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Based on record review and interview the hospital failed to ensure patients received care in a safe setting as evidenced by the hospital identifying that patients were gaining access to cigarettes and lighters on the unit as evidenced by two patients (#2, #8) found smoking in their rooms. The hospital failed to conduct investigations to identify how the contraband was introduced to the unit or implement a plan to prevent introduction of hazardous items into the hospital. This has the potential to affect all patients in the hospital. Findings:

Patient #2

Review of a Risk Management Report, with the name of patient #2 documented on the report, dated 06/04/11 at 1930 (7:30 p.m.) (one day after admission) revealed the following: "Location: Room. Occurrence Involves: Patient. Type of Occurrence: Contraband found. Description of Occurrence: Cigarettes and lighter found in patient's room. Charge Nurse Responsibilities: Assessment Findings: Staff smelled smoke while checking rooms. Smoke smelled strongly in room (room #). Mandatory room search performed. Actions Taken: Mandatory room search performed. Cigarettes and lighter found in room. Cigarettes and lighter confiscated. Actions Taken to Prevent Further Occurrences: Explained rules and regulations. Documentation of event in medical record of all patients involved: Yes. Communication of event to ensure awareness between shifts: (checked) Change of Shift Report. (checked) Verbal Report.(checked) White Board. (checked) Patient Treatment Plan." Further review of the document revealed S18MD signed on 06/05/11, S1Administrator signed on 06/06/11, and S2DON signed on 06/06/11.

Review of patient #2's "Admission Inventory of Valuables and Restricted Items" dated 06/03/11 at 1225 (12:25 p.m.) revealed that patient #2 was in possession of Marlboro Red cigarettes and a red lighter and the disposition was documented as "N" (locked in nurses station).

Patient #8

Review of a Risk Management Report, with the name of patient #8 documented on the report, dated 04/10/11 at 0500 (5:00 a.m.) revealed the following: "Location: Room. Occurrence Involves: Patient. Type of Occurrence: Contraband found. Description of Occurrence: While doing rounds smelled smoke, went into patient's room and patient (#8) was coming out of bathroom. Charge Nurse Responsibilities: Assessment Findings: Patient asked if he was smoking, patient stated "no". Room search performed. Two empty cartons of cigarettes found and a lighter. Actions Taken: Room search performed. 2 empty cartons of cigarettes found. Actions Taken to Prevent Further Occurrences: Went over rules with patient. Documentation of event in medical record of all patients involved: Yes. Communication of event to ensure awareness between shifts: (checked) Change of Shift Report. (checked) Verbal Report." Further review of the document revealed S16MD signed (no date), S1Administrator signed on 04/11/11, and S2DON signed on 04/11/11.

Review of patient #8's "Admission Inventory of Valuables and Restricted Items" dated 03/30/11 at 1730 (5:30 p.m.) revealed that patient #8 was in possession of 7 Pall Mall cigarettes and the disposition was documented as "N" (locked in nurses station). Further review of the document revealed Patient #8 was not in possession of a lighter.

In an interview with S2DON on 06/16/11 at 1:20 she stated the hospital has no policy relating to trying to identify how high-risk contraband was in the possession of a patient in a locked psychiatric hospital.

Review of a hospital policy titled "Patient belongings/contraband", policy number 618.1, adopted March 2004, last revised July 2008, read in part: "Policy: The limitations on personal items serve to provide safety...The purpose of this policy is to outline the process for evaluation and storage of patient belongings that pose a risk to the patient's welfare and/or integrity of the milieu...Procedure: 1. During the pre-admission process, staff will inform the patient, and whenever appropriate, family members and friends of approved items and those considered to be contraband...5. The Patient Inventory Sheet is completed by the staff member in which all items considered to be valuables and/or contraband and to be retained by the hospital are logged along with their disposition...7. All items that are considered to be contraband that are to be retained by the hospital are to be labeled and stored in the patient storage area...11. Items that are considered contraband include but are not limited to the following:...Cigarettes...Lighters..."

Based on record review and interview the hospital failed to ensure there was documented evidence of continuous face-to-face monitoring of a patient in simultaneous restraint and seclusion per hospital policy for 1 of 1 patients reviewed for restraint/seclusion use in a total sample of 12. (#12) Findings:

Review of the Monthly Restraint Log for March 2011 revealed patient #12 was placed in simultaneous seclusion and restraint on 03/19/11 at 1300 (1:00 p.m.) and remained in seclusion and restraints until 03/20/11 at 0900 (9:00 a.m.).

Review of the Observation Flowsheet for March 19, 2011 revealed documentation by S11MHT (Mental Health Technician) that patient #12's Observation level was "RO" (routine observation). Further review of the Observation Flowsheet revealed documentation at 15 minute intervals from 1300 (1:00 p.m.) through 1845 (6:45 p.m.) and each documentation listed patient #12's observation status as "RO".

Review of a hospital document titled "Shift Amp Level and Staffing Report" revealed the line labeled "Staff assigned to 1:1" (one to one observation) had no documented evidence that the RN (Registered Nurse) assigned a specific MHT to monitor patient #12 while in simultaneous seclusion/restraint use.

In an interview on 06/15/11 at 1:25 p.m. with S10RN, Charge Nurse on 03/19/11 from 7:00 a.m. through 7:00 p.m., he confirmed there was no documented evidence of which staff member was assigned continuous 1:1 monitoring of patient #12 while in continuous seclusion/restraints per hospital policy. S10RN further confirmed that the Observation Flowsheet had "Routine Observation" documented every 15 minutes from initiation of restraint/seclusion at 1300 (1:00 p.m.) through 1845 (6:45 p.m.) when S10RN went off shift.

In an interview on 06/15/11 at 2:02 p.m. with S2DON she confirmed that she was the person responsible to audit the seclusion/restraint use on patient #12. S2DON confirmed that she checked the box marked "Evaluation of MHT monitoring of pt." S2DON further confirmed that there was no documented evidence of which staff member was assigned the 1:1 monitoring of patient #12 while in simultaneous seclusion/restraints per hospital policy. S2DON further confirmed that the Observation Flowsheet for patient #12 indicated his observation status was documented as "RO" from the initiation of simultaneous seclusion/restraint at 1300 (1:00 p.m.) through 1845 (6:45 p.m.).

Review of a hospital policy titled "Levels of Observation", policy number 605-1, adopted March 2004, last revised May 2006, read in part: "...Definitions: 1. Routine Observation (RO) - Patient is checked every 15 minutes to determine location and describe behavior...4. One to One (1:1) - Patient remains in close proximity (within easy reach) of staff at all times..."

