January 2015 to May 2017.

Findings Include:

Cross Refer to C-0344 for the facility's failure to ensure the contracted OPO was notified of all patient deaths in a timely manner, within one (1) hour of a patient's death, in accordance with the facility OPO policy and procedure and OPO contract.