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.
| SANDHILLS REGIONAL MEDICAL CENTER | 1000 WEST HAMLET AVENUE HAMLET, NC 28345 | April 10, 2014 |
| VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS | Tag No: A0810 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, closed medical record reviews, and staff interviews, the facility failed to complete assessments per policy in 3 of 8 (Patient#7, #8, and #9) behavioral health patients reviewed. Review of hospital policy, "Care Management, DEPARTMENT: Behavioral Health Institute" reviewed 1/12 revealed, "Once a Care Manager/Social Worker or QMHP (Qualified Mental Health Practitioner) or Nurse have been assigned a patient, they begin a routine process of attending to and tracking tasks required to manage the case...Care management activities must include at least the following: Psychosocial Assessment is completed within 72 hours of admission..." 1.) Closed medical record review of patient #7 revealed a [AGE] year old male IVC (involuntary committed) to the hospital on [DATE] at 2239 for Schizophrenia. Record review revealed documentation of a referral to case management/social services on 03/21/2014 at 2135. Record review of the "Psychosocial Assessment" revealed documentation it was completed "March 25, 2014" (4 days after the patient was admitted ). Interview with Administrative Staff #1 on 04/10/2014 at 1236 revealed the psychosocial assessments were not completed within 72 hours. 2.) Closed medical record review of Patient # 8 revealed a [AGE] year old male IVC (involuntary committed) to the hospital on [DATE] at 1614 for schizophrenia. Record review revealed documentation of a referral to case management/social services on 03/21/2014 at 1950. Record review of the "Psychosocial Assessment" revealed documentation it was completed "March 25, 2014" (4 days after the patient was admitted ). Interview with Administrative Staff #1 on 04/10/2014 at 1236 revealed the psychosocial assessments were not completed within 72 hours. 3.) Closed medical record review of Patient #9 revealed a [AGE] year old male IVC (involuntary committed) to the hospital on [DATE] at 1626 for schizophrenia. Record review revealed documentation of a referral to social services on 03/21/2014 at 2140. Record review of the "Psychosocial Assessment" revealed documentation it was completed "March 25, 2014" (4 days after the patient was admitted ). Interview with Administrative Staff #1 on 04/10/2014 at 1236 revealed the psychosocial assessments were not completed within 72 hours. |
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| VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT | Tag No: A0806 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, closed medical record review, and staff interviews, the facility failed to evaluate the patient's home environment prior to discharge in 1 of 11 patients (Patient #8) discharged from the facility. Review of hospital policy, "POLICY FOR DISCHARGE PLANNING AND REFERRAL OF PATIENTS TO POST-ACUTE ANCILLARY SERVICE PROVIDERS" revised Sepember 2013 revealed, "(2) Discharge planning evaluation ...A written copy of the Evaluation must include...the possibility of the patient being cared for in the environment from which he or she entered the hospital..." Closed medical record review of Patient # 8 revealed a [AGE] year old male involuntarily committed (IVC) to the hospital on [DATE] for schizophrenia. Record review of documentation written on 03/21/2014 revealed, "D/C pt (patient) to previous living arrangements..." Record review of documentation on 03/25/2014 at 0800 revealed, "Pt (patient) seen - low functioning with possible psychotic disorder...self care poor...pt has guardian - coordinate care with her." Record review of documentation at 1105 on 03/25/2014 revealed, "Pt (patient) stated that he lives with his grandmother." Further record review revealed, "this therapist contacted pts mother (legal guardian), who stated that pt lives with his father...The grandmother...stated she wishes she could keep pt (patient), but is [AGE] years old and cannot keep up with pt. The father, stated that he would like for his son to remain hospitalized or admitted into a group home..." Record review revealed documentation on 03/26/2014, "Determine who he is going to live with." Record review of documentation on 03/27/2014 at 1315 revealed Patient #8 was transported via Sheriff to his mother's address. Record review revealed no documentation of additional discussions with the legal guardian or father about patients living arrangements. Interview with Behavioral Health Staff #1 on 04/10/2014 at 1027 revealed staff attempted to call father but did not get an answer. Interview revealed the psychiatrist was notified of patient being "between" homes. Futher interview revealed, "the psychiatrist felt the patient was stable and the hospital had no grounds to keep him." Interview revealed the patient was discharged to the address on file (the legal guardian/mother). Interview with Administrative Staff on 04/08/2014 at 1210 revealed patient and family involment is to be documented in the medical record. Interview revealed no documentation of additional discussions with the legal guardian or father about the patient's living arrangements. |