Review of a hospital policy titled "Mental Health Technicians", policy number 406.14, adopted March 2004, last revised March 2010, reads in part: "...Summary of Major Functions: Under the supervision and/or direction of the Nurse Manager, Charge Nurse or Staff Nurse, the Mental Health Technician performs various duties assisting nursing or clinical staff in the treatment and care of psychiatric patient [sic] in accordance with the established methods and procedures of the Program...Duties and Responsibilities:..6. Knowledgeable and proficient in the use of Seclusion and Restraints and monitoring during seclusion and restraint episode outlined in the hospital policy and procedure, and completion of appropriate documents...12. Consistently document accurately and completely on all required paperwork in accordance with policy and procedure..."

Review of a hospital policy titled "Registered Nurse", policy number 406.11, adopted March 2004, no date of last revision, reads in part: "Summary of Major Functions: The registered Nurse executes comprehensive nursing care activities and provides psychiatric nursing staff leadership. He/she assesses patient needs, plans and implements patient care activities and evaluated[sic] the patient's response to treatment. He/she manages/acts within the therapeutic milieu and directs the delivery of nursing care by members of the nursing treatment team. He/she will supervise psychiatric aids...Duties and Responsibilities: Patient Care:..2. Serves as the primary nursing care coordinator for assigned patients...4. Plans, implements and coordinates nursing care activities for assign patients...6. Interprets the nursing and treatment needs for the patient to non-professional staff members assigned to the patient...11. Provides for patient safety...13. Documents continuous psychiatric assessment, intervention and evaluations relative to patient progress..."

Review of a hospital policy titled "Seclusion and/or Restraints", policy number 607, adopted 2004, last revised February 2008, reads in part: "Purpose: To define guidelines for appropriate therapeutic and safe use of seclusion and restraints that support patient health, welfare, safety, security, rights, and person [sic] dignity...Procedure:..14. Simultaneous restraint and seclusion is only permitted if the patient is continually monitored face-to-face by an assigned, trained staff member...21. All episodes of seclusion/restraint will be audited by the Director of Nursing or designee and a physician..."

Based on record review and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to update the nursing care plan for sexually inappropriate behavior, including goals and interventions, for 2 of 2 patients exhibiting sexually inappropriate behavior from a total of 12 sampled patients (#1, #2). Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/11 at 7:50am with a diagnosis Depression. Further review revealed he had a PEC (physician emergency certificate) signed on 06/02/11 at 7:00pm due to being suicidal, dangerous to self, and unable to seek voluntary admission. Further review revealed a CEC (coroner's emergency certificate) was signed on 06/03/11 at 3:10pm due to Patient #1 being gravely disabled and unwilling to seek voluntary admission.

Review of the "Multidisciplinary Administration of the Master Treatment Plan" revealed the problem list included 1) safety related to depression and suicidal ideation's; 2) medical related to neuropathy, fall precautions, and back pain; and 3) activities of daily living related to hygiene, nutrition, sleep, and medication non-compliance.

Review of the "7P-7A Nursing Assessment" revealed an entry on 06/04/11 at 2120 (9:20pm) of "patient was in the dayroom holding hands with another patient. Patient redirected and explained inappropriate behavior...".

Review of the "7P-7A Nursing Assessment" revealed an entry on 06/05/11, with no documented evidence of the time the entry was written, revealed "...Noted holding hands with a female peer. Rules provided to pt (patient)...".

Review of the "7A-7P Nursing Assessment" for 06/06/11 revealed an entry (no documented evidence of the time the entry was written) of "states another pt was sex inappropriate with him yesterday".

Review of the "Multidisciplinary Administration of the Master Treatment Plan" revealed an entry on 06/06/11 of "sexually inappropriate added to pt problem for holding hands with peer-redirection provided...". This addition was made two days after the behavior had first been observed. Further review revealed no documented evidence of short-term goals developed and interventions implemented for the added problem of sexually inappropriate behavior.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/03/11 at 12:25pm with a diagnosis of Depression. Further review revealed her legal status was Formal Voluntary Admission (FVA).

Review of the "Multidisciplinary Administration of the Master Treatment Plan" revealed the problem list included 1) safety related to depression and anxiety; 2) medical related to chronic back/neck/knee pain, and fall risk; and 3) ADLs related to sleep. Further review revealed the "Nursing Plan of Care Safety" was updated on 06/04/11 to add patient holding hands with another patient. Further review revealed no documented evidence of short-term goals developed and interventions implemented for the added problem of sexually inappropriate behavior.

In a face-to-face interview on 06/15/11 at 1:10pm, RN (registered nurse) S9 indicated the first time any sexually inappropriate behavior is witnessed, the patient's treatment plan should be updated.

In a face-to-face interview on 06/16/11 at 10:20am, RN S13 indicated, after reviewing Patient #1's medical record, the addition of Patient #1 holding hands with another patient was not dated when the nurse updated his care plan. She further indicated the short-term and long-term goals should be more individualized for the patient.

Review of the hospital policy titled "Master Treatment Plan", policy number 208.2 revised 06/07 and submitted by Administrator S1 as one of their care plan policies, revealed, in part, "... 1. Master Treatment Plan will be initiated upon admission by various disciplines conducted initial assessments. 2. The initial treatment team meeting/staffing is held within 5 days of admission. The initials assessments are utilized to determine what issues will be addressed as part of the patient's Treatment Plan. Problem numbers are assigned based on priority and should be sequential, and each problem should have a separate page. 3. The patient's treatment plan will define goals for problems resolution. 4. Define behavior objective for each treatment intervention which will be indicators of movement toward the goal. Objective must be specific, measurable, representing steps toward reaching the goal. Including except achievement date. 5. Define specific intervention which will be utilized to help patient achieve objectives and goals. Include the frequency of each activity ... which discipline will be responsible for implementation and name person responsible... 6. List specific, measurable criteria for goal attainment, i. e. (that is) what the patient will do to demonstrate they have accomplished the goal. 7. Each time the plan is revised, enter date. If plan has been revised, indicated this and note any revisions in appropriate area on the Master Treatment Plan Review form. ... 13. Definitions ... b. Goals - observable, measurable actions, in which the patient will engage within a specified time frame. ... Objective should be written so that they are: i. Specific - Objective should be consistent and clearly defined. 99. Observable - The objective should be behaviors that can be observed... iii. Measurable - the objective should be stated that they can be defined in terms of frequency, quantity, duration. iv. Realistic - the objective should be obtainable considering the patient, staff and resources available to carry out the program. ... e. Interventions - are specific action steps or treatment strategies that the treatment team employs to facilitate the accomplishment of the goal. Interventions are: i. Specific: clearly defined ii. Measurable: provide indicators of behavior change. iii. Time Limited: revisions can be made if not successful or appropriate. iv. Reinforcing: by completing the action required by the intervention, patients can experience success".

