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.

HOLLY HILL MENTAL HEALTH SERVICES 3019 FALSTAFF RD RALEIGH, NC 27610 June 18, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and medical record reviews, the hospital staff failed to provide patients the second notification of the right to appeal their discharge as per the IM (Important Message From Medicare) for 3 of 3 patients.(#3, #9, and #10)

Findings include:

Interview with AS #1 on 06/17/2015 at 1500 revealed the facility has no IM policy and procedure that speaks to who is responsible for providing patients the IM notification prior to discharge.

1. Closed medical record review on 06/17/2015 of patient #3's PATIENT DEMOGRAPHIC PROFILE, dated 05/02/2015, revealed a [AGE] year old male with "MEDICARE INPATIENT" listed in the Insurance Carrier Information section. Patient #3 was admitted on [DATE] with a diagnosis of Bipolar Disorder (a serious medical illness that causes shifts in mood, energy, and the ability to function) and Suicidal Ideation (thoughts about killing oneself). Record review revealed the patient was discharged on [DATE]. Further review of the medical record revealed the IM letter signed and dated by the patient upon admission on 05/02/2015 at 1350. Patient #3's signature is not present on the signature line for the "Second Notification" of the IM.

Interview with AS #1 on 06/17/2015 at 1500 revealed the hospital staff failed to provide patients #3, #9, and #10 with the second IM notification.

2. Closed medical record review on 06/17/2015 of patient #9's PATIENT DEMOGRAPHIC PROFILE dated 05/18/2015, listed "MEDICARE INPATIENT" as the [AGE] year old female patient's Insurance Carrier. Patient #9 was admitted on [DATE] with a diagnosis of Severe Major Depression and Suicidal Ideation. Record review revealed the IM letter signed and dated by patient #9 upon admission on 05/18/2015 at 1930. Further record review revealed the patient was discharged on [DATE]. Patient #9's signature is not present on the signature line for the "Second Notification" of the IM.

Interview with AS #1 on 06/17/2015 at 1500 revealed the hospital staff failed to provide patients #3, #9, and #10 with the second IM notification.

3. Closed medical record review on 06/17/2015 of patient #10's PATIENT DEMOGRAPHIC PROFILE, dated 05/02/2015, revealed a [AGE] year old male with "MEDICARE INPATIENT" listed as the patient's insurance carrier. The patient was admitted on [DATE] with a diagnosis of Schizophrenia (A serious disorder that affects how a person thinks, feels and acts. A person with schizophrenia may have difficulty determining the difference between what is real and what is imaginary). Per the medical record, the patient was discharged on [DATE]. Patient #10's IM was signed and dated upon admission on 05/02/2015 at 1700. Patient #10's signature is not present on the signature line as receiving the "Second Notification" of the IM.

Interview with AS #1 revealed the hospital staff failed to provide patients #3, #9, and #10 with the second IM notification.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of RULES AND REGULATIONS OF MEDICAL STAFF, medical record review, and staff interview, the medical staff failed to perform a complete physical examination for 1 of 11 patients. (#11)

Findings include:

Review of HOSPITAL RULES AND REGULATIONS OF MEDICAL STAFF for ADMISSION, dated March 2014, section 2.7 under the ADMISSION heading states, "Within 24 hours of admission, the complete physical examination shall be performed according to medical record guidelines ....either by a designated staff P.A. (physician assistant), nurse practitioner, internist, family physician, psychiatrist with clinical privilege, or by another physician only if that physician can assume continuous medical responsibility for the patient. " Section 2.7.1 states " The following should be included in the History and Physical ( " H&P " ): ....f. Review of systems ... "

1. Closed medical record review on 06/17/2015 of patient #11 revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Schizoaffective disorder (a condition where a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms - such as mania or depression). Rule out bipolar disorder, type I, mixed (a serious medical illness that causes shifts in mood, energy, and the ability to function), psychotic (severe mental disorder that cause abnormal thinking, perception and loss of touch with reality). Review of Hospital Psychiatric Evaluation History and Physical Exam Page 3 of 7 through Page 7 of 7 revealed PART 2 - REVIEW OF SYSTEMS, and PART 3 - PHYSICAL EXAM are incomplete. PSYCHIATRIC EVALUATION dated 05/20/2015 states, " PHYSICAL EXAMINATION ON ADMISSION: Could not be done as the patient was agitated and could not be approached. No gross abnormalities were noted. " Further review of the TREATMENT PLAN within the PSYCHIATRIC EVALUATION noted " 1. Medical ....The plan will consist of physical exam ... " . Continued review of the medical record did not reveal any notations of a physical examination performed prior to patient #11 ' s discharge on 05/27/2015.

Interview with AS #1 on 06/17/2015 at 1500 states patient #11 ' s chart did not have an admission H&P due to the patient ' s agitation at admission. AS #1 confirmed the medical record does not include an H&P and one should have been performed at the earliest possible time during the patient ' s admission.

NC 895