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.
|OCEANS BEHAVIORAL HOSPITAL OF SAN MARCOS||1106 N IH 35 SAN MARCOS, TX 78666||June 12, 2018|
|VIOLATION: CONTENT OF RECORD||Tag No: A0449|
|Based on review of documentation and interview it was determined that the hospital failed to ensure that medical records were completed.
The medical record of patient #1 was not completed.
During a review of the medical record of patient #1 the following issues were noted:
The area at the top of the Daily Nurse Assessment & Progress Notes where the patient's appearance was to be assessed (choices included: WNL, Obese, Emaciated, Disheveled, Poor Hygiene, Bizarre (Describe):) was blank for dates: 2/17/2018, 2/27/2018, and 3/2/2018. On the same form for 2/27/2018 the area where the patient's Respiratory status (choices included: Lungs clear to auscultation, Congested, Cough: Productive, Cough: Non-productive, Dyspnea at rest, Dyspnea on exertion) is assessed was also blank.
The patient belongings Inventory: On Unit form dated 2-10-18 listed 9 separate line items of personal property belonging to patient #1, 7 separate items were listed for 2-12-18 and 2 separate line items were listed for 2/12/18. Additionally there were 2 separate line items for personal property dated 2/13/18 listed as being either in the "Med room" or "Med cabinet." The right side of the form contained an area where staff was to initial and date when the patient was discharged . This area was blank. The bottom of the form contained an area where a witness was to sign during admission this area as well as the area where a staff member was to sign at both admission and discharge. No signatures were found.
The patient belongings Inventory: In Storage form, dated: 2/13 listed 23 separate line items of personal property belonging to patient #1, the right side of the form contained an area where staff was to initial and date when the patient was discharged . This area was blank. The bottom of the form contained an area where a witness was to sign during admission this was blank with no signature. Additionally there was an area where a staff member was to sign at discharge, this area was also blank.
Review of the inpatient master treatment plan revealed that it had been initiated on 2/12/2018 and had been signed on page three by patient #1, as well as Nursing, and Social Worker. The area where the Physician is to sign, date and time the treatment plan was found to be blank with no signature. Directly above the area where the physician is to sign was the comment: "Physician Certification Of The Level Of Care: I certify that this patient's inpatient psychiatric hospital admission is medically necessary for treatment which can reasonably be expected to improve the patient's condition and/or for diagnostic study."
Review of "Social Work and Nursing Discharge Instructions" dated 3/9/18 revealed that the sections entitled: "Reason for Admission, Services Provided, and Consultations Provided:" were blank. The areas for "Reason for Discharge:" and "Condition at Discharge:" were blank. The area where the Social Worker was to print their name and sign was blank. The area where the discharging nurse was to print their name was also blank. The area entitled: "To Be Completed By Discharging RN:" was found to be blank with no information in the following areas: "Date of actual discharge, Time of actual discharge, Method of Transportation, Mode of Transportation and Accompanied by (as applicable)."
Review of hospital policy entitled: "Medical Record Documentation" with an effective date of 2/1/2017 stated on page two under section 4. Interdisciplinary Treatment Plan (ITP). "c. The ITP is considered complete if all involved disciplines have clinically contributed to the formation of the plan and signed, dated, and timed the plan and any updates." Page 4 stated under section 12. "A medical record is ordinarily considered complete when the required contents have been completed and all entries and/or dictation have been authenticated by the responsible author."
In an interview with staff member #1 on the morning of 6/12/2018 the above findings were confirmed.