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.
| STRATEGIC BEHAVORIAL CENTER-GARNER | 3200 WATERFIELD DRIVE GARNER, NC 27529 | Jan. 15, 2014 |
| VIOLATION: MEDICAL STAFF BYLAWS | Tag No: A0353 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Staff Rules and Regulations, medical record review and staff interviews, the hospital's medical staff failed to follow medical staff rules and regulations by failing to ensure all discharge summaries and medical records were completed within 30 days following the patient's discharge for 4 of 6 closed medical records reviewed (#1, #6, #3, and #5). The findings include: Review of the hospital's Medical Staff Rules and Regulations, effective July 2012, revealed, "...5.9. Completion of Medical Records 5.9.1. All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent. 5.9.2. The Facility CEO (Chief Executive Officer) in consultation with the Medical Director shall be authorized to temporarily suspend the admitting privileges of Members when: a. The Member does not complete medical records within the time frame prescribed by these Rules and Regulations. ...". 1. Closed record review on 01/14/2014 of Patient #1 revealed a [AGE] year-old male admitted on [DATE] with conduct disorder. Record review revealed Patient #1 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (76 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #1 (76 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 2. Closed record review on 01/14/2014 of Patient #6 revealed a [AGE] year-old male admitted on [DATE] with psychosis and self-injurious behavior. Record review revealed Patient 61 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (48 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #6 (48 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 3. Closed record review on 01/14/2014 of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with mood disorder and post-traumatic stress disorder. Record review revealed Patient #3 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (36 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #3 (36 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 4. Closed record review on 01/14/2014 of Patient #5 revealed a [AGE] year-old female admitted on [DATE] with oppositional defiant disorder. Record review revealed Patient #5 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (35 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #5 (35 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. |
||
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of hospital policies and procedures, nursing job description, medical record review and staff interviews, the nursing staff failed to ensure ongoing assessment of patients for 4 of 10 medical records reviewed (#6, #5, #4 and #2). The findings include: Review of the hospital's nursing policy, "Documentation", effective 07/02/2012, revealed, "Policy: Nursing documentation will facilitate the recording of accurate, timely data, which reflects the current status of the patient, the care provided, and the progress made by the patient. Procedure: ...3. The Nurse will document daily for the duration of treatment. In addition, incident charting will be completed. The daily nursing notes will include the individual response to meds, any side effects and relevant lab values. 4. Incident charting includes any circumstances involving the patient, which indicate an immediate or unexpected change of status. ...5. Summary documentation is directed at recording progress toward achieving the measurable treatment plan goals. Summary documentation should include, but is not limited to: Patient's mental status, physical status, behavior in the therapeutic milieu, mood, affect, medication compliance and response, appetite and intake, percent of weight gain or loss, grooming and hygiene,quality of sleep, nursing interventions, current nursing care provided, and any restrictive interventions needed. ...". Review of the hospital's nursing policy, "Level of Patient Observation", effective 07/02/2012, revealed, "...Procedure: ...B. RN (Registered Nurse) responsibilities and documentation: ...2. The RN is required to reassess patients on close observations and document findings every shift...The RN note must specifically address the patient's response to a higher level of observation. ...". Review of the hospital's current job description for a Registered Professional Staff Nurse revealed, "...Summary of Major and Essential Functions: The Registered Staff Nurse...documents all data accurately and in a timely fashion...". 1. Closed record review of Patient #6 revealed a [AGE] year-old female admitted on [DATE] with psychosis and self-injurious behavior. Record review revealed a physician's order dated 10/30/2013 for "close obs (observation) while awake". Further record review revealed no documentation of a nursing assessment on 10/31/2013 and 11/05/2013. Record review revealed Patient #6 was discharged on [DATE]. Interview on 01/14/2014 at 1315 with administrative staff revealed, "the nurse should assess and document an assessment once per shift for patients on close observation". Interview confirmed Patient #6 was on close observation beginning 10/30/2013 and no documentation of an assessment was available for 10/31/2013 and 11/05/2013. Interview confirmed the nursing staff failed to follow the hospital's policy. Interview on 01/14/2013 at 1400 with a staff registered nurse while on tour of the acute care unit revealed, "the nurse should assess and document an assessment every shift for patients on close observation". 2. Closed medical record review of Patient #5 revealed a [AGE] year-old female admitted on [DATE] with oppositional defiant disorder. Record review revealed no documentation of a daily nursing assessment on 11/13/2013, 11/20/2013, 11/22/2013 and 11/30/2013. Record review revealed Patient #5 was discharged to the hospital's PRTF (Psychiatric Residential Treatment Facility) on 12/10/2013. Interview on 01/14/2014 at 1315 with administrative staff revealed, "the nurse should assess and document an assessment once daily for all patients". Interview confirmed no documentation of a daily assessment by the RN was available for 11/13/2013, 11/20/2013, 11/22/2013 and 11/30/2013. Interview confirmed the nursing staff failed to follow the hospital's policy. Interview on 01/14/2013 at 1400 with a staff registered nurse while on tour of the acute care unit revealed, "the nurse should assess and document an assessment daily for all patients". 3. Closed medical record review of Patient #4 revealed a [AGE] year-old male admitted on [DATE] with conduct disorder and ADHD (attention deficit hyperactive disorder). Record review revealed no documentation of a daily nursing assessment on 11/26/2013 and 12/01/2013. Record review revealed Patient #4 was discharged to the hospital's PRTF on 12/23/2013. Interview on 01/14/2014 at 1315 with administrative staff revealed, "the nurse should assess and document an assessment once daily for all patients". Interview confirmed no documentation of a daily assessment by the RN was available for 11/26/2013 and 12/01/2013. Interview confirmed the nursing staff failed to follow the hospital's policy. Interview on 01/14/2013 at 1400 with a staff registered nurse while on tour of the acute care unit revealed, "the nurse should assess and document an assessment daily for all patients". 