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.

KALAMAZOO REGIONAL PSYCHIATRIC HOSPITAL 1312 OAKLAND DR KALAMAZOO, MI March 30, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to protect the rights of patients for one of five pregnant patients (#17) resulting in the potential for all current and future pregnant patients at risk for loss of their rights.

Findings include:

1. The facility failed to provide adequate antepartum services to 1 of 5 pregnant patients (#17), out of a total of sample of 28, resulting in increased pain and mental anguish for Patient #17, who gave birth while alone in the facility toilet area. (See A-145)
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide adequate antepartum services to 1 of 5 pregnant patients (#17), out of a total of sample of 28, resulting in increased pain and mental anguish for Patient 17, who gave birth while alone in the facility toilet area. Findings include:

During an interview with Patient (Pt) #17 on 03/28/18 at 1305, Pt #17 said she was pregnant when admitted to the facility on [DATE] with a due date of 02/07/18. Pt #17 said she remembered the due date because it was the same day as her mother's birthday. Pt #17 said she had experienced some abdominal pain in the facility "a few days before" her due date (on 02/05/18) and the facility sent her to a local hospital emergency room (ER). Pt #17 said, at that time, the hospital ER clinicians examined her and told her she wasn't ready to deliver the baby and sent her back to the facility. Note, for clarity, the facility was a psychiatric facility without a dedicated ER and since it had a limited ability to provide advanced medical services, it was reliant upon the local hospital to treat of patients having emergent care needs. Pt #17 said, on 02/08/18 during the early evening hours, she began experiencing painful periods of abdominal pain described as "hurting really bad", like her stomach was "tightening up over and over" and "pushing down". Pt #17 said she reported the pain to the afternoon shift staff on 02/08/18 and a doctor (MD O) came to examine her. Pt #17 said MD O placed their "hand on her belly" and told her to "lay down". Pt #17 said some afternoon staff tried to help by walking with her in the unit hallway, but other staff didn't believe her, insisting she wasn't experiencing any pain. Pt #17 said, throughout the evening, she kept telling staff she needed to go to the hospital ER because the pain was getting worse, however, no one did anything to facilitate the transfer. Pt #17 said the abdominal pain intensified into the midnight shift on 02/09/18 making her feel very uncomfortable and restless. Pt #17 said she moved from her bedroom to the unit dayroom at different times during the night. Pt #17 said a midnight nurse (RN M) put her hand on her belly and gave her a blanket. Pt #17 said she kept telling midnight staff she was in pain and needed to go to the ER, but again, no one did anything to treat the pain or facilitate the transfer to the local hospital. Pt #17 said, "no one believed" that she was in pain. Pt #17 said, on 02/09/18 at approximately 0600, as the pain and pressure intensified, she felt like she was going to have a bowel movement and entered the toilet area on the unit. Pt #17 said facility staff were in the hallway, however, she didn't see any inside the bathroom. Pt #17 said as she was sitting alone on the toilet and pushing downward she heard a loud splash and "the baby came out into the toilet". Pt #17 said there was "blood and water everywhere". Pt #17 said, at that point, multiple staff quickly entered the toilet area to help her. Pt #17 said "911 came" and she and the baby went to the hospital ER. Pt #17 said she and the baby were "doing fine".

