The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|NOVANT HEALTH ROWAN MEDICAL CENTER||612 MOCKSVILLE AVE SALISBURY, NC 28144||Sept. 23, 2015|
|VIOLATION: FORM AND RETENTION OF RECORDS||Tag No: A0438|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, review of medical records, and staff interviews, the facility failed to document group therapy sessions for 8 of 12 days, and treatment team meetings for 2 of 3 scheduled meetings for 1 of 3 patients (#9).
The findings include:
Closed medical record review of patient (patient #9) revealed a [AGE] year old female admitted on [DATE] to facility after presenting in ER (emergency room ) with complaints of "more depressed over the past few weeks." Past medical history revealed a major depressive disorder with multiple previous hospital admissions. Patient was discharged on [DATE] to home.
Review of individualized care plan of patient #9 revealed group therapy orders on 08/08/2015 at 0515 through 08/19/2015 at 1052.
Review of the schedule for the assigned floor for patient #9 revealed daily morning scheduled group therapy sessions.
Further review revealed documentation of attendance to group therapy meetings as follows: 08/08/2015: did not attend sleeping; 08/11/2015: attended; 08/12/2015: did not attend; and 08/18/2015: attended. (Documentation revealed only 4 days out of 12 days of hospital stay). Further review of treatment team notes revealed documentation on 08/11/2015, Tuesday at 1028 by therapy staff member. Further review revealed no other documentation of treatment team notes on other scheduled days: August 13, Thursday; or August 18, Tuesday.
An interview was conducted on 9/23/15 at 0900 with AS #5 (administrative staff) and AS #6 regarding group therapy and treatment team process and documentation. AS #5 stated "we do not have a group therapy policy, but we do have expectations and a schedule of group therapy meeting. Each patient is given a group therapy schedule on admission." AS #6 stated "our staff go around the unit before each group therapy meeting to remind all patients of the upcoming meeting and encourage them to attend. Patients can refuse to attend." AS #5 further stated that "staff are expected to document attendance and non-attendance (including reason) at all group meetings." Interview with AS #6 revealed treatment team meets twice weekly: Tuesdays and Thursdays. Further interview revealed "treatment team meeting members all have a laptop during the meeting, and should be documenting a note on each patient during each treatment team meeting."