4. Closed medical record review of Patient #2 revealed a [AGE] year-old male admitted on [DATE] with mood disorder, Aspergers' syndrome and ADHD. Record review revealed no documentation of a daily nursing assessment on 10/27/2013. Record review revealed Patient #2 was discharged on [DATE]. Interview on 01/14/2014 at 1315 with administrative staff revealed, "the nurse should assess and document an assessment once daily for all patients". Interview confirmed no documentation of a daily assessment by the RN was available for 10/27/2013. Interview confirmed the nursing staff failed to follow the hospital's policy. Interview on 01/14/2013 at 1400 with a staff registered nurse while on tour of the acute care unit revealed, "the nurse should assess and document an assessment daily for all patients". |
||
| VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY | Tag No: A0468 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the hospital's Medical Staff Rules and Regulations, medical record review and staff interviews, the hospital failed to ensure a discharge summary was completed within 30 days following the patient's discharge for 4 of 6 closed medical records reviewed (#1, #6, #3, and #5). The findings include: Review of the hospital's Medical Staff Rules and Regulations, effective July 2012, revealed, "...5.9. Completion of Medical Records 5.9.1. All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent. 5.9.2. The Facility CEO (Chief Executive Officer) in consultation with the Medical Director shall be authorized to temporarily suspend the admitting privileges of Members when: a. The Member does not complete medical records within the time frame prescribed by these Rules and Regulations. ...". 1. Closed record review on 01/14/2014 of Patient #1 revealed a [AGE] year-old male admitted on [DATE] with conduct disorder. Record review revealed Patient #1 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (76 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #1 (76 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 2. Closed record review on 01/14/2014 of Patient #6 revealed a [AGE] year-old male admitted on [DATE] with psychosis and self-injurious behavior. Record review revealed Patient 61 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (48 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #6 (48 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 3. Closed record review on 01/14/2014 of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with mood disorder and post-traumatic stress disorder. Record review revealed Patient #3 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (36 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #3 (36 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 4. Closed record review on 01/14/2014 of Patient #5 revealed a [AGE] year-old female admitted on [DATE] with oppositional defiant disorder. Record review revealed Patient #5 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (35 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #5 (35 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. |
||
| VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS | Tag No: A0469 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the hospital's Medical Staff Rules and Regulations, medical record review and staff interviews, the hospital failed to ensure the completion of medical records within 30 days following discharge for 5 of 6 closed medical records reviewed (#1, #6, #3, and #5). The findings include: Review of the hospital's Medical Staff Rules and Regulations, effective July 2012, revealed, "...5.9. Completion of Medical Records 5.9.1. All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent. 5.9.2. The Facility CEO (Chief Executive Officer) in consultation with the Medical Director shall be authorized to temporarily suspend the admitting privileges of Members when: a. The Member does not complete medical records within the time frame prescribed by these Rules and Regulations. ...". 1. Closed record review on 01/14/2014 of Patient #1 revealed a [AGE] year-old male admitted on [DATE] with conduct disorder. Record review revealed Patient #1 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (76 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #1 (76 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 2. Closed record review on 01/14/2014 of Patient #6 revealed a [AGE] year-old male admitted on [DATE] with psychosis and self-injurious behavior. Record review revealed Patient 61 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (48 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #6 (48 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 3. Closed record review on 01/14/2014 of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with mood disorder and post-traumatic stress disorder. Record review revealed Patient #3 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (36 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #3 (36 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. 4. Closed record review on 01/14/2014 of Patient #5 revealed a [AGE] year-old female admitted on [DATE] with oppositional defiant disorder. Record review revealed Patient #5 was discharged on [DATE]. Record review revealed no documentation of a discharge summary completed by the attending physician (35 days after discharge). Interview on 01/14/2014 at 1315 with administrative staff revealed a discharge summary is to be completed within 30 days following the patient's discharge. Interview further revealed the medical record is not considered complete until the discharge summary is completed and signed by the attending physician. Interview confirmed there is no documentation of a discharge summary being completed for Patient #5 (35 days after discharge). Interview on 01/15/2014 at 1000 with the director of medical records revealed, "(Physician A) is not completing medical records in a timely fashion. (Physician A) has not completed medical records, including discharge summaries, since May 2013 (8 months ago). I have notified (Administrative Staff) of her delinquency". Interview on 01/15/2014 at 1025 with administrative staff revealed, "I have sent numerous emails to the CEO about (Physician A's) delinquent medical records". Interview on 01/15/2014 at 1055 with the hospital's chief executive officer revealed, "I found out yesterday that (Physician A) had not done discharge summaries since May. Our next discussion will be to suspend her privileges". Physician A was not available for interview. NC 875 |
||