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.

SAMARITAN BEHAVIORAL CENTER 5555 CONNER AVENUE, SUITE 3N DETROIT, MI March 26, 2015
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
This CONDITION is not met as evidenced by:

Based on record review and interview the facility failed to maintain a medical record service that was accessible, failed to ensure that medical records were timed, dated and authenticated in a timely manner, and failed to ensure that discharge summaries were completed in a timely manner, resulting in increased risk of harm for all patients. Findings include:

-The facility failed to retain the complete medical record of one discharged patient, resulting in increased risk of records not being maintained for all patients. (A-0438)
-The facility failed to ensure that all physician orders were signed, dated and timed, resulting in increased potential for medical errors and patient harm. (A-0454)
-The facility failed to ensure that all medical records contained a discharge summary completed according to facility policy resulting in increased risk of poor communication and lack of care coordination at discharge for all patients. (A-0468)
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on observation, interview and record review, one of one current patients (#10) was physically restrained when lying calmly of a bed and kept in restraints for 45 minutes without any documentation of risk of harm to self or others, resulting in increased risk of unnecessary restraint for all patients. Findings include:

Video Review:
On 3/26/15 at 1145 staff N showed a video of the above incident, showing patient #10 being placed in 4-point restraints, in the Restraint/Seclusion Room, on 3/21/15. At 1108 patient #10 was lying calmly on a bed in the R/S room. The patient had placed himself on the bed without staff assistance. At 1109 two Mental Health Technicians applied 4-point leather restraints to patient #10's wrists and ankles. Staff N confirmed these findings during video review.

Record Review:
Record review was conducted on 3/25/15 from 1300-1600. In an "Incident Report," (IR) dated 3/21/15 at 1554, nurse Z stated that patient #10 was placed in 4-point leather restraints from 1110-1300. The IR stated that at 1105 on 3/21/14: "Patient (#10) picked up a book and attempted to throw it at staff without provocation and then went and struck seclusion/restraint window with his left fist shattering it stating "I want to die." From 1215-1300 there was no documentation of the need for physical restraint. Staff Q documented that patient #10 was "quiet" at 1215, and "calm" at 1230 and 1245. Nurse Z's IR documentation stated: "Restraints discontinued at 1300 goals met, patient was calm and cooperative for 30 minutes..." Staff D confirmed these findings during record review.

Interview:
On 3/26/15 attempts were made to contact nurse Z to ask if there is a rule that patients must be calm for 30 minutes before being released from restraints and to seek clarification regarding what "book" patient #10 attempted to throw prior to being physically restrained on 3/21/15. Attempts to reach nurse Z by phone were unsuccessful. On 3/25/15, during record review, staff D confirmed that no books were present in the area of the nurses station or available in the Day Room. A 19-page paper booklet was visible in a wall mounted holder adjacent to the nurses's station. Nurse D stated that it was unclear from documentation whether patient #10 attempted to throw a book or a paper booklet. Nurse D agreed that throwing a paper booklet would not pose a threat of injury to staff.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to implement its policy regarding proper administration of medication to ensure that the over use of telephone orders did not occur for two (#1 and #7) of two patients from a total sample of 19 resulting in telephone orders being used as a common practice. Findings include:

Patient #1
On 03/25/15 at 1630 a review of clinical records for patient #1 revealed that patient #1 was admitted into the facility on [DATE] with diagnoses that included psychosis, diabetes, hepatitis B and C, and hypertension among other diagnoses.

Physician's orders and Medication administration records were reviewed for the time period that the patient stayed in the facility. The documentation indicated that the patient received prn (as needed) Haldol (antipsychotic) and Ativan (antianxiety) IM (intramuscular) without indication for giving, throughout his stay (12/18/14 through 01/15/15). The following telephone orders reviewed with the CNO (Chief Nursing Officer) on 03/26/15 at 1205 revealed:

On 12/19/14 at 0110, Haldol 5 milligrams (mg) and Ativan 2 mg IM was administered to patient #1. There was no documentation in the record that provided the indication for use.

On 12/24/14 at 0230, Haldol 5 mg and Ativan 2 mg IM was administered with no explanation of reason for use.

On 12/25/14 at 0830 and at 235 Haldol 5 mg and Ativan 2 mg was also administered with an explanation of breakthrough psychosis, but no detailed explanation of reason for use.

