HospitalInspections.org

Based on document review and staff interview, it was determined that in two (2) of four (4) grievances the hospital failed to furnish the complainant with written notice of the hospital's decision. This has the potential to adversely affect the resolution of grievances filed with the hospital.

Findings include:

1. A review of the hospital's complaint file revealed there has been four (4) grievances filed from January 2010 through present. One (1) of these was filed on 1/22/10 and one had been filed on 4/2/10. As of 5/5/10, letters had not been sent to either of the complainants.

2. The Quality Management Director was interviewed in the afternoon of 5/5/10. She agreed written notification had not been sent to either of the complainants listed above.

Based on medical record review, review of hospital documents and staff interview it was determined the hospital failed to ensure the patients' right to participate in the development and implementation of their treatment plans. This failure impacted ten (10) of ten (10) patient records reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) and has the potential to violate the rights of all patients.

Findings include:

1. The current Admission handbook for the Children's Unit was provided for review. Review of the "Patient's Rights and Responsibilities," statement #5 revealed it states "You have the right to help develop your treatment plan with staff. This written plan of care must be made a part of your record within three (3) days and must be reviewed at proper times during your hospital stay."

2. An interview was conducted with the Director of Social Services in the early afternoon of 5/4/10. During this interview, the 3/21/10 master treatment plan for patient #1, age 7, was reviewed and discussed. This patient's treatment plan reflected the plan was reviewed with the guardian on 3/21/10. The record lacked documentation to reflect the guardian was provided the opportunity to participate in the development of the treatment plan. The Director stated that typically nursing staff review the plan with the family when they come during the evening visiting hours. He stated the treatment plan meeting is usually held in the morning and acknowleged that currently families/guardians are not afforded the opportunity to attend and participate in the treatment plan meeting.

3. The policy, "Master Treatment Plan," last revised 5/09, was provided for review. It states in part: "Presentation of the MTP (Master Treatment Plan) with guardian, significant other or family should take place as soon as possible following the MTP meeting."

4. Review of the 3/7/10 MTP for patient #2, age 5, revealed no documentation the guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

5. Review of the 3/12/10 MTP for patient #3, age 9, revealed no documentation the mother participated. The record lacked documentation reflecting the opportunity to participate was provided.

6. Review of the 4/12/10 MTP for patient #4, age 5, revealed no documentation the guardian participated. The record lacked documentation reflecting the opportunity to participate was provided.

7. Review of the 4/26/10 MTP for patient #5, age 10, revealed no documentation the mother participated. The record lacked documentation reflecting the opportunity to participate was provided.

8. Review of the 4/19/10 MTP for patient #6, age 6, revealed no documentation the mother participated. The record lacked documentation reflecting the opportunity to participate was provided.

9. Review of the 4/30/10 MTP for patient #7, age 9, revealed no documentation the father participated. The record lacked documentation reflecting the opportunity to participate was provided.

10. Review of the 5/2/10 MTP for patient #8, age 6, revealed no documentation the guardian or family participated. The record lacked documentation reflecting the opportunity to participate was provided.

11. Review of the 3/29/10 MTP for patient #9, age 6, revealed no documentation the family participated. The record lacked documentation reflecting the opportunity to participate was provided.

12. Review of the 3/7/10 MTP for patient #10, age 13, revealed no documentation the mother participated. The record lacked documentation reflecting the opportunity to participate was provided.

Based on document review and staff interview, it was determined the hospital failed to analyze all adverse patient advents, specifically incidence reports. This has the potential to negatively affect patient care throughout the hospital.

Findings include:

1. Review of the hospital's "Incident Report Policy" (reviewed 7/3/09) revealed (in part) the following: "3. The incident reports are sent to the Department Head for review, referral or further action as necessary. The Department Head will do any additional collection and investigation of facts and record the findings on the Outcome section or Report Follow-up Form or as additions thereto."

2. The hospital's incidence reports from January 2010 through April 2010 were reviewed. Approximately twenty (20) of one hundred fifty (150) incident reports reviewed lacked adequate followup.

3. The Quality Management Director was interviewed on 5/5/10 in the afternoon. She agreed these twenty (20) incident reports lacked adequate followup and indicated the incident reporting needed to be "tweaked.".

Based on medical record review, review of medical staff rules and regulations and staff interview it was determined the hospital medical staff failed to enforce the requirement for the physician to participate in the development of the master treatment plan and/or the Treatment Plan Review for seven (7) of ten (10) patients reviewed (patients #1, 2, 4, 5, 6, 7 and 8). This failure creates the potential for the quality of care for all patients to be adversely affected.

Findings include:

1. Review of the Medical Staff Rules and Regulations, last revised 10/09, revealed the following under "Multidisciplinary Master Treatment Plan: All physicians with active medical staff membership and privileges to admit and treat patients shall participate in the development of the master treatment plan."

2. Review of the 3/21/10 Master Treatment Plan (MTP) for patient #1 revealed the plan was not signed by the psychiatrist. Review of the 3/28/10 Treatment Plan Review revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

Interview was conducted with the Attending Psychiatrist for patient #1 during the morning of 5/4/10. During this interview, the unsigned MTP and Treatment Plan Review for patient #1 were discussed. He indicated he may not always be able to attend due to difficulty with scheduling.