During an interview with Registered Nurse (RN) M on 03/29/18 at 0835, RN M said she was the nurse assigned to care for Pt #17 during the midnight shift from approximately 02/08/18 at 2245 to 02/09/18 at 0645. RN M said her job position classification was an RN 1 Manager. RN M said she usually didn't work on the unit assigned and was unfamiliar with the patients. RN M said she knew Pt #17 was pregnant, however, she was unaware of Pt #17's due date. RN M said she instructed all staff working on the unit to "keep a close eye" on Pt #17 during the shift. RN M said she was present on the unit when Pt #17 gave birth in the unit toilet area. RN M said, at the start of the work shift, she received report from the afternoon shift nurses indicating Pt #17 had been directly evaluated by the medical physician (MD O) on 02/08/18 at approximately 1700 and MD O advised staff to let Pt #17 rest and monitor Pt #17 for leakage of blood or fluids. RN M said she first assessed Pt #17 on 02/08/18 at approximately 2300 when Pt #17 was sitting in the dayroom and had no complaints. RN M said she checked on Pt #17 again, now in her bedroom, on 02/09/18 at approximately 0100 and Pt #17 had no complaints. RN M said, on 02/09/18 at approximately 0130 she notified the on-call psychiatrist (MD N) via phone that Pt #17 was complaining of pain and MD N reiterated MD O's previous instructions, to let Pt #17 rest and monitor for leakage of blood or fluids. RN M said MD N did not give any new orders. RN M said she did not write MD N's instructions as a verbal order. RN M said, soon after the call with MD N at 0130, she placed her hands-on Pt #17's abdomen and felt no evidence of contractions. RN M said she gave Pt #17 a blanket and asked her to remain in the dayroom because it was a high visibility location. RN M said, on 02/09/18 at approximately 0200, Pt #17 began crying and having complaints of increased pain. RN M said she offered Pt #17 a Tylenol for pain which Pt #17 refused and went to her bedroom slamming the door. RN M said for the remainder of the shift, up until the point of giving birth, Pt #17 was angry, refused to rest, threw a blanket, and spent her time walking between her bedroom and the dayroom. RN M said, on 02/09/18 at approximately 0600, Pt #17 gave birth to the child in the unit toilet area. RN M said she did not witness the birth but responded immediately when notified by staff. RN M said she wasn't sure if staff were present in the bathroom when Pt #17 gave birth. RN M said Pt #17 had episodes of pain throughout the night, however, the pain was not constant, and staff did not report her condition was worsening. RN M said, prior to the birth, Pt #17's water did not break and there were no signs of bleeding. RN M said she only contacted the on-call psychiatrist (MD N) one time (02/09/18 at 0130) during her work shift. RN M said, until the point the child was born, she did not "feel any reason" to contact the on-call psychiatrist a second time to address Pt #17's pain and did not feel Pt #17 required emergent medical services. RN M said the birth was sudden.

During an interview with the Associate Director of Nursing (RN Z) on 03/28/18 at 1435, RN Z said the facility electronic medical record system allows facility nursing staff to view outside consult and clinical information from the local community hospital system. RN Z said the local hospital health system provided medical services to most patients in the facility having more complex medical needs. RN Z said the facility also had a physician (MD O) who attended to and coordinated the medical needs of patients in the facility.

During an interview with Psychiatrist (MD) N on 03/29/18 at 1030, MD N said he was the physician on-call for the entire facility starting on 02/08/18 at approximately 1700 until 02/09/18 at approximately 0830. MD N said the on-call physician is responsible for the behavioral and medical needs of the patients in the facility during the on-call period, including consultation with other members of the treatment team, if needed. MD N said he was aware that Pt #17 was pregnant and that her due date was 02/07/18, however, he never directly assessed Pt #17 during the time frames of his on-call duty because there was no indication to do so. MD N said he was aware Pt #17 had been evaluated by the facility medical physician (MD O) on 02/08/18 at approximately 1700, near the time frames his on-call duty began. MD N said staff did not provide him with any information indicating Pt #17 required emergent medical services until 02/09/18 at approximately 0600 when staff called him reporting Pt #17 gave birth in the facility toilet area. MD N said the last call he received from staff prior to the birth of the child was on 02/08/18 at approximately 1730 when the afternoon nursing staff reported Pt #17 was experiencing "abdominal discomfort". MD N said abdominal discomfort was not the same as a contraction. MD N said there was no mention that Pt #17 was experiencing contractions. MD N said he gave the nurse a verbal order to continue Pt #17 on Elevated Monitoring status (EM) which required the documentation of more frequent observations, and to monitor Pt #17 to make sure her water hadn't broken and that she was not bleeding. MD N said the nurse told him Pt #17 was already on EM status, to which MD N said to continue. MD N said on 02/08/18 at approximately 2100 he received a call from the afternoon nurse inquiring about another patient on the same unit were Pt #17 resided. MD said he asked the nurse if "everything was OK on the unit" and the nurse replied, "yes". MD N said he assumed this meant all patients were doing fine on the unit, including Pt #17. MD N denied ever receiving a phone call from the midnight nurse (RN M) on 02/09/18 at approximately 0130. MD N held out his cell phone and said, "check the phone, there is no evidence I received a phone call (from the midnight nurse, RN M)". MD N reiterated, the last communication he had with staff specific to Pt #17's status, prior to the birth of the child, was on 02/08/18 at approximately 1730. MD N said he did eventually receive a phone call on 02/09/18 at approximately 0600, however, this was staff informing him that Pt #17 had already given birth in the facility toilet area. MD N said he depends on nursing staff to provide relevant clinical information and to manage the unit milieu. MD N said he didn't send Pt #17 to the hospital because the nurse reported Pt #17 was experiencing abdominal discomfort. MD N reiterated that abdominal discomfort was not the same as a contraction. MD N said he did not ask the nurse to clarify any of the information or to examine the patient.