On 12/26/14 Haldol 5 mg and Ativan 2 mg IM was administered with no indication.

On 12/28/14 at 0015 Haldol 5 mg and Ativan 2 mg IM was administered, and at 2000 Haldol 10 mg and Ativan 4 mg IM was administered for breakthrough psychosis.

On 12/29/14 at 0830 and on 12/31/14 at 0845 Haldol 10 mg and Ativan 4 mg IM was administered with on indication that the IM was needed.

On 01/01/15 at 2045 Haldol 10 mg and Ativan 4 mg IM was administered for breakthrough psychosis.

On 01/02/15 at 1140 Haldol 5 mg and Ativan 2 mg was administered.

On 01/09/15 at 0130 and 2028 Haldol 10 mg and Ativan 4 mg was administered, and on 01/13/15 Ativan 1 mg IM was administered to the patient.

On 03/26/15 at approximately 1215 an interview was conducted with the CNO who reviewed the orders and associated progress notes. The CNO confirmed that telephone orders were utilized excessively, and that the indication for the use of the medication was not documented appropriately. It was unclear why the patient's scheduled medication was not adjusted for stabilization to avoid the over use of prn (given as needed) medications.

Patient #7
The clinical record for patient #7 was reviewed on 03/26/15 at 1100. Patient #7 was admitted into the facility on [DATE] with diagnoses of schizophrenia and hypertension among other diagnoses.

A review of the physician's orders and MAR for patient #7 revealed that prn orders were written for the patient with no documented reason for use. Orders revealed the following:

On 03/11/15 at 1945 patient #7 was administered a telephone order of 10 mg of Haldol, 4 mg of Ativan and 50 mg of Benadryl IM for extreme agitation, however there was no description of behaviors or events that justified the use of the medication.

On 03/12/15 at 2444(?) According to the orders and MAR a telephone order of Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM was administered, however the progress note dated 3/12/15 revealed ...patient...loud and hyper verbal ...order obtained for prn, not given ...

On 03/18/15 at 0900 the MAR indicated Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM was administered with no indication for use

On 03/19/15 at 2431 (sic) Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM was administered.

The facility policy entitled, "TELEPHONE, VERBAL AND WRITTEN ORDERS FOR MEDICATION" (#MM-4.445), dated March 7, 2011 revealed, "Verbal and telephone orders are allowed; however, in an effort to reduce medication error, the use of these types of orders are discouraged. The medical staff is educated on a continual basis to make all attempts to minimize the use of verbal and telephone orders."
VIOLATION: PATIENT RIGHTS Tag No: A0115
This CONDITION is not met as evidenced by:

Based on observation, interview and record review, the facility failed to protect and promote patient rights, resulting in increased risk of the right to care in a safe setting, protection from abuse and neglect and protection from unnecessary restraint for all patients. Finding include:

-The facility failed to ensure patient safety by assessing, monitoring and providing appropriate care to one current patient with undocumented bruises, failing to protect one current patient's skin from a wrist band that cut into the patient's skin and failing to protect 8 current patients diagnosed with diabetes from exposure to two soiled glucose meters. These deficient practices resulted in bruises of unknown origin not being assessed, a skin abrasion not being noticed, and the potential for cross contamination of an infectious disease for eight patients. (See A-0144)
-The facility failed to protect patients from abuse and neglect by failing to conduct timely, thorough abuse/neglect investigations for two patients and failing to provide timely assessment and treatment to one current patient following a traumatic injury, resulting in increased risk of abuse and neglect for all patients. Findings include: (See A-0145)
-The Facility failed to protect one current patient (#10) from unnecessary restraint, resulting in increased risk of unnecessary restraint for all patients. (See A-0154)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, facility's policy and procedure review and staff interview the facility failed to ensure patient safety by assessing, monitoring and providing appropriate care to 9 of 19 patients (#3, 5, 8, 10, 11, 13, 19, 20 & 21) who: 1) had multiple bruises on his body that were not documented at the time of admission (#11), 2) wore an identification wrist band that cut into his skin (#10), and 3) exposed 8 patient's (#3, 5, 8, 11, 13, 18, 19 & 20) diagnosed with diabetes to two soiled glucose meters. One of the eight patient's (#3) had a diagnosis of HIV (Human Immunodeficiency Virus) documented in his clinical record. These deficient practices resulted in bruises of unknown origin (#11), a skin abrasion to (#10's) wrist, and the potential for cross contamination of an infectious disease. Findings include:
During the initial tour of the facility on 03/25/15 at 0945, observations of the medication room on the A unit revealed a soiled glucose monitor with a dark reddish brown substance on the monitor. RN (J) was alerted to the soiled monitor and was queried about the facility policy of cleaning glucose monitors. RN (J) proceeded to clean the glucose monitor with an alcohol pad and stated that "the monitors are supposed to be clean after each use." When queried about the dark reddish brown stains on the monitor, RN (J) was not sure what they were.