Review of the hospital policy titled "Inappropriate Sexual Behavior of Patients" , policy number (blank), adopted March 2008, last revised May 2008, revealed "Purpose: To assure assessment, identification, monitoring and treatment interventions for patients exhibiting inappropriate sexual behaviors. Policy: Patient's are assessed upon admission and re-assessed on a daily basis for sexually inappropriate behaviors. Patient's identified exhibiting sexually inappropriate behaviors will be monitored according to physician's orders with treatment interventions focused on modifying behaviors as reflected in the patient's treatment play [sic]. Definition: Sexually Inappropriate Behaviors - behaviors of a sexual nature that include but are not limited to crude gestures or comments, inappropriate touching, or intimate actions between patients. Procedure: 1. If either upon admission or during the patient's stay, a patient is identified as exhibiting inappropriate sexual behaviors via observation or report, the RN will provide documentation of behaviors and actions taken either on the Adult Admission Data Base and/or the Daily Nursing Assessment, on the patient's treatment plan, and on the change of shift report via code number (4). 2. In addition, the RN will ensure appropriate monitoring of the patient according to the ordered observation level and that appropriate monitoring is reflected by the MHT on the Observation Flow Sheet. 3. If sexually inappropriate behaviors occur between two patients, documentation of the event is to be in both patients medical records along with adjustments of both patients treatment plans and codes on the change of shift report to ensure on-going communication between shifts and disciplines and to ensure the re-assessment of behaviors are reflected on a daily basis in the Daily Nursing Assessment."

Based on record review and interview the hospital failed to ensure the RN (Registered Nurse) made patient care assignments as evidenced by no documented evidence of which staff member was assigned the continuous face-to-face monitoring of a patient in simultaneous restraint and seclusion per hospital policy for 1 of 1 patients reviewed for restraint/seclusion use in a total sample of 12. (#12) Findings:

Review of the Monthly Restraint Log for March 2011 revealed patient #12 was placed in simultaneous seclusion and restraint on 03/19/11 at 1300 (1:00 p.m.) and remained in seclusion and restraints until 03/20/11 at 0900 (9:00 a.m.).

Review of the Observation Flowsheet for March 19, 2011 revealed documentation by S11MHT (Mental Health Technician) that patient #12's Observation level was "RO" (routine observation). Further review of the Observation Flowsheet revealed documentation at 15 minute intervals from 1300 (1:00 p.m.) through 1845 (6:45 p.m.) and each documentation listed patient #12's observation status as "RO".

Review of a hospital document titled "Shift Amp Level and Staffing Report" revealed the line labeled "Staff assigned to 1:1" (one to one observation) had no documented evidence that the RN (Registered Nurse) assigned a specific MHT to monitor patient #12 while in simultaneous seclusion/restraint use.

In an interview on 06/15/11 at 1:25 p.m. with S10RN, Charge Nurse on 03/19/11 from 7:00 a.m. through 7:00 p.m., he confirmed there was no documented evidence of which staff member was assigned continuous 1:1 monitoring of patient #12 while in continuous seclusion/restraints per hospital policy. S10RN further confirmed that the Observation Flowsheet had "Routine Observation" documented every 15 minutes from initiation of restraint/seclusion at 1300 (1:00 p.m.) through 1845 (6:45 p.m.) when S10RN went off shift.

In an interview on 06/15/11 at 2:02 p.m. with S2DON she confirmed that she was the person responsible to audit the seclusion/restraint use on patient #12. S2DON confirmed that she checked the box marked "Evaluation of MHT monitoring of pt." S2DON further confirmed that there was no documented evidence of which staff member was assigned the 1:1 monitoring of patient #12 while in simultaneous seclusion/restraints per hospital policy. S2DON further confirmed that the Observation Flowsheet for patient #12 indicated his observation status was documented as "RO" from the initiation of simultaneous seclusion/restraint at 1300 (1:00 p.m.) through 1845 (6:45 p.m.).

Review of a hospital policy titled "Levels of Observation", policy number 605-1, adopted March 2004, last revised May 2006, read in part: "...Definitions: 1. Routine Observation (RO) - Patient is checked every 15 minutes to determine location and describe behavior...4. One to One (1:1) - Patient remains in close proximity (within easy reach) of staff at all times..."

Review of a hospital policy titled "Mental Health Technicians", policy number 406.14, adopted March 2004, last revised March 2010, reads in part: "...Summary of Major Functions: Under the supervision and/or direction of the Nurse Manager, Charge Nurse or Staff Nurse, the Mental Health Technician performs various duties assisting nursing or clinical staff in the treatment and care of psychiatric patient [sic] in accordance with the established methods and procedures of the Program...Duties and Responsibilities:..6. Knowledgeable and proficient in the use of Seclusion and Restraints and monitoring during seclusion and restraint episode outlined in the hospital policy and procedure, and completion of appropriate documents...12. Consistently document accurately and completely on all required paperwork in accordance with policy and procedure..."

Review of a hospital policy titled "Registered Nurse", policy number 406.11, adopted March 2004, no date of last revision, reads in part: "Summary of Major Functions: The registered Nurse executes comprehensive nursing care activities and provides psychiatric nursing staff leadership. He/she assesses patient needs, plans and implements patient care activities and evaluated[sic] the patient's response to treatment. He/she manages/acts within the therapeutic milieu and directs the delivery of nursing care by members of the nursing treatment team. He/she will supervise psychiatric aids...Duties and Responsibilities: Patient Care:..2. Serves as the primary nursing care coordinator for assigned patients...4. Plans, implements and coordinates nursing care activities for assign patients...6. Interprets the nursing and treatment needs for the patient to non-professional staff members assigned to the patient...11. Provides for patient safety...13. Documents continuous psychiatric assessment, intervention and evaluations relative to patient progress..."

Review of a hospital policy titled "Seclusion and/or Restraints", policy number 607, adopted 2004, last revised February 2008, reads in part: "Purpose: To define guidelines for appropriate therapeutic and safe use of seclusion and restraints that support patient health, welfare, safety, security, rights, and person [sic] dignity...Procedure:..14. Simultaneous restraint and seclusion is only permitted if the patient is continually monitored face-to-face by an assigned, trained staff member...21. All episodes of seclusion/restraint will be audited by the Director of Nursing or designee and a physician..."

Based on observation and interview, the hospital failed to ensure patient medical records were properly filed to maintain the integrity of the record by having no means of protecting patient medical records from water damage caused by flooding, roof leakage, and/or sprinkler system activation. Findings:

Observation on 06/15/11 at 11:00 am revealed two rooms used for the storage of patient medical records. The room adjacent to the medical record office contained seven rows of wooden shelves constructed in a "U" formation. Further observation revealed three of the rows were filled with patient medical records, and the first part of row four contained patient medical records. Further observation revealed patient medical records awaiting the discharge summary to be dictated were stacked on top of a shelf in the room. Observation of the second room, located across the hall from the medical record office, revealed three wooden racks each containing seven rows of shelves. Further observation revealed one double-sided rack in the center of the room that contained a total of fourteen rows of shelves. Further observation revealed all shelves were filled with patient medical records except half of one row of shelving. Observation of the storage of medical records in each room revealed no evidence of a means of protecting the records from water damage. Further observation revealed each room had a sprinkler system present.

