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WELLSTONE REGIONAL HOSPITAL 2700 VISSING PARK RD JEFFERSONVILLE, IN 47130 April 5, 2016
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on document review and interview, the medical record (MR) lacked documentation of assessment to justify continued hospitalization for 1 of 3 patients who requested AMA (against medical advice) release (P1).

Findings:

1. Review of IC 12-26-3-4 indicated the following:
a. Written request for release; time for release. Sec. 4. Except as provided in section 5 of this chapter, an individual who has been admitted to a facility under this chapter shall be released within twenty-four (24) hours of a written request for release made to the superintendent or the individual's attending physician by:
(1) the individual; or
(2) if the individual is less than eighteen (18) years of age, the parent or guardian who applied for the individual's admission to the facility.
As added by P.L.2-1992, SEC.20.
b. IC 12-26-3-5. Refusal to release individual; grounds; written report to court. Sec. 5. (a) The superintendent or the attending physician is not required to release an individual under section 4 of this chapter if the superintendent or the attending physician has reason to believe the individual is mentally ill and either dangerous or gravely disabled. (b) If the superintendent or the attending physician makes a determination under subsection (a), the superintendent or the attending physician must make a written report to a court:
(1) that has jurisdiction;
(2) in the county: (A) of the residence of the individual; or (B) where the facility is located; and
(3) not later than five (5) days of receiving the request made under section 4 of this chapter. (c) A report under subsection (b) must:
(1) state that there is probable cause to believe that the individual is mentally ill and either dangerous or gravely disabled;
(2) state that the individual requires continuing care and
treatment in the facility; and
(3) request a hearing on the report.
As added by P.L.2-1992, SEC.20.

2. Medical record review indicated that patient P1 requested AMA release on 2/28/16 at 13:05hrs. The Request for Release or Discharge Against Medical Advice form indicated that according to IC 12-26-3-4, "an individual who has been admitted to a facility shall be released within 24 hours of a written request for release made to the superintendent or the individual's attending physician"; therefore, the attending Physician has 24 hours to evaluate my status to determine my release... The MR lacked documentation of the physician being notified of the AMA request and lacked documentation of physician evaluation for justification of continued hospitalization within 24 hours of the written request.

3. On 4/6/16 at 3:35pm, A1, Director of Regulatory Compliance, indicated the MR for P1 lacked documentation of physician notification of the AMA request and lacked documentation of physician justification of continued hospitalization within 24 hours of written request.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to ensure 4 of 10 medical records (MR) were completed consistent with hospital policy and procedure/MS (medical staff) Rules and Regulations (P1, P4, P6 and P9) .

Findings:

1. Review of MS Rules and Regulations indicated the following: 5.3 Member Responsibility for Medical Record: 5.3.2 Members must complete the discharge summary within 30 days of discharge. The MS Rules and Regulations were approved 9/4/14.

2. Review of the following MRs (medical records) on 4/5/16 lacked documentation of a completed discharge summary as follows:
a. P1 discharged [DATE]
b. P4 discharged [DATE]
c. P6 discharged [DATE]
d. P9 discharged [DATE]

3. On 4/6/16 at 11:56am, A1, Director of Regulatory Compliance, indicated the discharge summary for P1, P4, P6 and P9 were not completed within 30 days of discharge per MS Rules and Regulations.