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 facility policy and procedure review, medical record review and staff interview, the facility failed to ensure a patient had timely access to medical records in 1 out of 10 cases reviewed (Patient #2).

Findings include:

Review on 08/02/2018 of facility policies and procedures failed to reveal a policy related to the timeframe in which medical record release requests would be completed.

Review on 07/31/2018 of an open medical record for Patient #2 revealed a [AGE]-year-old male who was admitted on [DATE] after displaying increased aggression and an episode of violence towards a pet. Review revealed he was brought to the facility by his grandmother, who was his legal guardian, and was admitted voluntarily for medication management and therapeutic programming. Review revealed the guardian requested that Patient #2 be discharged several times over the course of his admission. Review of therapy notes revealed a note on 07/05/2018 which revealed, "Thepriast [sic] expressed [to guardian] that discharge would have to wait until next week." Review of a therapy note dated 07/06/2018 revealed the guardian had contacted the patient's outpatient therapy provider to discuss discharge from the facility. Review revealed the therapist and the outpatient provider agreed a discharge would not be safe at that time even though the guardian was "irate about wanting [Patient #2] to discharge." Review revealed the therapist spoke with the guardian on 07/06/2018 to inform her of the process of removing the patient from the facility against medical advice [AMA] but the guardian did not sign the paperwork to remove the patient AMA. Review revealed a note on 07/13/2018 which revealed the therapist discussed a tentative discharge date of [DATE]. Review of a note dated 07/16/2018 revealed the therapist contacted the guardian to notify her the the discharge would not take place that day because the doctor had stated that the patient "was aggressive" over the weekend, necessitating an increased dose of Depakote (an antipsychotic medication), and that the discharge would not take place until the doctor was in agreement. Review revealed a note dated 07/17/2018 which stated that the guardian wanted the patient to be discharged and would be coming to the facility that day with a patient advocate to discuss it. Review revealed the therapist expressed concerns over the discharge, stating that medications should not be abruptly stopped, but that "guardian was adamant about discharging." Review of a physician progress note dated 07/17/2018 revealed, "No issues overnight, mild aggression and irritation during the day. Mother is angry over the fact that he has not been D/C yet as well as a medication change. Possible D/C this week." Review revealed that the patient was discharged AMA to the care of his guardian on 07/17/2018. Review revealed a form titled "STATEMENT OF UNDERSTANDING AND RELEASE FOR CLIENT LEAVING FACILITY AGAINST MEDICAL ADVICE" that was signed by the guardian on 07/17/2018 at 1649. Review of discharge documents revealed an Authorization to Release Protected Health Information signed on 07/17/2018 by the legal guardian. Review of the form failed to reveal a timeframe in which the facility could be expected to release the records.

Interview on 08/02/2018 at 1600 with the Health Information Manager (HIM) revealed that she was responsible for medical records requests. Interview revealed the medical records department had been slow to fulfill medical records requests for the past six weeks. Interview revealed the HIM kept a log of incoming requests and their fulfillment dates, but review of the log revealed it had not been updated since 04/2018. Interview revelaed, "July has been a wash...alot [of requests] have not been logged and the majority have not been sent out at all. We're very behind." Interview revealed the HIM did not know of any specific guidelines for turnaround times, but "we tell [patients] we'll get to it as quickly as possible." Interview revealed the HIM had not received a medical records request for Patient #2, but observation revealed the HIM found the record request in a stack of requests on her desk. Interview revealed the oldest request in the stack was dated 06/21/2018. Interview failed to reveal whether there were old requests that had not been fulfilled. Interview failed to reveal a current turnaround time on medical records requests. Interview revealed the most recent request that the HIM had filled was "probably last week," but failed to reveal a confirmation or log of the fulfillment.

NC 664

Based on facility policy and procedure review, medical record review and staff interview, the facility failed to monitor and treat the side effects of administered medication in 1 out of 9 patients (Patient #1).

Findings include:

Review of the hospital's policy on 07/31/2018 titled "Reassessment of the Patient" reviewed/revised: 11/2015 revealed "Policy: 1. Reassessment of the patient shall be completed per the following patient situations and frequencies: ...When there is a suspected medication side effect or adverse drug reaction... 3. The RN (Registered Nurse) will notify the physician whenever there is a change in the patient's condition or evidence of a significant acute abnormality in diagnostic testing, and document this notification including any order received or notation that none was reviewed in the patient's medical record."

Review on 07/31/2018 of a closed medical record for Patient #1 revealed a 7 year old male who was admitted on [DATE] with the chief complaint of anger outburst, suicidal ideations and paranoia and with medical history of cyclical vomiting syndrome (recurring attacks of intense nausea, vomiting, and sometimes abdominal pain). Review revealed Patient #1 was discharged home AMA (against medical advice) with his parent on 06/19/2018. Review of a nursing progress note dated 06/17/2018 at 1215 revealed "patient was medicated as ordered with no adverse reactions. Review of a nursing note dated 06/18/2018 at 1152 revealed the Patient #1 had "fine tremors of hands". Further review revealed no documentation of the physician being notified of the tremors and no interventions documented for the tremors.

Interview on 07/31/2018 at 1025 with RN #30 revealed patients on Lexapro (antidepressant medication) should be assessed for neck movements, gait disturbance, slurred speech, and tremors. Interview revealed the physician should be notified if a patient showed any of these symptoms. Interview revealed the medication of choice for these symptoms were Cogentin (used to treat a group of side effects [called parkinsonian side effects] that include tremors, difficulty walking, and slack muscle tone) but the physician had to be notified prior to the administration of the Cogentin.

Interview on 08/01/2018 at 1300 with RN #32 who was the primary nurse on 06/18/2018 revealed patients were assessed during medication administration and throughout the shift. Patients on Lexapro should be assessed for EPS (extrapyramidal side effects [drug-induced movement disorders that include acute and tardive symptoms]). Interview revealed the physician should be contacted prior to medicating a patient for EPS. Interview revealed hand tremors should be of concern for a patient on Lexapro and the physician should have been contacted. Interview revealed "I was aware that Patient #1 was on Lexapro and I am not sure why this symptom was not looked into further and the physician notified". Interview revealed Patient #1 did not have tremors on admission and RN #32 should have contacted the physician. Interview revealed RN #32 did not recall why the physician was not contacted but according to the notes the physician was not contacted.

Interview on 08/02/2018 at 0950 with the CNO (Chief Nursing Officer) revealed nurses were expected to assess the patients for medication side effects, effectiveness and contraindications of medications administered. Interview revealed if a patient had tremors while on Lexapro, the nurse would have stopped the Lexapro, notified the physician, and continued to monitor the patient. Interview revealed the patient's family should be notified once the physician decided on how to move forward.

NC 664; NC 727; NC 285; NC 257; NC 929; NC 919; NC 127