In a face-to-face interview on 06/16/11 at 1:10 pm, Administrator S1 confirmed there was no protection of the patient medical records from water damage in either room.

Based on record review and interviews, the hospital failed to ensure verbal orders were authenticated within 10 days after receipt of the order as evidenced by failure to have the physician date and time when he/she signs the verbal order for 4 of 4 patients reviewed for verbal order authentication from a total sample of 12 patients (#1, #2, #3, #4). Findings:

Patient #1
Review of Patient #1's "Admission Orders" revealed they were received by telephone order on 06/03/11 at 0750 (7:50 am). Further review revealed no documented evidence of the date and time Medical Director S16 authenticated the order.

Review of the "Medical Initial Doctors Order Set" revealed the verbal order was received on 06/03/11 at 7:50 am. Further review revealed no documented evidence of the date and time Physician S18 authenticated the order.

Patient #2
Review of Patient #2's "Admission Orders" revealed they were received by telephone order on 06/03/11 at 1225 (12:25 pm). Further review revealed no documented evidence of the date and time Medical Director S16 authenticated the order.

Review of the "Medical Initial Doctors Order Set" revealed the verbal order was received on 06/03/11 at 12:25 pm. Further review revealed no documented evidence of the date and time Physician S18 authenticated the order.

Patient #3
Review of Patient #3's "Medical Initial Doctors Order Set" revealed the verbal order was received on 05/31/11 at 2130 (9:30 pm). Further review revealed no documented evidence of the date and time Physician S18 authenticated the order.

Review of the "Psychiatric Initial Doctor's Order Set" revealed it was received by telephone order on 05/31/11 at 9:30 pm. Further review revealed no documented evidence of the date and time Medical Director S16 authenticated the order.

Review of the "Doctor's Order Sheet" revealed a telephone order was given on 06/01/11 at 0150 (1:50 am) by Psychiatrist S17. Further review revealed no documented evidence of the date and time Psychiatrist S17 authenticated the order.

Review of the "Doctor's Order Sheet" revealed a telephone order was given on 06/02/11 at 2100 (9:00 pm) by Psychiatrist S17. Further review revealed no documented evidence the verbal order had been authenticated by S17 as of the time of this review on 06/15/11.

Patient #4
Review of Patient #4's "Medical Initial Doctors Order Set" revealed the verbal order was received on 03/24/11 at 10:05 am. Further review revealed no documented evidence of the date and time Physician S18 authenticated the order.

Review of the "Psychiatric Initial Doctor's Order Set" revealed it was received by telephone order on 03/24/11 at 10:05 am. Further review revealed no documented evidence of the date and time Medical Director S16 authenticated the order.

Review of the "Doctor's Order Sheet" revealed a telephone order was given on 03/25/11 at 8:35 am by Physician S18. Further review revealed the verbal order was authenticated by Medical Director S16 with no documented evidence of the date and time S16 signed the verbal order. Further review revealed verbal orders received on 03/28/11 at 2:00 pm and 03/30/11 at 10:00 am had no documented evidence of the date and time Medical Director S16 authenticated the verbal orders.

In a face-to-face interview on 06/15/11 at 11:00 am, Medical Records Coordinator S4 indicated she flagged unsigned verbal orders for the physician to sign, but she did not know what the timeframe was for having them signed.

In a face-to-face interview on 06/15/11 at 1:30 pm, Administrator S1 indicated the medical staff rules and regulations allowed 10 days to have verbal orders co-signed by the physician. S1 further indicated that authentication meant, in his opinion, that it needed to be dated and timed when signed.

Review of the "Rules and Regulations", revised and approved 05/17/11 and submitted by Administrator S1 as their current medical staff rules and regulations, revealed, in part, "...H. All clinical entries in the patient's medical record shall be dated with signature and title. ... J. Verbal orders shall be authenticated within 10 days by the ordering or covering physician...".

Based on record review and interviews, the hospital failed to send medical information to physicians or outpatient providers who would provide after-care as evidenced by failure to develop a system to ensure a patient's medical information was sent to providers to whom the patient was referred for after-care for 4 of 6 patients reviewed for discharge planning from a total of 12 sampled patients (#1, #2, #4, #10). The hospital policy required patient medical records to be sent only when requested by the after-care provider. Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/11 at 7:50 am with a diagnosis of Depression. Further review revealed he was discharged on 06/15/11. Review of the "Discharge Instructions" completed on 06/15/11 at 9:30 am revealed Patient #1 had a follow-up appointment with Physician S21 on 06/27/11 at 9:00 am and Physician S22 on 06/17/11 at 11:00 am. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #1's medical records had been sent to these physicians who would provide his after-care.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/03/11 at 12:25 pm with a diagnosis of Depression. Further review revealed she was discharged on 06/15/11. Review of the "Discharge Instructions" completed on 06/15/11 at 1:20 pm revealed Patient #2 had a follow-up appointment with Physician S23 on 06/15/11 at 3:00 pm. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #2's medical records had been sent to Physician S23, the physician who would provide her after-care.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 03/24/11 at 10:05 am with a diagnosis of Depression. Further review revealed she was discharged on 03/30/11 at 12:05 pm.

Review of the "Discharge Instructions" completed on 03/30/11 at 12:05 pm by RN (registered nurse) S13 revealed she had a therapy appointment with Physician S20 on 03/31/11 at 10:00 am and a medical follow-up appointment with Physician S14 on 03/31/11 at 2:45 pm.

Review of the "Consent to Release Information" to Physician S14 signed by Patient #4 and witnessed by RN S8 on 03/28/11 revealed, in part, "...The following information from my treatment record may be released/obtained: (box to check left blank) Written (box to check left blank) Verbal (boxes checked for the following) Medical and Psychiatric History, Lab/X-ray findings, Physician Discharge Summary, Diagnosis, Psychosocial Assessment, Psychiatric Evaluation, Aftercare, Itemized Invoices, Other: Anything he request". Further review revealed no documented evidence of the completion of "This disclosure will be made for the following purposes: Continuation of care/aftercare, Transfer, Coordination of Treatment/Services, Family/significant other involvement in treatment, Other". Review of the entire medical record revealed no documented evidence that any medical records were sent to Physician S14 or that a release of information had been completed for and records sent to Physician S20.

Patient #10
Review of Patient #10's medical record revealed she was admitted on 03/29/11 at 7:50 pm with a diagnosis of Depression. Further review revealed she was discharged on 04/05/11 at 11:05 am. Review of the "Discharge Instructions" completed on 04/05/11 at 11:05 am revealed Patient #10 had a therapy appointment at Facility "c" on 04/12/11 at 9:00 am and a medical follow-up appointment with Physician S24 on 04/25/11 at 9:00 am. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #10's medical records had been sent to Physician S24 or Facility "c", providers who would be providing after-care for Patient #10.

