HospitalInspections.org

Based on random review of patient charts from September 2023 to December 2023 and confirmed in interview, the facility failed to accurately complete, date, and time the physician inpatient progress notes for one of five patient charts reviewed (Patient #D).

Findings included:

In review of Patient #D chart, the inpatient progress note for 10/31/2023 were dictated and transcribed by Staff #20 on 11/01/2023 at 15:56 hours and electronically signed by the same Staff #20 on 11/01/2023 at 16:11 hours.

In review of Patient #D chart, the inpatient progress note for 11/01/2023 were dictated and transcribed by Staff #21 on 12/08/2023 at 12:02 hours and electronically signed by the same Staff #21 on 12/08/2023 at 12:02 hours.

The time and date of each entry (orders, reports, notes, etc.) must be accurately documented. Timing establishes when an order was given, when an activity happened or when an activity is to take place. Timing and dating entries is necessary for patient safety and quality of care.

In an interview with Staff #19 on 12/08/2023 at 1:05 PM in the conference room she could not explain the discrepancies in the date and time. She stated that the providers dictate in real time when they perform their assessments. She stated that maybe they document their assessments and dictate at another time, but she was unaware if those notes are kept.

Based on review of the facility policy, random review of patient records from September to December 2023, and confirmed in interview, the facility failed to document the progress note to decrease or discontinue the level of observation for two of five patients (Patient #D, #E) reviewed and failed to reassess the need for increased level of observation for one of five patients (Patient #E) reviewed. The hospital failed to document the necessary information needed to monitor the patient's condition.

Findings included:

In review of the facility policy Levels of Observation and Precautions (PolicyStat ID 13048351, effective 02/2023), it stated:

"Purpose
To ensure there is clear differentiation between patients' needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior...

The nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendation based on the risk level assessment findings and patient behavior. It is critical that patient observation level and precautions are documented on the Close Observation sheet and communicated to team members. During the course of treatment, any clinical professional may determine an increase in observation and/or the additions of a precaution is warranted and clinically necessary. The charge nurse and the provider are notified when an increase in level of observations and/or precaution is indicated. Orders should be obtained for increased observation and/or precautions as noted above. A provider's order is required to decrease or discontinue a level of observation or precaution. A progress note by the provider accompanies the order with the rationale for decreasing or discontinuing the level observation or precaution."

Patient #D
In review of the Patient #D chart, the inpatient progress notes for 10/31/2023, Staff #20 documented "patient attempted to elope from the hospital last night and transferred to higher acuity unit...remains a danger to himself and others due to his psychotic symptoms behavior and paranoia. Lacks insight and judgment. Inability to contract for safety. Continue 1:1 supervision for safety."

Review of patient orders on 10/31/2023 revealed a decrease in observation to Q15 ordered. No documentation was provided for the rationale for decreasing the level of observation.

In review of the inpatient progress note for 11/01/2023, Staff #21 documented "limited response and remains at high risk still very high elopement risk still at risk to intrusive only act upon others."

In review of the inpatient progress note for 11/02/2023, Staff #22 documented "it was reported that patient was packing up all his belongings saying that he has been trapped, will be gone for a long time, and will finally be free. Patient was transferred from Willows after attempting to elope. He still has no insight and poor judgment ... Limited response and remains at risk."

In review of the inpatient progress note for 11/03/2023, Staff #22 documented "patient has become rather irritated and vocalizing more agitation. Has become threatening and posturing towards staff. Has absolutely no insight into his symptoms and need for hospitalization. Due to his aggression and verbalizing desire to elope he has received order for no visitation for 24 hours. Needs frequent redirection."

In review of the inpatient progress note for 11/04/2023, Staff #21 documented "the patient after our visit attempted to elope by breaking out the window in the break room. He indicated that he had not been taking his medicines that he had been cheeking most of them as he feels he does not treatment nor does he need medication."

Review of the patient orders on 11/4/2023 revealed an order for an increase in observation to 1:1 soon after his elopement.

An interview with Staff #2 on 12/08/2023 at 1:15 PM in the conference room confirmed the above findings. She presumed the reason Patient #D had a downgrade in observation level was because of his transfer to the higher acuity unit, but she was unable to provide documentation.

Patient #E
In review of the inpatient progress notes on 12/01/2023, Staff # 23 documented "patient is alert and oriented x4, mood good, affect engaging, eye contact good, speech rate volume tone prosody within normal limits, thought process logical and goal directed, thought content no suicidal ideation, no homicidal ideation, no auditory hallucination, no visual hallucination, fair judgment and developing insight ...
Continue precautions and observations."

In review of the inpatient progress notes on 12/02/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact good, speech rate volume tone prosody within normal limits, thought process logical and goal directed, thought content no suicidal ideation, no homicidal ideation, no auditory hallucination, no visual hallucination, poor judgment and poor insight...
Continue precautions and observations."

Review of the provider orders on 12/02/2023 revealed an increase of observation for a 1:1 level of observation ordered by Staff #23.
No documentation was available for review for the need for the increased level of observation.

In review of the inpatient progress notes on 12/03/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody low and slow, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ...
Continue precautions and observations."

Review of the provider orders on 12/03/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation.

In review of the inpatient progress notes on 12/04/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody low and slow, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ...
Continue precautions and observations."

Review of the provider orders on 12/04/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation.
In review of the inpatient progress notes on 12/05/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment, and poor insight ...
Continue precautions and observations."

Review of the provider orders on 12/05/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation.

In review of the inpatient progress notes on 12/06/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ...
Continue precautions and observations."

Review of the provider orders on 12/06/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation.

In review of the inpatient progress notes on 12/07/2023, Staff #23 documented "patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ...
Continue precautions and observations."

Review of the provider's orders for 12/08/2023 revealed a decrease in level of observation to a line of sight ordered by Staff #23 with no documentation as to the rationale.

An interview with Staff #2 on 12/08/2023 at 1:15 PM in the conference room confirmed the above findings. She stated that she discussed with Staff #23 regarding Patient #E and the reason for her increased precautions. She acknowledged that it would be 'best' if the providers documented the rationale for the change in observation levels, but it is not currently monitored.