Review of clinical records on 03/25/15 at 1100 revealed a psychiatric evaluation for patient #3 that indicated "History of HIV and diabetes..." According to the record patient #3 received blood glucose monitoring AC and HS (before meals and at night) Further review of various clinical records revealed that current patients #5, 8, 10, 11, 13, 19 and 20 were also diabetic and
received blood glucose monitoring four times daily.

An interview was conducted with the Infection Control Coordinator (ICC) on 03/25/15 at approximately 1410. The ICC was queried about the practice of cleaning glucose monitors, and verified that the monitors should be cleaned after each use.

According to the facility policy entitled, "BLOOD GLUCOSE TESTING" dated January 30, 2014, "Cleaning glucometer.. After each use cleanse monitor housing thoroughly with alcohol wipes..."





On 3/25/15 at 1305 patient #11 was interviewed in the patient's room. Patient #11 complained that staff had been physically abusive to him. Visual inspection of patient #11's body revealed bruises on both arms that were not documented on the patient's admission skin assessment, dated 3/23/15. The largest undocumented bruise was located under patient #11's right arm. It measured approximately 10 cm x 10 cm (centimeters) and appeared red and purple in color. On patient #11's left anterior (front) forearm a purple bruise measuring approximately 2 cm x 2 cm was observed. These finding were confirmed by staff D and staff L. Staff D stated that no Incident Reports had been filed that might have explained the cause of the bruises. On 3/25/15 at approximately 1315 review of patient #11's admission skin assessment revealed no documentation of the bruises described above. The facility initiated an abuse investigation on 3/25/15. Nurse D stated that the facility does not have a procedure for assessing patient's skin condition after admission unless the patient makes staff aware of a problem.