In a face-to-face interview on 06/15/11 at 11:15 am, Medical Records Coordinator S4 confirmed no part of Patient #4's medical record was released to Physician S14 or Physician S20 for after-care treatment. She further indicated she had not received a call from Physician S14 requesting Patient #4's medical records. S4 further indicated, if a request had been made, she would have had Patient #4 complete and sign another consent to release information.

In a face-to-face interview on 06/15/11 at 12:45 pm, RN S8 indicated Patient #4 told her that she (Patient #4) wanted any information requested to be shared with Physician S14. RN S8 further indicated she didn't remember Patient #4 asking her to send any records to Physician S14, just that he may be calling to check on her. S8 indicated she never spoke with Physician S14, and she thought that Physician S14 had called before the consent to release information had been signed, and that's the reason the consent was completed and signed (in anticipation of a return call from Physician S14).

In a face-to-face interview on 06/16/11 at 10:20 am, RN S13 indicated the therapy follow-up appointments for after-care were made by the social worker, and the medical appointments for after-care were made by the nurse. S13 further indicated the social worker usually faxes the medical information to the physicians or delegated it to the unit clerk. After review of Patient #4's medical record, RN S13 confirmed there was no documented evidence in the medical record that a consent to release information to Physician S20 had been completed and signed or that any records had been sent to Physician S20 or Physician S14.

Former Social Worker S19, the social worker who was involved with scheduling the after-care appointment with Physician S20 for Patient #4 was no longer employed at the hospital and was unable to be interviewed.

In a face-to-face interview on 06/16/11 at 11:05 am, LCSW (licensed clinical social worker) S7 confirmed that the social worker made after-care appointments for therapy and the nurse made them for medical appointments. S7 indicated she would obtain a consent to release information and fax patients' medical records for any appointment that she made. S7 further indicated she didn't always document in the patient's medical record that she had faxed records and what records she had faxed.

In a face-to-face interview on 06/16/11 at 1:00pm, DON (director of nursing) S2 indicated that discharge planning did not provide for continuity of care without patient medical records being sent to the providers who would see the patients for after-care.

Review of the hospital policy titled "Discharge Instructions and Process", policy number 212.2 revised 06/07 and submitted by Administrator S1 as their current discharge planning policy, revealed, in part, "...Discharge planning begins at time of admission; the patient's discharge plan is determined by the multidisciplinary treatment team with the primary goal to return to the most appropriate environment with after-care arrangements to maximize the patient's prognosis. ... If patient is transferred to another facility/institution the nurse will fill out appropriate transfer paperwork and provide requested information to receiving facility, accompanying family member, transfer driver, or nurse. 4. The Discharge Coordinator shall: a. Initiate Discharge Instruction Sheet to include but not limited to: Patient destination, Referrals for Outpatient Services (both psychiatric and medical), Community Support Groups/Resources, Special Instructions b. Review discharge and aftercare plan with the patient and, as possible, family. c. Make certain that all necessary releases of information have been signed...".

Review of the hospital policy titled "Discharge and Continuing Care Plan", policy number 212.1 revised 06/07 and submitted by Administrator S1 as their current discharge planning policy, revealed, in part, "...5. Referrals for after-care which include follow-up for psychiatric and medical issues as appropriate are insured by the discharge coordinator. ... 7. It is the responsibility of the primary therapist to ensure discharge planning and follow through occurs, and the responsibility of the director of social services to establish a mechanism whereby this process occurs".

Based on record review and interviews, the hospital failed to ensure an individualized comprehensive treatment plan was developed for each patient as evidenced by the use of generic treatment plans that had the same goals and interventions with a blank to be completed indicating the day the goal was to be met. This finding was evident for 3 of 3 patients reviewed for implementation of the treatment plan from a total sample of 12 patients (#1, #2, #4). Findings:

Review of the "Safety Nursing Plan of Care" revealed the choices of risk were danger to self, danger to others, elopement, and sexually inappropriate. Further review revealed the short-term goals were a list to be checked with a blank for the day to be written. The list included: patient will be appropriate for routine observation by day ___; patient's acuity score will decrease by ___ points by day ___; patient will demonstrate no self-injury by day ___; patient will not harm other's or destroy property by day ___; patient will exhibit increased impulse control by day ___; patient will not exhibit elopement risk behaviors by day ___; patient will demonstrate a decrease in sexually inappropriate behaviors by day ___; patient will exhibit a decrease in anxiety/agitation and/or psychotic features so that use of unscheduled medications are no longer required by day ___; patient will exhibit a decrease in high risk behaviors so that use of seclusion/restraint are no longer required by day ___; patient will no longer required MD (medical doctor) ordered restrictions by day ___ as evidenced by: ___.
Interventions included: MD ... will initiate treatment orders upon admit and as needed to include observation level appropriate to ensure patient safety; admit nurse will ensure daily that patient is monitored per ordered observational level, that frequent contact is made with pt (patient) to establish trust/encourage expression of feelings, that contributing factors to risk behaviors such as pain, anxiety, etc. (and so on) are assessed and addressed, and that scheduled and prn (as needed) medications are administered as ordered; social worker will assess patient upon admit/as needed to determine contributing factors to risk, develop effective coping skills, and motivate patient to become active in treatment; recreational therapist will assess patient upon admit and as needed to determine activities as possible outlets/expressions for patient's emotions; MD will assess need for continued restrictions every 24 hours. Further review revealed no documented evidence of choices to select for long-term goals.

Review of the "Medical Nursing Plan of Care" revealed the choices of risk were co-morbidity and/or disability: ___; fall risk - fall risk score ___ related to : ___; pain - pain score ___ pain goal ___ related to: ___; withdrawals related to: ___; med non-compliance.
The choice for short-term goals were as follows: patient will verbalize/exhibit a decrease in the following symptoms ___; patient will utilize aids/education to decrease fall risk by ___ points by day ___ and will not incur a fall or fall related injury by discharge; patient will report a decrease in pain by ___ points by day ___ and verbalize effective pain relief measures by discharge; patient will be compliant with medications by day ___ and verbalize medication education by discharge; patient will be compliant with detox regime by day ___ and not experience withdrawal signs/symptoms by discharge.
The long-term goal was patient will verbalize self-care related to disease process by discharge.
Intervention choices included the following: MD will initiate physician orders upon admit and as needed to ensure treatment interventions are initiated for pertinent medical disorders and/or disabilities; admit nurse will ensure orders are implemented upon admit and that treatment interventions are initiated; charge nurse will ensure that daily the physician orders are implemented, symptoms associated with co-morbidity are assessed and that significant findings are addressed and/or reported to the physician, and patient is educated as needed related to co-morbidity and treatment interventions; charge nurse will ensure that the patient's fall risk score is assessed daily, and that fall prevention education and encouragement of fall prevention aids is conducted as needed; charge nurse will ensure that patient's pain is assessed daily/as needed, that pain relief medications are administered as prescribed, effectiveness is monitored, and that education regarding alternative pain relief measures in provided as needed; charge nurse ensure that patient's compliance with medications is assessed daily and that patient is educated regarding medications as indicated; charge nurse will ensure that patient is monitored for signs/symptoms of withdrawals daily and as needed and that detox medications are administered as prescribed by physician.