3. Review of the 3/7/10 MTP for patient #2 revealed the plan was not signed by the psychiatrist. Review of the 3/14, 3/21 and 3/28/10 Treatment Plan Review revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

4. Review of the 4/12/10 MTP for patient #4 revealed the plan was not signed by the psychiatrist. Review of the 4/20, 4/27 and 5/3/10 Treatment Plan Reviews revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

5. Review of the 4/26/10 MTP for patient #5 revealed the plan was not signed by the psychiatrist. Review of the 5/3/10 Treatment Plan Review revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

6. Review of the 4/19/10 MTP for patient #6 revealed the plan was not signed by the psychiatrist. Review of the 4/26 and 5/3/10 Treatment Plan Review revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

7. Review of the 4/30/10 MTP for patient #7 revealed the plan was not signed by the psychiatrist.

8. Review of the 4/25/10 MTP for patient #8 revealed the plan was not signed by the psychiatrist. Review of the 4/26 and 5/3/10 Treatment Plan Review revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

Based on medical record review and staff interview it was determined the hospital failed to ensure the registered nurse assessed the condition of a patient with a fever. This failure impacted one (1) of one (1) patients reviewed with fever (patient #1) and has the potential to adversely impact the care and condition of all patients who experience a change of condition.

Findings include:

1. Review of the Graphic Chart for patient #1 revealed the patient's temperature was checked daily. The record reflected the patient was afebrile throughout her hospitalization. On 3/30/10 at 1845 the Licensed Practical Nurse (LPN) documented the patient's temperature was 101.1 and Tylenol was administered. At 1945 the LPN noted the temperature as 99.8. The record lacked a nursing assessment of the patient's condition and symptoms related to the fever. The patient was discharged home at 2125.

2. During the afternoon of 5/5/10 this record was reviewed and discussed with the LPN. She acknowleged the record lacked an assessment of the patient related to elevated temperature.

Based on medical record review, review of medical staff rules and regulations and staff interview it was determined the hospital medical staff failed to follow the current parameters for History & Physical (H & P) Examination for patients who are readmitted within thirty (30) days in two (2) of three (3) records reviewed for readmission H & P Examination (patients #6 and 8). This failure has the potential to negatively impact the quality of medical care provided to all patients who are readmitted.

Findings include:

1. The Medical Staff Rules and Regulations, last revised 10/09, were provided for review. The History and Physical Examination section states: "A complete medical history and physical exam shall be completed by a physician, nurse practitioner or physician assistant privileged to do the procedure within 24 hours of each patient's admission to the hospital. For patients being readmitted within 30 days, the attending physician must write a note specifying if a new history and physical examination is required and, if not, the note must state that nothing has changed since last examination."

2. Review of the current medical record for patient #6 revealed he was readmitted 4/16/10. Review of a unit tracking record revealed the date of the previous H & P exam was 3/19/10. Review of the medical record revealed no record of a History and Physical Examination. Additionally, the record lacked a note specifying if a new history and physical examination was required and, if not, a note stating that nothing had changed since the last examination.

3. Review of the medical record for patient #8 revealed he readmitted 4/22/10. Review of a unit tracking record revealed the date of the previous H & P exam was 3/27/10. Review of the medical record revealed no record of a History and Physical Examination. Additionally, the record lacked a note specifying if a new history and physical examination was required and, if not, a note stating that nothing had changed since the last examination.

4. These findings were discussed and confirmed with the RN on the Children's Unit in the afternoon of 5/5/10.

Based on medical record review and staff interview it was determined the hospital failed to ensure the medical record included documentation of discussion of the discharge plan with the family/guardians of two (2) of five (5) patients reviewed who were under the care of physician #1 (patients #1 and 5). This failure has the potential to adversely affect the post hospital care/arrangements for all patients.

Findings include:

1. Review of the medical record for patient #1, under the care of physician #1, revealed a 3/26/10 note documented by the Registered Nurse which reflected the guardian visited. The nurse documented the guardian wanted to know "how much longer the patient would be staying and wanted to have a general idea." The RN documented the guardian requested "RN to put it in the note if someone would let her know due to her not having the gas money to come and see pt and can't stay at the Ronald McDonald House."

During interview with the Director of Social Services conducted in the early afternoon of 5/5/10, this record was reviewed and discussed. He acknowleged the record lacked any documentation the guardian was contacted related to the discharge plans prior to the patient's discharge on 3/30/10.

During the course of the survey, confidential interviews were conducted with multiple staff members. All staff interviewed acknowleged chronic problems with the avoidance of family contacts by physician #1. All stated notes are routinely left on the front of the chart requesting the physician contact the family regarding questions. All staff stated the physician rarely responds to the messages or contacts the families. Two (2) staff members remembered leaving messages for the physician to contact the guardian of patient #1. Both indicated they were not aware of the contact occurring.

2. A 5/5/10 review of the open medical record for patient #5 revealed a note for physician #1 was taped on the front of the chart. This note was written by the Social Worker (SW) at 1530 on 5/3/10. The note asked the physician a question about the patient's discharge plan.

Review of the progress note documented by the SW at 1402 on 5/3/10 revealed she noted a phone message was left for the mother regarding attempts to make discharge arrangements. On 5/3/10 at 1623 the SW noted the mother returned the call to discuss problems related to arranging post discharge outpatient treatment.

Review of an undated physician progress note (apparently written on 5/3/10) revealed physician #1 documented in part: "Looking at discharge tomorrow."

Review of the note by the Licensed Practical Nurse (LPN) at 1253 on 5/4/10 revealed the nurse documented in part: "Pt (patient) hoping for discharge."

Review of the 5/4/10 physician progress note revealed the physician documented in part: "Pt is hoping to go home."

At approximately 1500 on 5/5/10, the Registered Nurse (RN) on the Children's Unit was observed to receive a phone call from the mother of patient #5. Following the phone call, the RN stated the mother called to ask if the staff had heard of discharge plans for the patient. The mother stated the patient had told her he was to be discharged.

The record for patient #5 was reviewed and discussed with both the RN and LPN in the afternoon of 5/5/10. After review of the record, both stated neither was aware of the discharge plan for patient #5.

The Social Worker, who left the note for the physician, was not available for interview.