On 3/26/15 at 1015 patient #10 was observed wearing 3 hospital identification wrist bands. One of the bands, dated 3/20/15, was so tight that is cut into patient #10's skin, causing a red, abraded area on the top (anterior) of the patient's right wrist, approximately 2.5 cm. in length. Patient #10 was asked if the tight identification band was hurting him. The patient's verbal answer could not be understood by this surveyor. Staff B offered to cut off the tight wrist band. In response, patient #10 extended his wrist toward staff B to assist with removal. Staff B cut off the identification band and confirmed these findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to 1) protect the rights of one of two patient's (#1) reviewed for abuse and neglect; when unreasonable force was inflicted towards (#1) who sustained injuries that resulted in physical harm, pain and mental anguish; and 2) conduct a timely and thorough investigation for one of one patients (#1) and 3) provide timely, through assessment for pain and injury following a known traumatic injury to patient #10, from a total sample of 19 patients, resulting in increased risk of abuse and neglect for all patients. Findings include:
Deficient practice statement #1
On 03/25/15 at 3:30 p.m., clinical record review revealed that patient #1 was admitted into the facility on [DATE] with diagnoses that included [DIAGNOSES REDACTED].
An emergency room : patient transfer form dated 01/13/15 revealed, "Altercation with staff member, patient found on floor on side of bed in room. Noted abrasion to left forearm x 2 and below left eye. Some blood noted in mouth."
The integrated progress note dated 01/13/15 at 0645 revealed "Late entry. Writer was attacked by patient while writer was doing observation rounds, punched (error) patient attacked writer with punches to face and nose, writer was able to get patient off of writer and called staff, patient fell to floor and was subdued by staff without incident."
On 03/25/15 at approximately 1610, an interview was conducted with the recipient rights officer (RRO) regarding the incident. The RRO explained that an investigation was conducted with the individuals involved in the incident and Mental Health Tech/MHT (R) reported that he went to patient (#1's) room and the patient was behind the door of his room and proceeded to attack MHT (R). Reportedly, MHT (R) held his hands out to block patient (#1) from continuing to strike him. MHT(R) then called out for staff assistance and MHT(S) and Nurse (T) arrived into the room. MHT (R) denied using physical force toward the patient. The RRO explained that MHT (R) still works at the facility.
A review of the surveillance footage pertaining the incident was conducted in the presence of the RRO on 03/25/15 at 1615. The video revealed that on 01/13/15 at approximately 0500, MHT (R) was observed in the unit A hallway outside of patient #1's door. MHT (R) entered the patient's room, and shortly thereafter, MHT(S) and Nurse (T) was observed running to the patient's room. There was no footage that revealed the activity inside of the patient's room.
The RRO also stated that a complaint was submitted to the recipient rights office from the local hospital that the patient was transferred to, because the patient voiced a concern that he was physically abused by two Mental Health techs at the facility, however, the RRO did not substantiate that excessive force was used against the patient. It is unclear how the patient sustained abrasions to his arms, a laceration to his face and blood in his mouth if force was not used against him.
An incident report dated 01/13/15 at 0500 was reviewed on 03/25/15 at 1625 with the quality manager which indicated, "writer was making observation rounds entered room, the patient jumped from behind the door, punched with a flurry of punches to the face. Patient continued to attack writer with an attempted bite, writer was able to block and push patient off, and called for staff who came quickly. While trying to subdue patient, patient fell on floor." The writer acknowledged in his statement that he pushed the patient. It was unclear what was done to subdue the patient. The Quality manager stated that the patient stumbled backward and fell over the bed.
Further review of the clinical record on 03/25/15 at around 1640 revealed a progress note dated 01/13/15 from the nurse practitioner that indicated, "patient was evaluated at (local hospital) following a trauma...left periorbital (around the eye) laceration...left periorbital swelling noted, areas of discoloration noted, laceration inferior to the left eye...left eye is somewhat injected.
A progress note dated 01/14/15 from the medical doctor revealed, "...following a recent altercation with another staff member. He (patient #1) had a laceration to his face, and hemato-conjunctivitis and scleral bleed...left eye injected (red eye), [DIAGNOSES REDACTED]tous...Left eye infraorbital laceration is sutured ...
The discharge instruction from the acute care hospital dated 01/13/15 revealed "reason for visit: facial laceration, multiple abrasions ... "
On 03/26/15 at 1000, and interview was conducted with the MN shift manager who stated that he worked on the day of the incident, but "By the time I got to the patient's room, he was on the floor between the bed and the window. He was laying on the floor and was screaming, he didn't want anybody to touch him."
An observation of the room in which the incident occurred was made on 03/26/15 at 1015 with the MN shift manager. The manager explained that he was informed that prior to the incident the patient was in his room and was repeatedly slamming his door, so the MHT went to the room to ask him (patient #1) to stop as he might wake the other patients. The manger further stated that an altercation between the patient and the tech ensued. The tech was at the room door when the patient allegedly attacked him (MHT R). The tech reportedly held his hands out in front of him to block patient (#1) from hitting him, however, following the altercation, the patient was found crying out, on the floor next to the window which was approximately 12 feet away from the door where the altercation initiated. The manager was unable to explain how the patient ended so far away from the door with injuries to his eye, face, arms and mouth if he was not handled improperly by the tech. The extent to which the patient sustained physical injuries following the altercation, did not concur with the explanation of the events reported by the facility.
The CNO (chief nursing officer) was queried on 3/26/15 at approximately 1110 about the incident, and verified that the injuries sustained by the patient could not have occurred from the tech standing in a blocking position.
According to the facility policy entitled, "IDENTIFYING ABUSE AND NEGLECT" (MH-05) dated February 2, 2014 "It is the policy of (the facility) to identify and report recipient abuse and neglect and to act upon this information ...It is also the policy of (the facility) that any instance of physical, psychological, sexual or any other abuse by any employee or another patient of the hospital will not be tolerated..."
deficient practice statement #2
On 03/26/15 at 1130 record review revealed an integrated progress note dated 12/31/14 which revealed " On 0130 rounds tech reported that she observed this patient (#1) performing oral sex on his roommate who appeared to be sleeping with eyes closed. Tech stated she grabbed a male tech to stop the incident. The other patient was transported while sleeping to B unit, and this patient (#1) slept in his room by himself ...
RRO was interviewed on 03/26/15 at approximately 1205 and was queried about the incident. An incident report dated 12/31/14 was provided which indicated, "On 12/31/14 at the 0130 round... I observed (patient #1) with his mouth on (his roommates) penis while (roommate) was laying down and seemed to be asleep and unaware of what was going on After seeing what was happening, I immediately attempted to verbally redirect patient shouting at patient to stop. Patient refused to stop and continued to perform on (roommate) After seeing that patient refused to follow verbal redirection, I called for MHT (S) to come down and help me address the issue and get (patient #1) off of (roommate). Immediate action was taken, unit charge nurse was notified and addressed the issue from there."
The nursing resolution details indicated, "No resolution required ...(roommate) was moved to B unit, (patient #1) was redirected and displayed lack of insight in tx (treatment) issue and required multiple redirections for compliance. Attempted to interview (roommate) for a sexual contact attestation form unsuccessful, client asleep. Recipients rights contacted and NP (nurse practitioner)...spoken for appropriate medical attention to be provided for these patients..."
There was no indication that the 'sexual contact attestation form' was readdressed to the roommate the following day or at any time thereafter.
The supervisor feedback section of the incident report revealed that the incident was not addressed nor was the form signed by the supervisor.
The quality resolution details revealed "nursing management and recipient rights to investigate and follow up." However, the RRO was queried on 03/26/15 at 1500 regarding an investigation for the incident and verified that no investigation was conducted for the incident. Patient #1 had a diagnosis of [DIAGNOSES REDACTED]
The RRO stated that testing was offered to the roommate of patient #1 and he refused testing, however, no documented evidence was provided to verify this claim.