Review of the "Activities of Daily Living (ADL) Nursing Plan of Care" revealed the short-term goals included: patient will conduct self-hygiene by day ___ with improved hygiene as evidenced by neat, clean, groomed appearance; patient will consume ___ % )per cent) of meals and snacks by day ___; patient will verbalize improved ability to fall asleep by day ___ with a reported sleep of 6-8 hours by day ___. The long-term goal was patient will perform self-ADLs without prompting related to proper hygiene, adequate nutrition and sleep by discharge.
The choice of interventions included: admit nurse will ensure orders are implemented upon admit and that treatment interventions are initiated; charge nurse will ensure that the patient is encouraged or assisted with ADL's daily and as needed; MD will initiate physician orders upon admit and as needed to ensure nutritional needs of patient are met related to diet and nutritional interventions; admit nurse will ensure that the need for a nutritional assessment is logged for patient's identified at nutritional risk; dietitian will conduct nutritional assessments as indicated and initiate nutritional interventions as applicable; charge nurse will ensure that patient's intake of meals and snacks is recorded per shift; charge nurse will ensure continued monitoring of patients weight on weekly basis or as ordered and monitor daily for other nutritional risk behaviors, i.e. bulemic/anorexic behaviors; charge nurse will ensure that patient's hours of sleep are recorded daily, and that sleep aids are administered as prescribed; social worker will assess patient upon admit and as needed related to contributing factors to poor hygiene, altered nutrition, altered sleep patterns and work collaboratively with patient to develop skills to improve ADL's; recreational therapist will assess patient upon admit/as needed related to contributing factors to poor hygiene, altered nutrition, or altered sleep patterns/work collaboratively with patient to develop skills to improve ADL's.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/11 at 7:50am with a diagnosis Depression. Further review revealed he had a PEC (physician emergency certificate) signed on 06/02/11 at 7:00pm due to being suicidal, dangerous to self, and unable to seek voluntary admission. Further review revealed a CEC (coroner's emergency certificate) was signed on 06/03/11 at 3:10pm due to Patient #1 being gravely disabled and unwilling to seek voluntary admission. Review of the "Social Service Progress Notes" dated 06/08/11 revealed he was admitted when he began withdrawing severely and became suicidal due to pain and withdrawal symptoms (from prescribed medications for pain and anxiety).
Review of Patient #1's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 06/06/11. Further review revealed the safety, medical, and ADL plans of care were initiated on 06/03/11. Further review of each revealed no documented evidence that the nursing, social service, or recreational therapy staff had made any additions to the generic-written care plans to individualize them for Patient #1.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/03/11 at 12:25pm with a diagnosis of Depression. Further review revealed her legal status was Formal Voluntary Admission (FVA). Review of the "Psychiatric Evaluation" revealed she was admitted voluntarily for treatment for panic attacks.
Review of Patient #2's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 06/06/11. Further review revealed the safety, medical, and ADL plans of care were initiated on 06/03/11. Further review of each revealed no documented evidence that the nursing, social service, or recreational therapy staff had made any additions to the generic-written care plans to individualize them for Patient #2.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 03/24/11 at 10:05am with a diagnosis of Depression. Further review revealed she had a PEC signed on 03/24/11 at 5:38am due to being suicidal, dangerous to self, and unwilling to seek voluntary admission. Further review revealed a CEC was signed on 03/26/11 at 1:55pm due to Patient #4 being gravely disabled and unwilling to seek voluntary admission.
Review of Patient #4's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 03/28/11. Further review revealed the safety, medical, and ADL plans of care were initiated on 03/24/11. Further review of each revealed no documented evidence that the nursing, social service, or recreational therapy staff had made any additions to the generic-written care plans to individualize them for Patient #4.

In a face-to-face interview on 06/16/11 at 10:20am, RN (registered nurse) S13 indicated the nursing treatment plans were more generic and not individualized for each patient. After review of the treatment plans for Patients #1, #2, and #4, S13 confirmed there were no additions written by the staff to individualize any of the interventions or goals specifically for each patient.

Review of the hospital policy titled "Master Treatment Plan", policy number 208.2 revised 06/07 and submitted by Administrator S1 as one of their care plan policies, revealed, in part, "... 1. Master Treatment Plan will be initiated upon admission by various disciplines conducted initial assessments. 2. The initial treatment team meeting/staffing is held within 5 days of admission. The initials assessments are utilized to determine what issues will be addressed as part of the patient's Treatment Plan. Problem numbers are assigned based on priority and should be sequential, and each problem should have a separate page. 3. The patient's treatment plan will define goals for problems resolution. 4. Define behavior objective for each treatment intervention which will be indicators of movement toward the goal. Objective must be specific, measurable, representing steps toward reaching the goal. Including except achievement date. 5. Define specific intervention which will be utilized to help patient achieve objectives and goals. Include the frequency of each activity ... which discipline will be responsible for implementation and name person responsible... 6. List specific, measurable criteria for goal attainment, i. e. (that is) what the patient will do to demonstrate they have accomplished the goal. 7. Each time the plan is revised, enter date. If plan has been revised, indicated this and note any revisions in appropriate area on the Master Treatment Plan Review form. ... 13. Definitions ... b. Goals - observable, measurable actions, in which the patient will engage within a specified time frame. ... Objective should be written so that they are: i. Specific - Objective should be consistent and clearly defined. 99. Observable - The objective should be behaviors that can be observed... iii. Measurable - the objective should be stated that they can be defined in terms of frequency, quantity, duration. iv. Realistic - the objective should be obtainable considering the patient, staff and resources available to carry out the program. ... e. Interventions - are specific action steps or treatment strategies that the treatment team employs to facilitate the accomplishment of the goal. Interventions are: i. Specific: clearly defined ii. Measurable: provide indicators of behavior change. iii. Time Limited: revisions can be made if not successful or appropriate. iv. Reinforcing: by completing the action required by the intervention, patients can experience success".