Attempts to interview the Medical Physician (MD O) were unsuccessful. On 03/29/18 at 1130, the Facility Director (Staff A) reported MD O was not available to speak as MD O had resigned from the facility effective today (03/29/18).

During an interview with the Director of Quality and Risk (Staff C) on 03/30/18 at 1135, Staff C acknowledged Pt #17's medical record did not contain any evidence of a physician order or physician documentation providing direction for the antepartum care of Pt #17 from 02/08/18 during the afternoon shift until 02/09/18 at approximately 0600 when Pt #17 gave birth to the child in the facility toilet area. Staff C also acknowledged the medical record did not contain evidence that Pt #17 was on EM status from 02/08/18 during the afternoon shift until the birth of the child, or any evidence that Pt #17 was monitored for leakage of blood or fluids or that the patients pain was regularly assessed and treated. Staff C indicated the facility investigation of the events had not been completed at the time the State agencies entered the facility.

On 03/29/18 at 1330 during review of the medical record, video, internal files, and policy and procedures, the following information was revealed:

Per Psychiatric Report on Competency report dated 11/14/17, Pt #17 was a [AGE] year old female with no alleged previous history of psychiatric treatment. This report indicated Pt #17 was referred for competency restoration on outstanding criminal charges. This report indicated Pt #17 had intellectual disabilities as evidenced by an extremely low range full scale IQ score. This report indicated Pt #17 had diagnoses of mild intellectual disability, adjustment disorder with mixed anxiety and depressed mood, poor impulse control and post-traumatic stress disorder. This report concluded that Pt #17 was incompetent to stand trial.

Per History and Physical report dated 09/12/17, Pt #17 was described as a female "with 20 plus or minus 2 weeks of pregnancy" admitted to the facility for treatment of her mental illness. This report summarized Pt #17 was "pregnant and her uterine size is consistent with a gestational period of about 20 weeks".

Per Obstetrics Report dated 10/18/17 from the local hospital Maternal Fetal Medicine department, Pt #17's EDD (Estimated Due Date) was documented as being 02/07/18.

Per Individual Plan of Service (IPOS) plan dated 01/04/18, Pt #17 had Nursing Teaching Care Plans for Alterations in health related to pregnancy, as well as other issues. The care plan for Alterations in health related to pregnancy indicated nursing will "2. Monitor and assess physical status reporting adverse changes to physician" and "4. Report any untoward signs and symptoms".

Per Patient Summary Report dated 02/07/18 at 0740, Pt #17, described as "currently at full term", was sent to the local hospital ER on 02/05/18 for complaints of abdominal contractions and returned to the facility hours later with a diagnosis of false labor after finding out she (Pt #17) was not yet dilated.

Per Patient Summary Report dated 02/08/18 at 2119, Pt #17 complained of groin/lower abdomen pain and MD O was notified and advised Pt #17 to rest and for staff to monitor for leakage of blood or fluids. This report indicated MD O came to the unit and assessed Pt #17 and the patient was encouraged to lie down but she refused and said she would remain in the dayroom. This report indicated, on 02/08/18 at 1725, "as another peer was getting loud and irritated, she (Pt #17) became angry while talking loud and went to the pt (patient) phone complaining that she (Pt #17) wasn't sent to the hospital". This report indicated MD N was notified on 02/08/18 at 1730 and was informed that Pt #17 "was upset and wanted to be sent out" and MD N said to monitor Pt #17 and "make sure her water hasn't broken or no bleeding". This section of the report concluded, "Tried to re-assure patient (Pt #17), but she continued to cry and retort in an angry voice".

