HospitalInspections.org

Based on record review and interview it was determined that the facility failed to ensure that quality patient care was provided; a psychiatrist ordered a "medical consult" for Patient #1, the "medical consult" was not carried out until 5 days after it was ordered.

Findings were:
Review of Patient #1's medical record on 12/22/11 revealed the following:

A psychiatrist ordered a "medical consult" for Patient #1 on 11/2/11.

No evidence could be found indicating that the medical consult was carried out until the afternoon of 11/7/11.

A nurse's note dated 11/7/11 and timed 1600 (4:00PM) indicated that a physician assistant saw Patient #1. The nurses note stated "Physician assistant assess pt. Advises staff to encourage & offer pt to drink fluid Q hr."

During an interview with the Chief Nursing Officer on 12/22/11 she stated that the above documentation was evidence of the "medical consult" ordered on 11/2/11 being carried out. She stated that there was no evidence that the first medical consult on 11/2/11 was carried out for 5 days, from 11/2/11 to 11/7/11 at 4 PM.

A psychiatrist ordered a second "medical consult" for Patient #1 on 11/7/11.

A progress note from a psychiatrist on 11/7/11 at 1900 (7:00PM) stated the following "I evaluated the pt, he was lying on the bed mumbling a few intelligible words. Per staff reports, the patients nutritional intake, fluid intake, and out put has been minimal in the past 4 days. Internal medicine services was consulted by myself on 11/2/11. Per records they have not ordered any labs or imaging. At this time I feel that the patient's current condition is not entirely due to his mental health condition, but more so due to his nutritional and general medical status, which has severely deteriorated since admission."

After being seen by an internal medicine physician on 11/9/11 Patient #1 was transferred to a hospital for treatment of dehydration.

During an interview with the Chief Nursing Officer on 12/22/11 she confirmed the above findings.