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 | June 15, 2017 |
| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0168 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on hospital policy review, medical record review and staff interview, the hospital staff failed to obtain a complete physician order for a restraint for 1 of 4 patient restraint records reviewed (#6). The findings include: Review of the hospital policy on 06/14/2017 titled "Physical Restrictive Interventions and Seclusion" reviewed/revised 05/24/2016 revealed "Justification, Physician's Order, and Documentation 1 ...b. Any order for restrictive intervention must be dated, timed, behaviorally specific, and time limited, (e.g., 2-15-11, 1800. - physical restrictive intervention or seclude now and up to one (1) hour, to prevent harm to self or others) ..." Review of an open medical record on 06/14/2017 for Resident #6 revealed a [AGE]-year-old female admitted to the facility on [DATE] at 1130 with diagnoses of Schizoaffective Disorder - Bipolar type and Dementia of the Alzheimer type. Review of the physician's orders dated 05/03/2017 at 0813 revealed a verbal order obtained by a nurse for seclusion for up to one hour related to aggressive behaviors. Further review of the physician's orders dated 05/03/2017 at 0915 revealed a verbal order obtained by a nurse for seclusion for up to one hour with no documentation of a reason (justification) for the restrictive intervention. Continued review of the physician's orders dated 05/03/2017 at 1015 revealed a verbal order obtained by a nurse for seclusion for up to one hour with no documentation of a reason (justification) for the restrictive intervention. Interview with Interim CEO (Chief Executive Officer) on 06/15/2017 at 1100 revealed there was no available documentation in the record for patient #6 of the justification for the restrictive intervention ordered on [DATE] at 0915 and 05/03/2017 at 1015. Interview revealed the facility staff did not follow the facility policy for restrictive interventions by failing to obtain behaviorally specific physician restraint orders. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0178 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on hospital policy review, medical record review and staff interview, the hospital staff failed to complete a face-to-face assessment within one hour after a seclusion restraint intervention for 1 of 4 patient restraint records reviewed (#6). The findings include: Review of the hospital policy on 06/14/2017 titled "Physical Restrictive Interventions and Seclusion" reviewed/revised 05/24/2016 revealed "Time limitation ...Once a restrictive intervention has been implemented the qualified RN (registered nurse) shall conduct a face-to-face assessment. The RN shall inform the psychiatrist of the resident's current condition. The psychiatrist will decide whether or not to continue the restrictive intervention or seclusion." Review of an open medical record on 06/14/2017 for Resident #6 revealed a [AGE]-year-old female admitted to the facility on [DATE] at 1130 with diagnoses of Schizoaffective Disorder - Bipolar type and Dementia of the Alzheimer type. Review of the physician's orders dated 05/03/2017 at 0813 revealed a verbal order obtained by a nurse for seclusion for up to one hour related to aggressive behaviors. Further review of the physician's orders dated 05/03/2017 at 0915 revealed a verbal order obtained by a nurse for seclusion for up to one hour with no documentation of a reason (justification) for the restrictive intervention. Continued review of the physician's orders dated 05/03/2017 at 1015 revealed a verbal order obtained by a nurse for seclusion for up to one hour with no documentation of a reason (justification) for the restrictive intervention. Review of the medical record revealed documentation on 05/03/2017 at 0813 (time of restrictive intervention initiation) of a face-to-face assessment completed by a Registered Nurse. Review of the face-to-face assessment revealed a "Rational for continuing/discontinuing the restrictive intervention" with a circle drawn around "continuing". Further review of the face-to-face assessment documented at 0813 revealed "Release of Patient from Restrictive Intervention" with a note written across the form which read "Released from seclusion @ 1110 to bedroom." Review of the medical record revealed no available documentation of a face-to-face assessment completed after the restrictive intervention order on 05/03/2017 at 0915 and on 05/03/2017 at 1015. Interview with Interim CEO (Chief Executive Officer) on 06/15/2017 at 1100 revealed there was no available documentation in the record for patient #6 of a face-to-face assessment completed for the restrictive intervention ordered on [DATE] at 0915 and 05/03/2017 at 1015. Interview revealed the facility staff did not follow the facility policy for restrictive interventions by failing to complete a face-to-face assessment. |
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| VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY | Tag No: A0468 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical Staff Bylaws review, medical record reviews and staff interviews, the hospital staff failed to ensure 1 of 5 discharged patients had a discharged summary. (Patient #4). The findings include: Review on 06/13/3017 of the facility's "BYLAWS OF THE MEDICAL STAFF" approved 04/2016 revealed, "MEDICAL STAFF RULES AND REGULATIONS [sic] Admission of the Patient 1...Medical Record Requirement 3...Treatment Plan 8...Laboratory Testing 9....Care of the Patient 12...Transfers for Medical Emergencies 24...Discharge of the Patient 25. Patients shall be discharged by order of the attending physician...26. The physician shall complete the discharge summary within thirty (30) DAYS of the discharge of the patient..." Closed medical record review on 06/13/2017 revealed on 05/02/2017 at 1537, Patient #4, a [AGE] year-old female was voluntarily admitted to the hospital and received a diagnosis of Depressive Disorder. Review revealed the patient was admitted under the care of Psychiatrist #1. On 05/05/2017, the patient's father requested the patient to be discharged . At 1800, RN #1 wrote Psychiatrist #1 gave a telephone order for Against Medical Advise (AMA) discharge to home with father. Review revealed the patient was stable for discharge, contracted for safety and was provided a follow-up appointment. Review revealed the father signed the AMA discharge forms releasing the organization from any liability and the patient was discharge from facility to the care of her father. Review revealed on 05/06/2017 at 1100, Psychiatrist #1 wrote to disregard the discharge order because he did not order the discharge. Review revealed no discharge summary was available for review. Interview on 06/14/2017 at 1310 with RN #1 revealed the nurse remembers the circumstances surrounding this AMA discharge on 05/05/2017. Interview revealed the nurse was working on another unit and received a telephone from the another nurse requesting assistance with the patient's father. Interview revealed the patient's father had been calling the facility since 0800 and he was upset with his daughter's placement and wanted her discharged . The nurse contacted Psychiatrist #1 and informed him of the situation. The psychiatrist did not prefer for the patient to go home and he decided to consult with the former Chief Executive Officer (CEO). Interview revealed the psychiatrist provided a telephone order to discharge the patient. Interview on 06/15/2017 at 0915 with Psychiatrist #1 revealed he remembers the patient and the circumstances surrounding the AMA discharge. Interview revealed the patient was transferred from Hospital #1 for safety concerns and soon after the patient's admission, the father requested the patient's discharge. The psychiatrist spoke with the father on 05/04/2017 or on 05/05/2017 and explained the patient was not safe for discharge. Interview revealed Prozac (antidepressant) was ordered to treat the patient's depression but medication consent was not granted. Interview revealed the psychiatrist did not give a telephone order for RN #1 to discharge the patient as documented on 05/05/2017 at 1800. Interview revealed the psychiatrist did receive a telephone call from the nurse related to AMA discharge; at which, the nurse informed him to speak with the former CEO. Interview revealed it was not until 05/06/2017, while performing patient rounds, the psychiatrist was made aware of the patient's discharge. Interview revealed the psychiatrist did not write a discharge summary because he did not order the patient's discharge. Interview on 06/15/2017 at 0930 with the Senior Executive Vice President CEO revealed the survey investigation had identified areas of concerns and a plan of correction had been established and would be followed-up with monitoring. Interview reviewed the former CEO was unavailable for interview. NC 332 NC 725 NC 139 NC 312 NC 448 |
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