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BLOOMINGTON MEADOWS HOSPITAL 3600 N PROW RD BLOOMINGTON, IN 47404 April 14, 2021
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for documentation in a medical record (MR) for 5 (patient 1, 3, 5, 6, 8) of 10 MR's reviewed:

Findings:

1. Patient 1's MR: Review of Nursing Progress Note and Observation Rounds/Precautions note dated 4/12/21 each lacked documentation of patient identifying information on the note.

2. Patient 3's MR: Review of Observation Rounds/Precautions note dated 3/31/21 lacked documentation of patient identifiers on the note.

3. Patient 5's MR: Review of Observation Rounds/Precautions note dated 2/2/21 lacked documentation of patient identifying information on the note. Review of patient 5's MR found a blank/undocumented Discharge Suicide Risk Reassessment note containing a patient identification sticker only.

4. Patient 6's MR: Review of Discharge Safety Plan dated 1/11/21 per staff N12 (Registered Nurse [R.N.]) lacked documentation of time the assessment was initiated. Review of Discharge Suicide Risk Reassessment note dated 1/12/21 per staff N12 lacked documentation of time the assessment was initiated.

5. Patient 8's MR: Review of Discharge Suicide Risk Reassessment indicated staff N15 completed the patient assessment on 12/9/20 at 1320 hours but failed to document his/her credentials with his/her name and signature.

6. Policy/procedure, Policy No: 1000.06, Medical Records Documentation Requirements, reviewed/revised 3/17, indicated:
a. page 1: "Bloomington Meadows Hospital requires all individuals who have access to and responsibility for documentation in the Medical Record to know, understand and abide by the documentation requirements for his/her discipline".
b. page 5: "Nursing staff complete the Nursing Assessment documentation includes: identifying information".
c. page 6: "Nursing and/or case management completes the Discharge Plan...".

7. On 4/14/21 at approximately 1545 hours, staff N10 (Director of Clinical Services) was interviewed and confirmed patients' MR documents should be documented accurately and completely.
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, the facility failed to ensure medical staff followed their by-laws related to authentification of medical record (MR) documents in 7 (patient 2, 3, 4, 5, 6, 7, 8) of 10 MR's reviewed:

Findings:

1. Patient 2's MR: Review of Discharge Summary dated 12/10/20 per medical staff D5 (Nurse Practitioner [N.P.]) lacked documentation of review/authentification by a Doctor of Medicine (MD) per signature/time/date.

2. Patient 3's MR: Review of Discharge Safety Plan dated 4/5/21 per staff N11 (Licensed Mental Health Counselor [LMHC]) lacked documentation of an MD's review and authentification per signature/date/time. Review of Discharge Suicide Risk Assessment Note dated 4/5/21 at 1100 hours per staff N12 (Registered Nurse [RN]) lacked documentation of an MD's review, approval and discharge decision per signature/date/time.

3. Patient 4's MR: Review of Discharge Safety Plan dated 4/11/21 at 1800 hours lacked documentation of an MD's review and authentification per signature/date/time. Review of Discharge Suicide Risk Reassessment dated [DATE] lacked documentation of an MD's authentification for review, approval, assessment and discharge decision per signature/date/time.

4. Patient 5's MR: Review of Discharge Safety Plan per staff N11 (Therapist) lacked documentation MD's authentification for review/approval per signature/date/time.

5. Patient 6's MR: Review of Discharge Safety Plan dated 1/11/21 per staff N12 lacked documentation of an MD's authentification for review/approval per signature/date/time. Review of Discharge Suicide Risk Reassessment note dated 1/12/21 per staff N12 (Registered Nurse [RN]) lacked documentation of an MD's authentification of review, assessment and discharge decision per signature/date/time. Review of Physician Progress Note dated 1/9/21 at 1230 hours and 1/10/21 at 1305 hours per medical staff D10 (N.P.) lacked documentation of an MD's review per signature/date/time. Review of Physician Progress Note dated 1/11/21 at 1346 hours per medical staff D6 (N.P.) lacked documentation of an MD's review per signature/date/time.

6. Patient 7's MR: Review of patient 7's MR indicated the Discharge Plan was initiated on 3/5/21 at 0800 hours per medical staff D2. Review of Discharge Safety Plan dated 3/5/21 at 1124 hours per staff N13 (Licensed Social Worker [LSW])) lacked documentation of an MD's authentification per signature/date/time for review and approval of the assessment. Review of Discharge Suicide Risk assessment dated [DATE] lacked documentation of an MD's authentification per signature/date/time for review, approval, assessment and discharge decision.

7. Patient 8's MR: Review of Physician Progress Note dated 12/5/20 at 0927 hours per medical staff D8 (N.P.) lacked documentation of review/approval by an MD per signature/date/time. Review of Physician Progress Note dated 12/6/20 at 1420 hours per medical staff D9 (N.P.) lacked documentation of MD's review/approval by signature/date/time.

8. Medical Staff By-laws, indicated:
a. page 8: "3.3.3 abide by all applicable federal and state laws, rules, and regulations and comply with the applicable standards of The Joint Commission and CMS"
b. page 9: "3.3.10 prepare and complete in a timely manner the medical and other required records for all patients he/she admits or in any way provides care in the Facility".

9. On 4/14/21 at approximately 1215 hours, staff N9 (Chief Executive Officer) was interviewed and confirmed MD's should be reviewing/approving and authenticating medical record documents per signature/date/time completed by mid-level providers such as N.P.'s.
VIOLATION: DISCHARGE PLANNING TIMELY EVALUATION Tag No: A0805
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for discharge planning in a medical record (MR) for 5 (patient 1, 3, 5, 6, 8) of 10 MR's reviewed:

Findings:

1. Patient 1's MR: Review of patient 1's MR lacked documentation of initiation of a discharge plan. Patient 1 was admitted on [DATE].

2. Patient 2's MR: Review of Discharge Plan indicated it was initiated on 12/2/20 per medical staff D5 (Nurse Practitioner [N.P.]). Patient 2 was admitted on [DATE].

3. Patient 3's MR: Review of Discharge Plan indicated it was initiated on 4/5/21 per staff N11 (Licensed Mental Health Counselor [LMHC]). Patient 3 was admitted on [DATE].

4. Patient 4's MR: Review of Discharge Plan indicated it was initiated on 4/12/21 per staff N11. Patient 4 was admitted on [DATE].

5. Patient 5's MR: Review of Discharge Plan indicated it was initiated on 2/12/21 per medical staff D2 (Doctor of Medicine [M.D.]). Review of patient 5's MR found a blank/undocumented Discharge Suicide Risk Reassessment note containing a patient identification sticker only. Patient 5 was admitted on [DATE].

6. Patient 6's MR: Review of Discharge Plan indicated it was initiated on 1/12/21 per medical staff D1 (M.D.). Patient 6 was admitted on [DATE].

7. Patient 7's MR: Review of Discharge Plan indicated it was initiated on 3/5/21 at 0800 hours per medical staff D2. Patient 7 was admitted on [DATE].

8. Patient 8's MR: Review of Discharge Plan indicated it was initiated on 12/9/20 per medical staff D7 (M.D.). Patient 8 was admitted on [DATE].

9. Policy/procedure, Policy No: 703.02, Aftercare/Discharge Plan, reviewed/revised 1/20, indicated: "Interdisciplinary team begins discharge planning at time of admission...".