HospitalInspections.org

Based on policy and procedure review, document review, medical record review, and personnel interview, the facility failed to follow policy and procedure related to accurate documentation of intent versus risk for 1 of 5 (N1) closed patient medical records reviewed; failed to ensure accurate documentation of referral source for 1 of 5 (N1); and completion of depression screening for 4 of 5 (N2, N3, N4 and N5) closed patient medical records reviewed.

Findings:

1. Policy titled, "Admissions Process", revised/reapproved 2/6/12, was reviewed on 1/15/13 at approximately 10:40 AM and indicated on pg. 2, under Screening Policy section, "[Facility] will ensure the proper documentation of ongoing monitoring."

2. Email from facility administrative personnel dated 1/31/13 at 9:18 AM, indicated:
A. the patient, accompanied by [D1], arrived directly at F1 seeking emergency psychiatric services. Previous to the patient's arrival, F1 had not received a referral for the patient from F3 [facility patient receives outpatient psychiatric services from]. Therefore, the patient was placed on the "Patient Walk-In" process track. Documentation from the Patient's Health History, completed [at F1] during the registration and/or medical clearance process, does not indicate that another individual or provider directed the patient to F1. However, the Service Activity Record [from F1] for the date of service does indicate that the nurse who performed the Behavioral Health Screening documented F3 as the Initial Referral Source. The counselor [from F3] did direct the patient to F1 for an assessment if during the weekend anything changed. Personnel from F3 confirmed to personnel at F1 that this information had not been communicated to F1.

3. Review of Service Activity Record dated 12/7/13 to 12/13/13 on 1/15/13 at 10:13 AM, indicated for patient N1, the Specific Initial Referral Source or Info is listed as their current psychiatric counselor from F3 [facility patient receives outpatient psychiatric services from].

4. Review of Rules and Regulations of the Medical Staff, revised/reapproved 12/12/12, on 1/15/13 at approximately 10:40 AM, indicated on pg. 6, under Medical Records section, point 1., "Content of the Medical Record: All patient record entries must be legible, complete...accurately reflects the patient's care and condition."

5. Review of closed patient medical records on 1/15/13 at approximately 3:20 PM, indicated patient:

A. N1:
a. was a 14-year-old who presented to the facility on 12/7/12 at 20:11 PM with a presenting problem of "hallucinations".
b. per Patient Health History dated 12/7/12, "Who asked you to come here today? (Be specific)", documented as 0.
c. per Psychiatric Intake Notes dated 12/7/12 at 20:15 PM, "patient has been hearing voices...the voices are telling him/her, 'I want to kill this person, make him bleed out.' Patient reports that he/she is having command hallucinations to kill people...the voices had stopped for a long while and now they are back today. [D1] is concerned about his/her safety and the safety of his/her family at home while [N1] is having command hallucinations...Patient reports he/she is currently hearing voices during this screening. Voices are telling him/her that he/she 'needs to go punch somebody'...Assault Hurt Others: No...Assault Thoughts: Denies..."
d. intent to do harm to others versus risk are not congruent. Intent to hurt or thought about hurting others is documented in the medical record as no and/or denies, but the patient is stating voices are telling him/her to harm others.

B. N2 was a 50-year-old who presented to the facility on 12/6/12 at 18:15 PM with a presenting problem of "major depression".
a. per Patient Health History dated 12/6/12, "Current Medical Condition: Depression."
b. lacked completion of a Patient Health Questionnaire (PHQ-9).

C. N3:
a. was a 15-year-old who presented to the facility on 12/10/12 at 16:53 PM with a presenting problem of "suicidal ideation".
b. per Psychiatric Intake Notes dated 12/10/12 at 17:21 PM, "is crying and very upset...Depressed."
c. lacked completion of a Patient Health Questionnaire (PHQ-9).

D. N4:
a. was a 46-year-old who presented to the facility on 12/11/12 at 16:54 PM with a presenting problem of "major depression, break down".
b. per Psychiatric Intake Notes dated 12/11/12 at 17:35 PM, "depressed."
c. lacked completion of a Patient Health Questionnaire (PHQ-9).

E. N5:
a. was a 44-year-old who presented to the facility on 12/13/12 at 16:07 PM with a presenting problem of "major depression".
b. per Patient Health History dated 12/13/12, "Current Medical Condition: Depression."
c. per Psychiatric Intake Notes dated 12/13/12 at 16:13 PM, "on medications for depression."
d. lacked completion of a Patient Health Questionnaire (PHQ-9).

6. Personnel P9 was interviewed on 1/15/13 at approximately 2:43 PM and confirmed, the PHQ-9 Patient Health Questionnaire which is used to determine a patient's depression level should be completed for all clients expressing depression during the intake process. This was not done for 4 (N2, N3, N4 and N5) of the 5 closed patient medical records reviewed by the surveyor.

Based on policy and procedure review, document review, medical record review, and personnel interview, the facility failed to follow policy and procedure related to provision of referral for outpatient services and/or follow-up treatment for 4 of 5 (N1, N3, N4 and N5) closed patient medical records reviewed.

Findings:

1. Policy titled, "Admissions Process", revised/reapproved 2/6/12, was reviewed on 1/15/13 at approximately 10:40 AM and indicated on pg. 3, under Assessment section, "If admission is declined by the doctor, the intake rep/nurse will follow up with PT [patient] and arrange for appropriate level of care determined during staffing. (i.e. OP [outpatient] appointment, discharge from services, referral to another facility)."