Per Patient Summary Report generated on 02/08/18 at 0759, Pt #17 had On Grounds access.

Per staffing reports dated 02/08/18 for the second (afternoon) shift, on the unit that Pt #17 resided, there were a total of 17 patients on the unit with one registered nurse (RN), one licensed practical nurse (LPN), and six residential care aides (RCA).

Per staffing reports dated 02/09/18 for the third (midnight) shift, on the unit that Pt #17 resided, there were a total of 17 patients on the unit with one registered nurse (RN) and five residential care aides (RCA).

Per witness statement report made by Resident Care Aide (RCA) U on 02/26/18, RCA U indicated Pt #17 stated she was in pain and could not sleep and the RN manager was notified. This statement indicated Pt #17 waited in the "dayroom area and was told that she could not be sent out to the hospital per the physician". This statement also indicated Pt #17 "became upset because she was in pain and kept saying, "I just want to go get checked out to see what's going on with my baby"". Note that RCA U was listed on the staffing report list as working the third (midnight) shift on 02/09/18 during the timeframes Pt #17 gave birth.

The Facility Time Line report (undated) indicated the following dates, times, events and data sources: Note the video evidence contained no sound.

Per Video Review and 24-Hour Report Sheet, on 02/08/18 at 1536, Pt #17 returned from choir practice holding her stomach with both hands. The nurse notified MD O who advised Pt #17 to rest and for the nurse to monitor for leakage of blood or fluids.

Per Video Review and 24-Hour Report Sheet, on 02/08/18 at 1624, Pt #17 tells staff that she is in more pain and MD O directly assessed Pt #17 on the unit, asking her if her water broke, and Pt #17 said, "no". MD O then advised Pt #17 to lay down and rest.

Per Video Review, on 02/08/18 at 1651, Pt #17 walks toward dayroom, stops and bends over with both hands on her knees as if she is in pain.

Per Video Review, on 02/08/18 at 1707, MD O puts on a glove and places hand on Pt #17's lower abdomen for 40 seconds. Afterward MD O speaks with the nurse and Pt #17.

Per Video Review and 24-Hour Report Sheet, on 02/08/18 at 1725, Pt #17 became upset with peer that is being loud. Pt #17 talks on the phone and reportedly is angry, loud and complaining that she wasn't sent to the hospital.

Per 24-Hour Report Sheet, on 02/08/18 at 1730, the nurse contacts the on-call psychiatrist (MD N) and notifies MD N that Pt #17 is upset about not being sent to the hospital. MD N told the nurse to monitor Pt #17 and make sure her water hadn't broken and that she was not bleeding.

Per Video Review, on 02/08/18 at 1904, Pt #17 leans forward abruptly in chair as if she is having pain.

Per Video Review, on 02/08/18 at 1937, Pt #17 comes out of bathroom holding her stomach with both hands. Pt #17 briefly leans up against the wall.

Per Video Review on 02/08/18 at 1958, Pt #17 is walking toward dayroom, she stops and grabs a door handle and hunches forward. Pt #17 appears to be in pain.

Per Video Review, on 02/08/18 at 2002, Pt #17 walks to Nursing Office door and speaks to staff inside. Pt #17 grabs the window sill of the office and hunches forward. Pt #17 appears to be in pain.

Per Video Review, on 02/08/18 at 2004, Pt #17 leaves bathroom and sits in dayroom. Pt #17 is rocking back and forth.

Per Video Review, on 02/08/18 at 2209, Pt #17 grabs the window sill of the office and hunches forward. Pt #17 appears to be in pain.

Per Video Review, on 02/09/18 at 0041, RN M enters Pt #17's room with another staff.

Per RN Progress Note, on 02/09/18 at 0045, RN M noted that Pt #17 was observed in room and Pt #17 said she was okay.

Per RN Progress Note, on 02/09/18 at 0130, RN M noted that Pt #17 was complaining of pain and MD N was called, but no new orders were given.

Per Video Review, on 02/09/18 at 0145, Pt #17 leaves bedroom and walks to bathroom. Pt #17 is holding her stomach with both hands.

Per Video Review, on 02/09/18 at 0147, Pt #17 leaves bathroom and is holding stomach with both hands.

