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 policy and procedure review, closed medical record reviews, incident report review, and staff interviews, facility staff failed to ensure tracking of patient safety events by failing to complete an incident report for 1 of 1 records that documented inappropriate sexual behavior. (Pt# 10).

The findings include:

Review of "...POLICY AND PROCEDURE: PI 3.1.1 Incident Reporting Policy...", reviewed/revised date 03/06/2014, revealed "...Policy: Quality of care can always be improved and risks can always be minimized. Essential to the goal of Risk management is the commitment of leadership as well as staff to principles of safety and discretion. The (name and initials of facility) shall implement monitoring and evaluation of incidents, and accidents that will support attempts to minimize injuries/accidents....Definition Incidents - Any unusual or unexpected occurrence that results in injury or potential injury to patients, staff, or visitors, including....inappropriate sexual behavior....Procedure: A. Employees who witness or are aware of an incident are responsible for completing an Incident Report at the time they become aware of the incident or as soon as the situation is under control. B. An Incident Report must be completed anytime there is a potential injury (regardless of severity) to residents, employees or visitors. ..."

Closed medical record review of Patient (Pt) # 10, on 10/29/2015, revealed the patient, a 9 year old, was admitted on [DATE] with a complaint of auditory hallucinations (hearing sounds or voices that are not actual in the outside world). Review of Nursing Notes, dated 08/26/2015 (wrong date) at 1320, revealed Pt # 10 exhibited "...inappropriate sexual behavior between (Pt # 10) And are on close observation with peers until further notice. ..." Review of Physician Order Sheet revealed an order, dated 09/26/2015 at 1150, "...Close obs (observation) d/t (due to) inappropriate contact (with) peer....clarification: with peers, close obs. ..." Review of form for Special Monitoring, dated 09/26/2015, revealed close observation began at 1150.

Telephone interview with RN # 1, on 10/29/2015 at 1615, revealed RN # 1 cared for Pt # 10 on 09/26/2015 and wrote the note about the inappropriate behavior. Interview revealed RN # 1 notified the physician to get the child placed on close observation, but did not complete an incident report. Further interview revealed RN # 1 did not know an incident report was needed for inappropriate sexual behavior.

Interview with Administrative Staff (AS) # 1, on 10/29/2015 at 1630, revealed an incident report should have been completed for this occurrence. Interview confirmed policy was not followed.

Based on Hospital Bylaws review, Closed Medical Record review, and staff and physician interviews, facility staff failed to ensure a discharge summary was completed within 30 days of discharge for 1 of 1 Against Medical Advice (AMA) Discharges reviewed (Pt # 4)

Review of Hospital Bylaws, dated 2012, revealed "... a. Patient record requirements shall include the following....4. The time period in which patient records must be completed following discharge shall not exceed thirty (30) days. ..." Further bylaws review revealed "...Clients shall be discharged by order of the attending physician. At the time of discharge the attending physician shall indicate the final diagnosis according to the DSM IV (Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition], a classification of psychiatric disorders) published by the American Psychiatric Association, the clinical condition of the client, discharge medication(s) and aftercare plan. This should be indicated in a progress note. The physician shall complete the discharge summary within thirty (30) days after the discharge of the client. Discharge summaries will contain the following elements: brief history, mental status at admission, summary of goals, condition at discharge, medications(s) at time of discharge, aftercare plans, diet, physical activity and final diagnosis. If the physician has not so completed this summary, privileges to admit clients to the Facility may be suspended by the Medical Staff Committee, on recommendations of Health Information Management, until such time these records are up to date....Any client leaving against medical advice (AMA) shall be requested to sign the form provided by the Facility stating the discharge is against medical advise and that the responsible party has been advised and understands it....The attending physician, as well as the other staff members should document in the progress notes the circumstances surrounding the guardian's decision to take the client against medical advice and the interventions done in an effort to prevent the client from leaving. ..." Bylaws review did not reveal specific documentation requirements related to AMA for a discharge summary.

Closed medical record review for Patient (Pt) # 4 on 10/27/2015 revealed the patient, a 14 year old, was admitted [DATE]. Review of "DISCHARGE NOTIFICATION" form, dated 09/22/2015 at 1455, stated a disposition of "Home (with) Outpt (Outpatient) services" and a discharge diagnosis of "Schizoaffective Disorder NOS (not otherwise specified). Review revealed the form was signed by a Registered Nurse. Further review revealed a "CONTINUING CARE/DISCHARGE SUMMARY" Form, dated 09/22/2015, which stated the type of discharge was AMA. Review revealed the line for the Psychiatrist Signature was left blank. Further review did not reveal any specific documentation made by the Psychiatrist on the form. Review of a Physician Progress Note, dated 09/22/2015 at 1520, did not reveal documentation of the guardian's decision to leave AMA. Review revealed the Discharge Summary was not complete with Psychiatrist signature at the time of record review (35 days after the AMA discharge).

Interview on 10/28/2015 at 1310 with MD # 1 revealed MD # 1 is a Psychiatrist and worked with Pt # 4. Interview revealed the Psychiatrist did not complete the Discharge Summary because the Patient was not discharged , the guardian signed Pt # 4 out AMA.

Interview on 10/28/2015 around 0930 with Administrative Staff # 1 revealed there was not a complete Discharge Summary, including the signature of MD # 1, for Pt # 4. Interview revealed the physician does not complete a Discharge Summary when a Patient leaves AMA. Interview revealed MD # 1 states the patient was not discharged .

Intake NC 442