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.


Based on review of hospital policies, grievance file reviews and staff interviews, the hospital staff failed to provide a written letter of resolution for 1 of 7 grievances reviewed (Patient #11).

The findings include:

Review of the hospital's current policy and procedure "Patient & Family Grievances/The Role of the Patient Advocate" last review date 08/2010 revealed "for the purpose of this policy a 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care ...5. The staff person (Program Director, Designee or Patient Advocate) responding to the grievance should inform the patient of the timeframe for follow up. This time frame should not exceed 72 hours unless there are extenuating circumstances. The patient should be notified of the need for an extended timeframe and an agreement made as to when follow up will occur. 6. Once the issue has been resolved, the Patient Advocate will provide a written response to the patient and/or family member. The response includes: A. The name of the contact person; B. The steps taken to investigate the grievance; C. The results of the grievance process (i.e., how the grievance was resolved); D. Date of Completion ...10. Any grievance received after the patient is no longer at (Named Facility) is documented by the staff member receiving the complaint and forwarded to the Patient Advocate. The Patient Advocate follows up on the grievance consistent with the procedures above ..."

Closed medical record review on 09/10/2013 for Patient #11 revealed a [AGE] year old male admitted on [DATE] with diagnosis of Attention Deficit Hyperactive Disorder and Oppositional Defiant Disorder. Continued review of the medical record revealed Patient #11 was discharged to home with his parents on 04/05/2013.

Review on 09/10/2013 of facility incident and grievance reports provided by administrative managment staff for the sampled medical records list revealed no available documented evidence of a grievance filed on behalf of Patient #11 by his mother.

Interview on 09/10/2013 at 1552 with Administrative Staff revealed "On 08/12/2013 this patient's (#11) mother showed up at the facility along with the patient (#11) to speak with me. She said they had just come from the patient's outpatient therapy session where (name of Patient #11) revealed while a patient here at this facility in March 2013 ...around 0600 one morning while he was bent over brushing his teeth 'some kid' came into his room pulled down his (Patient #11's) pants and put his penis in his (Patient #11's) crack and told him not to tell anyone. The patient could not give me a name of 'the boy' that was accused of the assault and he could not give me a specific date. He could not or would not provide a description....he said the 'boy' was discharged the next day ...I did complete an investigation but I did not follow up with the patient's mother ...I should have filed a formal grievance and followed our process but I did not do this ...I did not send the patient nor his mother a letter of resolution..." Interview confirmed the hospital staff failed to provide the patient's mother with a written letter of resolution for a grievance related to an allegation of sexual misconduct.

Based on hospital policy reviews, medical record reviews and staff interviews, the nursing staff failed to ensure a nutritional consult was ordered for 1 of 6 patients who were minors (#6).

The findings include:

Review of hospital policy, "Nutritional and Dietary Needs" approval date of "11/10" revealed, "POLICY STATEMENT: To provide an accurate and consistent means to meet the special dietary needs and nutritional requirements of each patient served by the programs of (Hospital Name) DEFINITIONS: Policy: ...Nursing Staff collaborates with the MD (Medical Doctor) staff, the Registered Dietician and the dietary staff as indicated to provide for the patient's dietary needs. Procedure: A. ...B. Diet Orders ...2. When assessing the nutritional status at the time of admission, if the patient scores 15 points or higher or is found to have signs/symptoms of dehydration the nurse will consult with the physician regarding the need for a nutritional consult."

Closed record review on September 10, 2013 revealed Patient #6, a [AGE]-year-old female was IVC (involuntary committed) to the hospital on July 9, 2013. Review revealed the patient had a medical diagnosis of diabetes.

Review of the nutritional screen assessment performed on July 9, 2013 at 2059 by the admitting nurse revealed the patient's nutritional screen score was assessed as a "15." Review revealed a nutritional score greater than or equal to 15 required a consult. Further record review failed to reveal any available documentation of a nutritional consult being performed on Patient #6 during her hospitalization .

Interview with the unit manager on September 12, 2013 at 1005 revealed the nutritional assessment is part of the nursing admission assessment. Interview revealed nutritional consult is required for nutrition score of 15. Interview revealed "the admission nurse would be required and expected to consult dietician." Interview revealed the dietician consult form was located at the nursing station. Interview confirmed no available documentation of a nutritional consult for Patient #6.

Based on hospital policy reviews, medical record reviews, and staff interviews, the hospital staff failed to reassess a patient's discharge plan for continuing care medication needs for 1 of 6 minor patients (#6).

The findings include:

Review of the hospital policy, "Discharge Planning/Discharge Process", approval date "11/10" revealed, "PURPOSE: To assure each patient being discharged from (Hospital Name) has a documented aftercare plan to assist in a successful transition back into their community. DEFINITIONS: Policy: ...Upon discharge a RN (Registered Nurse) will ensure that each patient has a discharge summary which will outline aftercare plans and instructions...Procedure: ...E. Written instructions (Discharge/Aftercare Plan) will be given to the patient at the time of discharge including, but not limited to the following: 1. Medications - the patient will be asked to state the name of the medication, the reason for use, the dosage and the times to be taken..."

Closed record review conducted September 10, 2013 revealed Patient #6, a [AGE]-year-old female was IVC (involuntary committed) to the hospital on July 9, 2013.

Review revealed the patient had a medical diagnosis of diabetes. Review revealed the patient was taking Metformin (diabetes medication) prior to hospital admission. Review revealed the physician assistant ordered Metformin during hospitalization . Review revealed the patient received Metformin on July 10, 2013 through July 19, 2013. Review of the discharge medications document revealed no documentation of diabetes medications. Review of the discharge prescription revealed no documentation of a diabetes medication being prescribed for the patient until follow-up with a primary doctor post discharge.

Interview with the discharge nurse on September 11, 2013 confirmed no discharge documentation of diabetes medication reminders nor prescription.

Interview on September 10, 2013 at 1540 with the Psychiatrist revealed, "I routinely do not prescribe medical prescriptions at discharge because of the legal liability. I was not asked or told the patient needed diabetes medication at discharge. If I would have been told the patient needed diabetes medication, then I would have prescribe them. The Nurse Practitioner usually see patients for medical condition."

Interview on September 11, 2013 at 1011 with the PA (Physician Assistant) revealed, "I performed the patient's admission history and physical on July 9, 2013. Interview revealed the discharge summary had no documentation of diabetes medication. Interview revealed the patient did not receive a diabetes medication prescription. Interview revealed the attending (Psychiatrist) is responsible to write for discharge prescriptions and supplies.

Interview on September 11, 2013 at 1340 with the discharge nurse revealed,"the (Psychiatrist) normally does not deal with the medical. Normally the PA. If the patient has something medical going on, I would call the (Psychiatrist) and the PA."

NC 054
NC 732