Deficient practice statement #3
Observation:
On 3/25/15 at 1240 patient #10 was observed with a cast/splint covering his left forearm and left hand.

Video Review:
On 3/26/15 at 1145 staff N showed a video showing patient #10 walking unassisted into the Restraint/Seclusion room and lying down on a bed on 3/21/15 at approximately 1106. Two staff entered the room. At 1108 patient #10 was lying calmly on a bed in the R/S room. At 1109 the two staff (Mental Health Technicians) put patient #10 in 4-point leather restraints, applied to both wrists and both ankles. At 1111 staff Q appeared to touch patient #10's raised (restrained) left hand and talk with the patient. These findings were confirmed during video review by staff N.

Record Review:
On 3/25/15 from 1300-1600 review of patient #10's clinical record revealed the following findings. Patient #10 was admitted to the facility on [DATE]. In an "Incident Report," (IR) dated 3/21/15 at 1554, nurse Z stated that patient #10 had shattered a window with his left fist at 1105. The IR states that patient #10 was placed in 4-point leather restraints from 1110-1300. On 3/21/15 at 1210 nurse J documented the "One Hour RN/Physician Assessment (FACE TO FACE)" of patient #10. The patient was still in 4-point leather restraints at the time of this assessment. Nurse J's note did not mention assessing patient #10's left hand for signs of trauma injury. On the 1554 IR, Nurse Z noted that patient #10's left wrist was "slightly swollen." This was the first documentation of a nurse assessing the patient's left hand for signs of injury since the hand trauma occurred at 1105. There was no documentation of staff asking patient #10 if his left hand hurt on 3/21/15.

A physician's order dated 3/21/15 at 1100 was noted as faxed to an unidentifiable physician at 1205. The order states: "Bacitracin ointment to open areas 3 x daily x 5 days. x ray L (left) hand. Trauma R/O (rule out) fx (fracture)." There was no documentation on 3/21/15 identifying the location of the "open areas" referenced in this order. There was no documentation in patient #10's record indicating when staff put a call out to Mobile x-ray or what time the x-ray was done. A copy of the faxed final x-ray report was timed 3/21/15 at 1715. The x-ray showed "a fracture involving the distal metacarpal with mild displacement" and "associated tissue swelling." This report was not signed off as received or noted by the facility until 3/22/15. An order to send patient #10 to an acute care hospital for treatment was not obtained until 2300 on 3/21/15.

The above findings were confirmed by staff D during record review. Staff D confirmed that the record contained no notes documenting when the Mobile x-ray was requested and done or when x-ray results were received by facility staff and reported to a physician.