2. Policy titled, "Behavioral Health Screening and Nursing Assessment", revised/reapproved 2/6/12, was reviewed on 1/15/13 at approximately 10:40 AM and indicated on pg. 1, under Procedure section, point 8., "The RN Intake Coordinator or Intake Representative...Informs the patient and family of recommended disposition."

3. Review of Rules and Regulations of the Medical Staff, revised/reapproved 12/12/12, on 1/15/13 at approximately 10:40 AM, indicated on pg. 6, under Medical Records section, point 1., "Content of the Medical Record: All patient record entries must be legible, complete...accurately reflects the patient's care and condition."

4. Review of closed patient medical records on 1/15/13 at approximately 3:20 PM, indicated patient:

A. N1:
a. was a 14-year-old who presented to the facility on 12/7/12 at 20:11 PM with a presenting problem of "hallucinations".
b. per Psychiatric Intake Notes dated 12/7/12 at 21:13 PM, "Disposition Recommended: Outpatient..."
c. per Patient Health Questionnaire (PHQ-9) dated 12/7/12 at 20:33 PM, score 19. Score interpretation and possible actions for a score of 15-19 is, "Moderately severe depression" and "Initial Assessment - Treatment for depression using antidepressant, referral for psychotherapy and/or combination of treatment..."
d. lacked documentation that patient/family were given a referral form for outpatient services and/or treatment options.

B. N3:
a. was a 15-year-old who presented to the facility on 12/10/12 at 16:53 PM with a presenting problem of "suicidal ideation".
b. per Psychiatric Intake Notes dated 12/10/12 at 18:50 PM, "Disposition Recommended: Outpatient..."
c. lacked documentation that patient/family were given a referral form for outpatient services and/or treatment options.

C. N4:
a. was a 46-year-old who presented to the facility on 12/11/12 at 16:54 PM with a presenting problem of "major depression, break down".
b. per Psychiatric Intake Notes dated 12/11/12 at 18:24 PM, "Disposition Recommended: Outpatient..."
c. lacked documentation that patient/family were given a referral form for outpatient services and/or treatment options.

D. N5:
a. was a 44-year-old who presented to the facility on 12/13/12 at 16:07 PM with a presenting problem of "major depression".
b. per Psychiatric Intake Notes dated 12/13/12 at 22:37 PM, "Disposition Recommended: Outpatient..."
c. lacked documentation that patient/family were given a referral form for outpatient services and/or treatment options.

5. Personnel P1 was interviewed on 1/15/13 at approximately 3:50 PM and confirmed, a referral form for follow up treatment and/or outpatient services should be given to all patients who have an intake completed.

6. Medical record review confirmed patients N1, N3, N4, and N5 had outpatient services recommended upon disposition and lacked documentation of receipt of a referral form for follow up treatment and/or outpatient services.

Based on policy and procedure review, document review, and medical record review the facility failed to follow policy and procedure for inpatient mental health admission for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy titled, "Admission, Continued Stay, and Discharge Criteria for all [facility] Inpatient Units", revised/reapproved 4/8/12, was reviewed on 1/15/13 at approximately 10:40 AM and indicated, on pg. 1, under Admission Criteria section, point:
A. A., "The following criteria is necessary for inpatient mental health admission:
B. 1. Individual presenting for admission is assessed by or staffed with a licensed clinician and determined to have symptomatology consistent with DSM-IV-TR Axes 1 and 2 (if present) diagnosis, which can be treated, which is of an intensity where inpatient care is required, and where there is a reasonable expectation that the patient will respond to treatment. In addition, there must be evidence that the patient is potentially a threat to themselves or others or to have severe functional impairment as evidenced by at least one of the below criteria:
C. e. Command Hallucinations directing the individual to harm self or someone else.

2. Email from facility administrative personnel dated 1/31/13 at 9:18 AM, indicated:
A. the patient, accompanied by [D1], arrived directly at F1 seeking emergency psychiatric services.

3. Review of DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders Text Revision) Classification Axes I and II on 1/15/13 at approximately 4:00 PM, indicated Asperger's Disorder was classified as Axis I.

4. Review of closed patient medical records on 1/15/13 at approximately 3:20 PM, indicated patient N1:
A. was a 14-year-old who presented to the facility on 12/7/12 at 20:11 PM with a presenting problem of "hallucinations", but was not admitted.
B. per Psychiatric Intake Notes dated 12/7/12 at:
a. 20:15 PM, "he/she has been hearing voices...the voices are telling him/her, 'I want to kill this person, make him bleed out.' Patient reports that he/she is having command hallucinations to kill people...the voices had stopped for a long while and now they are back today. Patient has a diagnosis of Asperger's. [D1] is concerned about his/her safety and the safety of his/her family at home while [N1] is having command hallucinations...Patient reports he/she is currently hearing voices during this screening. Voices are telling him/her that he/she 'needs to go punch somebody'..."
b. 21:13 PM, "Disposition Recommended: Outpatient..."

5. Patient N1 has a diagnosis of Asperger's Disorder (an Axis I classification per DSM-IV-TR) and report of command hallucinations to harm others upon presentation to the facility. This met facility policy and procedure for admission criteria, which was not followed.