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| VIOLATION: DOCUMENTATION OF EVALUATIONS | Tag No: A0811 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, closed medical record review, and staff interviews, the facility failed to discuss the patients treatment plan with the legal guardian in 3 of 8 (Patient #7, #8 and #9) behavioral health records reviewed. Review of hospital policy, "POLICY FOR DISCHARGE PLANNING AND REFERRAL OF PATIENTS TO POST-ACUTE ANCILLARY SERVICE PROVIDERS" revised Sepember 2013 revealed, "(3) Inclusion of the Evaluation in the patient's medical record ...The results of the Evaluation must also be discussed with the patient or with an individual acting on behalf of the patient..." 1.) Closed medical record review of Patient #7 revealed a [AGE] year old male involuntary committted (IVC) to the hospital on [DATE] at 2239 for Schizophrenia. Medical record review revealed documentation of guardianship papers effective 10/10/2006. Record review of treatment plan dated 3/21/2014 revealed, "PATIENT/FAMILY INVOLVEMENT: I have had an oportunity to meet with staff prior to treatment team meeting and to participate in the preparation of my treatment and discharge plan." Further review revealed evidence the legal guardian was involved. Interview with Behavioral health staff #1 on 04/10/2014 at 1027 revealed the guardian lives "far away". Interview revealed, "I discuss plans over the phone." Interview revealed there was no evidence of the patient's legal guardian was notified about the discharge plan. Interview with Administrative staff #1 on 04/10/2014 at 1019 revealed,"we discuss all care with the individual listed as guardian. This should be clearly documented in the record (medical)." Interview revealed there was no evidence of the patient's legal guardian was notified about the discharge plan. 2.) Closed medical record review of Patient # 8 revealed a [AGE] year old male IVC to the hospital on [DATE] at 1614 for schizophrenia. Record review of physician documentation on 03/25/2014 at 0800 revealed, "Pt. has guardian - coordinate care with her." Record review of treatment plan dated 3/21/2014 revealed, "PATIENT/FAMILY INVOLVEMENT: I have had an oportunity to meet with staff prior to treatment team meeting and to participate in the preparation of my treatment and discharge plan." Further review revealed no evidence the guardian was notified about the discharge plan. Interview with Behavioral Health Staff #1 on 04/10/2014 at 1027 revealed staff attempted to call father but did not get an answer. Interview revealed there was no evidence of the patient's legal guardian notified about the discharge plan. Interview with Administrative staff #1 on 04/10/2014 at 1019 revealed,"we discuss all care with the individual listed as guardian. This should be clearly documented in the record (medical)." Interview revealed there was no evidence of the patient's legal guardian notified about the discharge plan. 3.) Closed medical record review of Patient #9 revealed a [AGE] year old male IVC to the hospital on [DATE] at 1626 for schizophrenia. Record review of treatment plan dated 3/21/2014 revealed, "PATIENT/FAMILY INVOLVEMENT: I have had an opportunity to meet with staff prior to treatment team meeting and to participate in the preparation of my treatment and discharge plan." Further review revealed no evidence the patient's legal guardian was notified about the discharge plan. Interview with Behavioral health staff #1 on 04/10/2014 at 1027 revealed the staff assigned to complete the discharge plans. Interview revealed there was no evidence the patient was informed about the discharge plan. |
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| VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN | Tag No: A0820 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, closed medical record review and staff interviews, the facility failed to counsel family members to prepare for a patient's post hospital care in 1 of 11 (Patient #8) medical records reviewed. Review of hospital policy, "POLICY FOR DISCHARGE PLANNING AND REFERRAL OF PATIENTS TO POST-ACUTE ANCILLARY SERVICE PROVIDERS" revised Sepember 2013 revealed, "(3) Inclusion of the Evaluation in the patient's medical record ...The results of the Evaluation must also be discussed with the patient or with an individual action on behalf of the patient...