Interview:
On 3/26/15 at approximately 1025 nurse J was asked if she assessed patient #10's left hand for signs of trauma when she did the "FACE TO FACE" assessment of patient #10 at 1210 on 3/21/15. Nurse J stated that she did not ask because she was not informed that patient #10 may have injured the left hand.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation and interview the facility failed to have the entire closed medical record available for one patient (#1) of two closed records reviewed resulting in the medical record not being available on site at the facility. Findings include:
On 03/25/15 at 1430, the clinical record for Patient #1 was requested to the Chief Nursing Officer (CNO) for review. It was reported that the record would be pulled and placed in the conference room.
On 03/25/15 at 1515, observations made in the conference room revealed that the medical record was not present. The Administrative Assistant was queried as to the location of the medical record and she reported that the Medical Records Coordinator was looking for it. At 1530 the Quality Manager (QM) provided part one, of a two part medical record and explained that only one part of the record was available for review, the other part was at another location outside of the hospital. The QM reported that the record was taken to another hospital so that he could work on it. When the QM was asked to retrieve the record on that day, he replied, "I can have it here tomorrow."
On 03/26/15 at 0900, The QM provided part two of the medical record. Unlike the part one record which was tattered and worn, the part two record appeared clean, crisp and new. The forms located in the second record were the Morse Fall Scales, Flow sheets, Group documentation, and therapy group notes which all appeared fresh and new. The patient observation records which was also in the second record were older.
According to the "MEDICAL STAFF GENERAL RULES AND REGULATIONS," revised on 9/11/2013, "Records may be removed from the hospital's jurisdiction and safekeeping only in accordance with a court order, subpoena or statue..."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on interview and record review the facility failed to ensure that all orders were signed, dated, timed and authenticated for 3 (patients #10, #19, and #20) of 5 medical records reviewed resulting in increased potential for medical errors and patient harm. Findings include:

Review of patient #10's medical record, on 3/25/15 at approximately 1300, revealed that patient #10's "Adult Formal Voluntary Admission Application," dated 3/20/15, had not been signed by the patient's physician. Staff D stated that patient #10 was currently admitted on a Voluntary basis. The "Action By Hospital" section of the form requires that the patient's physician make a determination as to whether the patient is accepted or not as a Formal Voluntary Admission. The entire section was blank. This finding was confirmed by staff D during record review.

On 3/25/15 at approximately 1050, review of patient #20's medical record revealed unsigned physician's telephone orders for orders initiated on 3/11/15, 3/13/15 and 3/16/15. These findings were confirmed during record review by staff D on 3/25/15 at approximately 1050.

On 3/25/15 at approximately 1055, review of patient #19's medical record revealed a slash mark indicating a physician's signature, on an undated, untimed order noted as "faxed" on 3/20/15. This finding was confirmed during record review by staff D on 3/25/15 at approximately 1055.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure that all medical records contained a discharge summary completed according to facility policy increasing the risk of poor communication and lack of coordination at discharge for all patients. Findings include:

Policy "HIM" stated that all patient discharge summaries will be completed within 30-days of discharge.

On 3/26/15 at 1125, during a tour of the Medical Records Room, staff BB confirmed that physician AA had 6 banker's boxes of incomplete patient Discharge Summaries that were at least 30-days past due.

On 3/26/15 at 1130 Medical Records staff O confirmed the "MR Chart Deficiency" report, dated 3/26/15, indicating that physician AA had 19 Monthly Admits, 22 Monthly Discharges and 302 incomplete D/S (Discharge Summaries). The report listed 144 records as D/C (discharge) over 30-days for physician AA. These findings were confirmed by Medical Records staff O on 3/26/15 at approximately 1130.




On 03/26/15 at 1500 during record review of Patient (#1) clinical record, a completely blank Discharge Summary as noted in the record. Patient (#1) was admitted into the facility on [DATE] and discharged on [DATE], which was over two months prior to the date of the survey.
On 03/26/15 at the Medical Records supervisor was interviewed and queried about documentation missing from the clinical record. The Medical Records supervisor was unable to explain why the discharge summary was incomplete.
According to the, "MEDICAL STAFF GENERAL RULES AND REGULATIONS, " revised on 9/11/2013, "a discharged clinical summary shall be written or dictated on all medical records of patients hospitalized over 48 hours ... "