Based on record review and interview, the hospital failed to ensure the written treatment plan was developed according to hospital policy by failing to have specific and measurable short-term and long-term goals for 3 of 3 patients reviewed for development of the treatment plan from a total sample of 12 patients (#1, #2, #3). Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/11 at 7:50am with a diagnosis Depression. Further review revealed he had a PEC (physician emergency certificate) signed on 06/02/11 at 7:00pm due to being suicidal, dangerous to self, and unable to seek voluntary admission. Further review revealed a CEC (coroner's emergency certificate) was signed on 06/03/11 at 3:10pm due to Patient #1 being gravely disabled and unwilling to seek voluntary admission. Review of the "Social Service Progress Notes" dated 06/08/11 revealed he was admitted when he began withdrawing severely and became suicidal due to pain and withdrawal symptoms (from prescribed medications for pain and anxiety).

Review of Patient #1's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 06/06/11. Further review revealed the long-term goal was "patient will meet 75% of goals and be less depressed, no s/i (suicidal ideation's), be medically stable, report improvement in ability to perform ADL's (activities of daily living) without difficulty". There was no documented evidence of indicators or behaviors that would be used to determine that Patient #1 would be less depressed, be medically stable, and show improvement in the ability to perform ADLs.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/03/11 at 12:25pm with a diagnosis of Depression. Further review revealed her legal status was Formal Voluntary Admission (FVA). Review of the "Psychiatric Evaluation" revealed she was admitted voluntarily for treatment for panic attacks.

Review of Patient #2's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 06/06/11. Further review revealed the long-term goal was "patient will meet 75% of goals and mood improved, less depressed, less anxious, no si/hi/ah/vh (suicidal ideations/homicidal ideations/auditory hallucinations/visual hallucinations), medically stable, no sexually inappropriate behavior, improved sleep pattern". There was no documented evidence of indicators or behaviors that would be used to determine that Patient #2's mood had improved, she was less depressed and anxious, she was medically stable, and her sleep pattern had improved.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 03/24/11 at 10:05am with a diagnosis of Depression. Further review revealed she had a PEC signed on 03/24/11 at 5:38am due to being suicidal, dangerous to self, and unwilling to seek voluntary admission. Further review revealed a CEC was signed on 03/26/11 at 1:55pm due to Patient #4 being gravely disabled and unwilling to seek voluntary admission.

Review of Patient #4's "Multidisciplinary Administration of the Master Treatment Plan" revealed it was initiated on 03/28/11. Further review revealed the long-term goal was "patient will meet 75% of goals and mood stabilized, decreased depressed mood, no si, medically stable, report improved sleep pattern". There was no documented evidence of indicators or behaviors that would be used to determine that Patient #4's mood had stabilized, she was less depressed, was medically stable, and had an improved sleep pattern.

In a face-to-face interview on 06/16/11 at 10:20am, RN (registered nurse) S13 indicated the nursing treatment plans were more generic and not individualized for each patient. After review of the treatment plans for Patients #1, #2, and #4, S13 confirmed the interventions were not based on patient behaviors which could then be used to determine when the patient achieved the goal.

Review of the hospital policy titled "Master Treatment Plan", policy number 208.2 revised 06/07 and submitted by Administrator S1 as one of their care plan policies, revealed, in part, "... 1. Master Treatment Plan will be initiated upon admission by various disciplines conducted initial assessments. 2. The initial treatment team meeting/staffing is held within 5 days of admission. The initials assessments are utilized to determine what issues will be addressed as part of the patient's Treatment Plan. Problem numbers are assigned based on priority and should be sequential, and each problem should have a separate page. 3. The patient's treatment plan will define goals for problems resolution. 4. Define behavior objective for each treatment intervention which will be indicators of movement toward the goal. Objective must be specific, measurable, representing steps toward reaching the goal. Including except achievement date. 5. Define specific intervention which will be utilized to help patient achieve objectives and goals. Include the frequency of each activity ... which discipline will be responsible for implementation and name person responsible... 6. List specific, measurable criteria for goal attainment, i. e. (that is) what the patient will do to demonstrate they have accomplished the goal. 7. Each time the plan is revised, enter date. If plan has been revised, indicated this and note any revisions in appropriate area on the Master Treatment Plan Review form. ... 13. Definitions ... b. Goals - observable, measurable actions, in which the patient will engage within a specified time frame. ... Objective should be written so that they are: i. Specific - Objective should be consistent and clearly defined. 99. Observable - The objective should be behaviors that can be observed... iii. Measurable - the objective should be stated that they can be defined in terms of frequency, quantity, duration. iv. Realistic - the objective should be obtainable considering the patient, staff and resources available to carry out the program. ... e. Interventions - are specific action steps or treatment strategies that the treatment team employs to facilitate the accomplishment of the goal. Interventions are: i. Specific: clearly defined ii. Measurable: provide indicators of behavior change. iii. Time Limited: revisions can be made if not successful or appropriate. iv. Reinforcing: by completing the action required by the intervention, patients can experience success."

Based on record review and interviews, the social service staff failed to ensure there was an exchange of medical information with after-care providers as evidenced by the hospital policy requiring medical information to be sent only when requested by the after-care providerfor 4 of 6 patients reviewed for discharge planning from a total of 12 sampled patients (#1, #2, #4, #10). Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/11 at 7:50 am with a diagnosis of Depression. Further review revealed he was discharged on 06/15/11. Review of the "Discharge Instructions" completed on 06/15/11 at 9:30 am revealed Patient #1 had a follow-up appointment with Physician S21 on 06/27/11 at 9:00 am and Physician S22 on 06/17/11 at 11:00 am. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #1's medical records had been sent to these physicians who would provide his after-care.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/03/11 at 12:25 pm with a diagnosis of Depression. Further review revealed she was discharged on 06/15/11. Review of the "Discharge Instructions" completed on 06/15/11 at 1:20 pm revealed Patient #2 had a follow-up appointment with Physician S23 on 06/15/11 at 3:00 pm. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #2's medical records had been sent to Physician S23, the physician who would provide her after-care.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 03/24/11 at 10:05 am with a diagnosis of Depression. Further review revealed she was discharged on 03/30/11 at 12:05 pm.

Review of the "Discharge Instructions" completed on 03/30/11 at 12:05 pm by RN (registered nurse) S13 revealed she had a therapy appointment with Physician S20 on 03/31/11 at 10:00 am and a medical follow-up appointment with Physician S14 on 03/31/11 at 2:45 pm.

Review of the "Consent to Release Information" to Physician S14 signed by Patient #4 and witnessed by RN S8 on 03/28/11 revealed, in part, "...The following information from my treatment record may be released/obtained: (box to check left blank) Written (box to check left blank) Verbal (boxes checked for the following) Medical and Psychiatric History, Lab/X-ray findings, Physician Discharge Summary, Diagnosis, Psychosocial Assessment, Psychiatric Evaluation, Aftercare, Itemized Invoices, Other: Anything he request". Further review revealed no documented evidence of the completion of "This disclosure will be made for the following purposes: Continuation of care/aftercare, Transfer, Coordination of Treatment/Services, Family/significant other involvement in treatment, Other". Review of the entire medical record revealed no documented evidence that any medical records were sent to Physician S14 or that a release of information had been completed for and records sent to Physician S20.