(4) Hospital responsibility for initial implementation ...This includes arranging for necessary post-hospital services and care, and education patients/family/caregivers/community providers about post-hospital care plans...(6) Counseling for post-hospital care The patient and family members or interested persons must be counseled by the hospital to prepare them for post-hospital care..." Closed medical record review of Patient # 8 revealed a [AGE] year old male involuntarily committed (IVC) to the hospital on [DATE] for schizophrenia. Record review of documentation on 03/25/2014 at 0800 revealed, "Pt (patient) seen - low functioning with possible psychotic disorder...self care poor...pt has guardian - coordinate care with her." Record review of documentation at 1105 on 03/25/2014 revealed, "Pt (patient) stated that he lives with his grandmother." Further review revealed, "this therapist contacted pts mother (legal guardian), who stated that pt lives with his father...The grandmother...stated she wishes she could keep pt, but is [AGE] years old and cannot keep up with pt. The father, stated that he would like for his son to remain hospitalized or admitted into a group home..." Record review revealed documentation on 03/26/2014, "Determine who he is going to live with." Record review of documentation on 03/27/2014 at 1315 revealed Patient #8 was transported via Sheriff to his mother's address. Record review revealed no evidence that the mother, father, or grandmother was notified of the patient's discharge. Interview with Behavioral Health Staff #1 on 04/10/2014 at 1027 revealed staff attempted to call father but did not get an answer. Interview revealed no evidence of additional conversations with the father, mother, or grandmother prior to the patient being discharged . Interview revealed the patient was discharged [DATE] to the address on file (the mother's address). Interview with Administrative staff #1 on 04/10/2014 at 1019 revealed,"we discuss all care with the individual listed as legal guardian. This should be clearly documented in the record (medical)." Interview revealed there was no evidence the patient's legal guardian was notified of the discharge plan. |
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| VIOLATION: REASSESSMENT OF A DISCHARGE PLAN | Tag No: A0821 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, closed medical record review, and staff interviews the facility failed to reassess a patients discharge needs after the family requested additional assistance in 1 of 11 (Patient #8) medical records reviewed. Review of hospital policy, "POLICY FOR DISCHARGE PLANNING AND REFERRAL OF PATIENTS TO POST-ACUTE ANCILLARY SERVICE PROVIDERS" revised Sepember 2013 revealed, "(5) Reassessment of discharge plan as necessary. The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan for a patient..." Closed medical record review of Patient # 8 revealed a [AGE] year old male involuntarily committed (IVC) to the hospital on [DATE] for schizophrenia. Record review of documentation on 03/25/2014 at 0800 revealed, "Pt (patient) seen - low functioning with possible psychotic disorder...self care poor...pt has guardian - coordinate care with her." Record review of documentation at 1105 on 03/25/2014 revealed, "Pt (patient) stated that he lives with his grandmother." Further review revealed, "this therapist contacted pts mother (legal guardian), who stated that pt lives with his father...The grandmother...stated she wishes she could keep pt, but is [AGE] years old and cannot keep up with pt. The father, stated that he would like for his son to remain hospitalized or admitted into a group home..." Record review revealed documentation on 03/26/2014, "Determine who he is going to live with." Record review of documentation on 03/27/2014 at 1315 revealed Patient #8 was discharged and transported via Sheriff to his mother's address. Record review revealed no documentation regarding father's request for patient to be placed in a group home. Further record review revealed no evidence that the mother, father, or grandmother was notified of the patient's discharge. Interview with Behavioral Health Staff #1 on 04/10/2014 at 1027 revealed staff attempted to call father but did not get an answer. Interview revealed no evidence of additional conversations with the father, mother, or grandmother prior to the patient being discharged . Interview revealed the patient was discharged [DATE] to the address on file (the mother's address). Interview with Administrative staff #1 on 04/10/2014 at 1019 revealed, "we discuss all care with the individual listed as guardian. This should be clearly documented in the record (medical)." Interview revealed there was no evidence the patient's legal guardian was notified of the discharge plan. NC 326 NC 235 |
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