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.
|LOGAN REGIONAL MEDICAL CENTER||20 HOSPITAL DRIVE LOGAN, WV 25601||June 8, 2016|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on review of documents and interview of staff, it was determined the facility failed to follow it's policy for entering a list of home medications into the medical record for one (1) of ten (10) medical records reviewed (Patient #1). This has the potential to cause medication errors and/or errors in treatment with possible negative outcomes.
1. Facility policy entitled "Medication Reconciliation", last revised 3/2015, states: "Upon admission to the Emergency Department (ED) a Logan Regional Medical Center staff member will record a medication history in the hospital information system".
2. Patient #1's medical record was reviewed on 6/6/16 and revealed an ED visit on 5/1/16. A handwritten list of the patient's medications, dated 5/1/16, was found in the scanned documents portion of the record. Review of the Nurse's Notes and Physician's Notes of this visit revealed no reference to home medications. Review of the document entitled "Discharge Medication Reconciliation Order" for this date revealed the entry "No Home Medications Documented". Review of the document entitled "Discharge Information: Home Medication Form" under the heading "Home medications you should continue to take" revealed no documentation.
3. An interview of Physician's Assistant #1 was conducted on 6/2/16 at 1:50 p.m. She stated she attended Patient #1 on 5/1/16 in the ED and received a handwritten list of the patient's medications from the patient's caregiver. She stated she reviewed and copied the list and left it "in the slot" for scanning into the medical record. She stated a staff member present from 11:00 a.m. until 11:00 p.m. is responsible for entering medications into the electronic record, but because this patient had come to the ED at night they "got missed" and were never entered.
4. A brief interview was conducted with the ED Nurse Manager on 6/2/16 at 9:30 a.m. at which time she agreed with the above findings.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of documents and interview of staff, it was determined the facility failed to ensure a complete suicide risk assessment was conducted, per policy, for three (3) of six (6) patients presenting to the Emergency Department (ED) with complaints of suicidal thoughts. Failure to identify risk factors and initiate an appropriate plan of care places all such patients at risk of harm.
1. Facility policy entitled "Suicide Prevention", last revised 3/2015, was reviewed on 6/6/16. It states: "All patients presenting to (the facility) will be screened for suicide risk. If at any time within the ED...a patient exhibits behavior or emotions that are believed to be self-injurious...they will have a SAD PERSON screening tool completed by the nursing staff and reported to the physician...Patients will receive a second screening...at discharge". Further review of the policy revealed the SAD PERSON assessment to be a separate and more extended assessment than the initial Suicide Screening.
2. Patient #1's medical record was reviewed on 6/6/16. It revealed she (MDS) dated [DATE] with a presenting complaint of "...she was ready to commit suicide". Review of the Nurse's note timed 22:40 revealed the entry "Suicide Screening: Have you recently had thoughts about hurting yourself or others? Yes". No documentation of a SAD Person's Suicide Risk was found for this time or for the time of discharge.
3. Patient #2's medical record was reviewed on 6/7/16. It revealed the patient (MDS) dated [DATE] with a complaint of suicidal ideations. Review of Nurse's Notes for the visit revealed a suicide screening assessment was conducted to which the patient responded "Yes" to thoughts of self-harm. No documentation was found of a SAD Person's assessment.
4. Patient #8's medical record was reviewed on 6/8/16. It revealed the patient (MDS) dated [DATE] with a complaint of "I want to kill myself". Review of Nurse's Notes revealed the patient received an initial suicide screening, but no documentation was found of a SAD Person's assessment.
5. The records above were reviewed with the ED Nurse Manager on 6/8/16 at 11:30 a.m. at which time she agreed with these findings.