Patient #10
Review of Patient #10's medical record revealed she was admitted on 03/29/11 at 7:50 pm with a diagnosis of Depression. Further review revealed she was discharged on 04/05/11 at 11:05 am. Review of the "Discharge Instructions" completed on 04/05/11 at 11:05 am revealed Patient #10 had a therapy appointment at Facility "c" on 04/12/11 at 9:00 am and a medical follow-up appointment with Physician S24 on 04/25/11 at 9:00 am. Review of the entire medical record revealed no documented evidence a release of information had been completed to release records and that Patient #10's medical records had been sent to Physician S24 or Facility "c", providers who would be providing after-care for Patient #10.

In a face-to-face interview on 06/15/11 at 11:15 am, Medical Records Coordinator S4 confirmed no part of Patient #4's medical record was released to Physician S14 or Physician S20 for after-care treatment. She further indicated she had not received a call from Physician S14 requesting Patient #4's medical records. S4 further indicated, if a request had been made, she would have had Patient #4 complete and sign another consent to release information.

In a face-to-face interview on 06/15/11 at 12:45 pm, RN S8 indicated Patient #4 told her that she (Patient #4) wanted any information requested to be shared with Physician S14. RN S8 further indicated she didn't remember Patient #4 asking her to send any records to Physician S14, just that he may be calling to check on her. S8 indicated she never spoke with Physician S14, and she thought that Physician S14 had called before the consent to release information had been signed, and that's the reason the consent was completed and signed (in anticipation of a return call from Physician S14).

In a face-to-face interview on 06/16/11 at 10:20 am, RN S13 indicated the therapy follow-up appointments for after-care were made by the social worker, and the medical appointments for after-care were made by the nurse. S13 further indicated the social worker usually faxes the medical information to the physicians or delegated it to the unit clerk. After review of Patient #4's medical record, RN S13 confirmed there was no documented evidence in the medical record that a consent to release information to Physician S20 had been completed and signed or that any records had been sent to Physician S20 or Physician S14.

Former Social Worker S19, the social worker who was involved with scheduling the after-care appointment with Physician S20 for Patient #4 was no longer employed at the hospital and was unable to be interviewed.

In a face-to-face interview on 06/16/11 at 11:05 am, LCSW (licensed clinical social worker) S7 confirmed that the social worker made after-care appointments for therapy and the nurse made them for medical appointments. S7 indicated she would obtain a consent to release information and fax patients' medical records for any appointment that she made. S7 further indicated she didn't always document in the patient's medical record that she had faxed records and what records she had faxed.

In a face-to-face interview on 06/16/11 at 1:00 pm, DON (director of nursing) S2 indicated that discharge planning did not provide for continuity of care without patient medical records being sent to the providers who would see the patients for after-care.

Review of the hospital policy titled "Discharge Instructions and Process", policy number 212.2 revised 06/07 and submitted by Administrator S1 as their current discharge planning policy, revealed, in part, "...Discharge planning begins at time of admission; the patient's discharge plan is determined by the multidisciplinary treatment team with the primary goal to return to the most appropriate environment with after-care arrangements to maximize the patient's prognosis. ... If patient is transferred to another facility/institution the nurse will fill out appropriate transfer paperwork and provide requested information to receiving facility, accompanying family member, transfer driver, or nurse. 4. The Discharge Coordinator shall: a. Initiate Discharge Instruction Sheet to include but not limited to: Patient destination, Referrals for Outpatient Services (both psychiatric and medical), Community Support Groups/Resources, Special Instructions b. Review discharge and aftercare plan with the patient and, as possible, family. c. Make certain that all necessary releases of information have been signed...".

Review of the hospital policy titled "Discharge and Continuing Care Plan", policy number 212.1 revised 06/07 and submitted by Administrator S1 as their current discharge planning policy, revealed, in part, "...5. Referrals for after-care which include follow-up for psychiatric and medical issues as appropriate are insured by the discharge coordinator. ... 7. It is the responsibility of the primary therapist to ensure discharge planning and follow through occurs, and the responsibility of the director of social services to establish a mechanism whereby this process occurs".

Based on record review and interview, the hospital failed to develop a system to ensure that patient medical records were released upon receipt of a consent to release medical information by failure to have a system in place to ensure that faxed consents to release medical information received at the nursing station fax machine were communicated to the medical record department for 1 of 1 patient from a total of 6 patients reviewed for discharge planning from a total sample of 12 patients (#4). Findings:

Review of a faxed consent to release medical information, submitted by Office Manager S15 for Physician S14, Patient #4's primary care physician, revealed the consent was sent on 03/31/11 to release the following: complete health record; discharge summary; consultation reports; x-ray reports; history and physical exam; emergency report; operative report; progress notes; laboratory; pathology; and other: whole chart. Further review of the "transmission verification report" revealed the fax was received by Cypress Psychiatric Hospital on 03/31/11.

In a face-to-face interview on 06/15/11 at 11:00am, Medical Records Coordinator S4 indicated no medical record information had been released to Physician S14 for Patient #4. She further indicated she did not receive a phone call from S14's staff requesting medical information.

In a telephone interview on 06/16/11 at 8:50am, Office Manager S14 for Physician S15 indicated Physician S14 was on vacation and unavailable for interview. S14 indicated she requested the entire medical record of Patient #4 on 03/31/11 and received fax verification that the fax went through to Cypress Psychiatric Hospital. S14 confirmed that as of the time of this interview, Physician S14 had not received Patient #4's medical record from Cypress Psychiatric Hospital.

In a face-to-face interview on 06/16/11 at 12:40pm, Medical Records Coordinator S4 indicated, after told by the surveyor the number used to fax from Physician S14's office, the fax was sent to the fax machine at the nursing station and not the one in the medical record department. She further indicated when the nursing staff received a fax to release information, they were to place the form in the box attached to the wall in the nursing station designated for the medical record department. S4 further indicated there were times that she did not receive the faxes, as evident by the provider's office calling to ask about the records not being sent. S4 indicated when this occurred, she would give the provider the fax number for the machine located in the medical record department.

Review of the hospital policy titled "Release of Information", policy number 4 effective 03/04 and submitted by Medical Records Coordinator S4 as their current policy to release medical information, revealed, in part, "...Release Of Confidential Information From The Medical Record: 1. A signed authorization from the patient or his legal representative must be presented before any information of a confidential nature is released. The authorization should: ... C. Be dated after the date of the patient's hospitalization. ... I. The name of the person releasing information and the date the information is released must be documented. ... 2. Others' who have access to information without authorization: ... k. Prospective health care providers to secure their services as part of the continuum of care, as determined by the attending physician...". Review of the entire medical record revealed no documented evidence of a procedure to use when a fax was received from the fax machine located in the nursing station.