Per Video Review, on 02/09/18 at 0149, RN M appears to be speaking with Pt #17 and touches Pt #17's stomach for a few seconds.

Per Video Review, on 02/09/18 at 0152, Pt #17 is given a blanket.

Per RN Progress Note, on 02/09/18 at 0200, RN M documented Pt #17 went to bedroom and slammed the door.

Per Video Review, on 02/09/18 at 0205, Pt #17 tilts head back and appears to be in pain.

Per Video Review, on 02/09/18 at 0255, RN M comes out of nursing office and appears to be speaking with Pt #17.

Per Video Review, on 02/09/18 at 0354, Pt #17 goes to the nursing office door briefly, then sits back in dayroom, covers up with blanket and rocks back and forth.

Per Video Review, on 02/09/18 at 0415, Pt #17 moves in chair, appears to be in pain.

Per Video Review, on 02/09/18 at 0454, Pt #17 moves in chair, appears to be in pain.

Per Video Review, on 02/09/18 at 0500, Pt #17 walks to bedroom. She is holding her stomach with both hands.

Per Video Review, on 02/09/18 at 0543, Pt #17 leaves bedroom. She is holding her stomach and bends down and appears to be in a lot of pain.

Per Video Review, on 02/09/18 at 0545, Pt #17 enters unit bathroom.

Per Video Review, on 02/09/18 at 0554, Staff enters bathroom then walks out.

Per Video Review, on 02/09/18 at 0604, Staff enters bathroom and comes out and waving for other staff.

Per Video Review, on 02/09/18 at 0605, RN M ands other staff enter the bathroom. One staff walks out of bathroom crying.

Per Video Review, on 02/09/18 at 0619, Emergency Medical Technicians (EMT) arrive at facility.

Per Video Review, on 02/09/18 at 0630, EMT's pull cot out of bathroom with Pt #17 on it. Pt #17 is holding her baby who is wrapped up.

Per Video Review, on 02/09/18 at 0631, EMT's leave unit with Pt #17 and baby.

Per EMT Run-Sheet Report dated 02/09/18, the section labeled "Run Report Narrative" indicated "Pt (#17) states she has been having contractions all night and had asked to go to the ER and was told no."

Per local hospital emergency room documentation dated 02/09/18 at 0721, Pt #17 was described as presenting "via ambulance after precipitous delivery of infant in the toilet at the (facility). Per EMT, (Pt #17) and baby were stable upon arrival ...".

Upon completion of record review on 03/30/18 at 1130, the medical record did not contain any evidence of a physician order or physician documentation providing direction for the antepartum care of Pt #17 from 02/08/18 during the afternoon shift until 02/09/18 at approximately 0600 when Pt #17 gave birth to the child in the facility toilet area. Also, during these same times frames, there was no documented evidence that Pt #17 was on EM status or had contacts documented on the EM form (DCH J983). Also, during the same time frames, there was no documented evidence that Pt #17 was monitored for leakage of blood or fluids or regularly assessed for pain, even when clinical staff had knowledge the patient was at full term pregnancy, approximately two days past her estimated due date, and actively experiencing pain.

On 03/30/18 at 0920, a review was completed of Registered Nurse (RN) Manager job descriptions dated 10/25/15. These job descriptions indicated the RN Manager 1 position functioned as a first-line administrative supervisor of a limited work area compromised of ...Resident Care Aides" and, under Job Duties, "Supervises and participates in the provision of general nursing care services" and "Supervises admissions, conducts assessment of patient's needs, and initiates nursing care plans", and "Evaluates and documents patient progress ...".

On 03/30/18 at 0930, a review was completed of facility policy and procedure titled, "Patient Registration Policy and Procedure" last revised 04/14/16. This policy indicated, under policy section, "Medical Records shall be accurate, complete and timely." This policy included, within the Definitions section, regarding the Medical Record, "The information justifies the patient's care, treatment, and services", and under the Standards section, "b. To furnish documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition during the hospital stay" and "4. All significant clinical information pertaining to a patient is incorporated into the patient's medical record", and "18. Telephone orders shall be signed within 24 hours by the physician who initiated the order."

On 03/30/18 at 0940, a review was completed of facility policy and procedure titled, "Heightened Levels of Patient Supervision" last revised 07/25/17. This policy indicated, under Definitions section, "E. Elevated Monitoring (EM)- An increased level of monitoring and precautions, typically used for patients who present increased risk of suicide, self-abuse, or assault, but also available for other risk/precaution issues" and "The staff will monitor patients by making visual and verbal contact twice every 15 minutes at staggered intervals not less than five minutes and not greater than ten minutes apart. While patients are sleeping, patients on Elevated Monitoring will be checked every 15 minutes visually, at an approved nighttime hour, unless otherwise ordered by the psychiatrist. Only visual observation is required when monitoring the patient while sleeping. The contacts shall be documented on the Elevated Monitoring Form DCH J983". Also, under Standards section, "C. Upon notification, the psychiatrist shall issue a telephone order to continue or discontinue the heightened patient supervision. The psychiatrist shall see the patient, as soon as possible and no later than 24 hours, to complete a face-to face assessment and sign the appropriate written order" and, "D. Upon receiving either a telephone order or a written order from the psychiatrist for heightened patient supervision, the R.N. Unit Supervisor shall notify all members of the treatment team and unit staff who are present".

On 03/30/18 at 0950, a review was completed of facility policy and procedure titled, "Management of Emergency Obstetrical Delivery" last revised February 2016. This policy indicated, under general information section, "2. Signs of imminent delivery...", "e. Increased sensation of pressure in pelvis".

On 03/30/18 at 1000, a review was completed of facility policy and procedure titled, "Emergency Medical Services" last revised 08/02/17. This policy indicated, under policy section, "It is the policy of KPH to provide prompt and necessary emergency medical care to all patients at the hospital and transfer any patient requiring further care to an acute general hospital", and under Standards section, "D. Any patient who needs emergency medical care beyond the scope and services available at KPH, will be transferred by the contractual ambulance service (basic or advanced cardiac life support as necessary) to the emergency department at either of the two general hospitals in the area".

On 03/30/18 at 1010, a review was completed of facility policy and procedure titled, "General/Orientation Guidelines for Psychiatrist Duties" issued 03/01/18. This procedure indicated, "18. Medical problems on the units are addressed by the assigned Medical Physicians. Psychiatrists are expected to address medical or physical problems during the Medical Physician's absence or for reasons of expediency" and "If the Medical Physician is not available, problems determined to be complicated shall be referred as usual to the local hospital emergency room or consultants in the community". This procedure also indicated, under number 21, "G. The On-Call Psychiatrist will respond to emergencies as appropriate in a timely manner. Certain situations require response to the hospital in person".

On 03/30/18 at 1020, a review was completed of facility policy and procedure titled, "Patient Pain Management" (undated). This policy indicated, under Policy section, "It is the policy of KPH to recognize the rights of each patient to have their pain assessed, evaluated, and treated while at KPH", and under Standards, "A. All patients will be assessed for pain, and if present, interventions appropriate to the patient pain and general medical condition, will be instituted".

On 03/30/18 at 1030, a review was completed of the "Rules and Regulations Relating to the Medical Staff Bylaws" dated March 2018. These bylaws indicated, under Medical Staff Responsibilities Relating to Medical/Psychiatric Care section, 'E. Physician Orders: All physician orders for treatment shall be in writing. A verbal/telephone order shall be considered to be in writing if dictated to a registered nurse" and "H. The Medical Staff members have the responsibility for providing continuous care for their patients during the period of time the patients are assigned under their care", and under section Management of Pregnant Patients/Request for Abortions, "A. Pregnant patients will be referred to an obstetrician and will be transferred to one of the local hospitals for delivery."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to have a complete and accurate medical record for 1 (#10) of 20 patients that were reviewed for medical records out of a total sample of 28 patients resulting in the potential for adverse patient outcomes for all 140 patients served by the facility. Findings include:

As part of the investigation of complaint #MI 554 which had an allegation that Patient #10 had a sore on his bottom that had not been assessed, the medical record of Patient #10 was reviewed on 3/28/2018 at 1152. The medical record revealed that Patient #10 is a [AGE] year old male who was admitted to the facility on [DATE] for paranoid schizophrenia. Nothing is mentioned in the medical record regarding the alleged incident.

Incident reports from March 2017-March 2018 were reviewed on 3/29/18 at approximately 1400 and an incident report dated 2/17/2018 was found which corresponds with the complaint. The incident report indicated that staff witnessed Patient #10 approaching another patient who was watching television and punching him multiple times in the face. The EZ alarm (an alarm system used by staff members to indicate assistance is needed) was activated and staff responded immediately. At some point during the altercation, Patient #10 fell on to the floor. He stopped punching the other patient when a verbal order was given and complained of pain on his right buttock. The incident report further reveals that RN Staff Y completed a head to toe assessment immediately following the incident and discovered a "big abscess in right buttocks...a black wound as big as a ball on his right bottom." The on-call Psychiatrist Physician Staff S was notified. Staff S gave an order that Patient #10 be sent to the emergency room at the local acute care hospital for evaluation of the abscess.

An interview was conducted with Patient #10 on 3/28/2018 at 1330. He was unable to recall the incident and did not know how the wound was obtained.

An interview was also conducted with the unit RN, Staff I, on 3/28/2018 at 1340. Staff I was aware of Patient #10's wound and stated that the wound was assessed and re-dressed on a daily basis. "It has almost healed up completely." He also stated that the care plan was updated.

Further review of Patient #10's medical record was conducted 3/29/2018 at 0900. The latest plan of care for Patient #10 was dated 1/10/2018. No reference could be found regarding the assessment and treatment of the wound. This was confirmed by Associate Director of Nursing Staff Z who stated, "His care plan was not updated very well." Staff Z went on to say that the nursing staff review the care plan monthly and the treatment team reviews the care plan after the first seven (7) days following admission, followed by 30 days and then every 90 days thereafter.

Progress notes dated 2/17/2018-present were reviewed for wound care assessment information. Only five (5) entries were found relating to the wound or a wound dressing in that time frame and only two (2) entries, dated 2/19/2018 and 3/9/2018, described the assessment of the wound. On 3/30/2018 at 1030, Associate Director of Nursing Staff H confirmed that the wound assessments should be documented in the progress notes and that no further information of the wound was present in the progress notes.

Physician orders were also reviewed and revealed no orders were present regarding wound care and no physician assessment of the wound was present. This finding was confirmed by Staff H on 3/30/2018 at 1030. An order was present dated 3/8/2018 for the patient to be evaluated in an off-site wound clinic; however, no documentation could be found within the medical record or the 24-hour communication information as to whether the patient actually went to the wound clinic. Staff H was queried on 3/30/2018 at 1030 as to the lack of physician and nursing documentation to which he replied, "It's not surprising. Both the physician and the primary nurse on this case were extremely ineffective. The nurse (Staff X) has been fired ...We can contact the wound clinic to see if (Patient #10) actually went there or not."

The primary medical physician, Physician Staff O, was requested for interview on 3/29/2018. Upon the call from the facility requesting the interview, Staff O resigned effective immediately and was unable to be interviewed.

On 3/30/2018 at 1030, the 24-hour communication, an intra-departmental staff communication regarding patients, was reviewed and found to have several entries regarding Patient #10's wound and the care provided. Staff H was queried on 3/30/2018 at 1030 as to if the 24-hour communication was a part of the patient's medical record to which he replied "No. It is not."

On 3/30/2018 at 1200 just before exit of survey, a "Medical Treatment Record" dated February 2018 was reviewed. This record was in grid form with each day from 2/17-3/7 present across the top, with the exception of 3/3 which was not present. Under the start date the treatment is listed as "Wash with mild soapy water. Repack with gauze daily." No end date was present. No assessments of the wound are present on this form.

On 03/30/18 at 0930, a review was completed of facility policy and procedure titled, "Patient Registration Policy and Procedure" last revised 04/14/16. This policy indicated, under policy section, "Medical Records shall be accurate, complete and timely." This policy included, within the Definitions section, regarding the Medical Record, "The information justifies the patient's care, treatment, and services", and under the Standards section, "b. To furnish documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition during the hospital stay" and "4. All significant clinical information pertaining to a patient is incorporated into the patient's medical record", and "18. Telephone orders shall be signed within 24 hours by the physician who initiated the order."