HospitalInspections.org

Based on interviews and record review the hospital failed to ensure 1 of 1 patient record (Patient #7's) medical record was properly filed/retained and accessible. Nursing personnel was instructed to remove and re-write original nursing documentation for 06/17/15 when Patient #7 ingested a foreign body.

Findings ncluded:

Patient #7's High Risk Notification Alert dated 06/16/15 timed at 1445 reflected, "Suicidal/Self Harm...hang, ingestion of objects...involuntary."

The Child/Adolescent Admission Medication Orders dated 06/16/15 timed at 0530 reflected, "Bipolar Disorder mixed without psychotic features...(close observation) 15 minute checks...precautions, elopement and assault precautions..."

The Physician Daily Progress Note dated 06/17/15 timed at 0936 reflected, "Risk to self and others...suicidal intent...plan...hanging..."

The 06/17/15 multidisciplinary progress note dated 06/17/15 timed at 1815 reflected, "Patient eating dinner at 1700...began throwing up clear chunks of fruit...requested Maalox...for GI (gastrointestinal) upset at 1730...calm in large lounge...at 1800 patient began throwing up again...complained of stomach pain...reported it feels scratchy...stated I swallowed a piece of metal...history of swallowing objects...Dr. notified...order to go the the ER (emergency room)." No documentation was found as to what type of metal object was ingested and the details surrounding where the object was located.

On 06/30/15 at 1041 Personnel #36 was interviewed by telephone. Personnel #36 stated the technician reported Patient #7 was throwing up. Personnel #36 stated she gave the patient some Maalox and then a short time later the patient began throwing up again. Personnel #36 stated the patient told her he had swallowed a piece of metal. Personnel #36 stated she inquired as to where he obtained the metal. Personnel #36 said the patient informed her he ingested a piece of metal off the lid to a dominos box. Personnel #36 stated she asked the patient where the dominos box was located. The patient pointed to a corner of the dayroom behind a column. Personnel #36 said the dominos box was retrieved and she observed a large piece of metal missing from the lid of the box. Personnel #36 stated she sent the lid of the box with emergency personnel.

Personnel #36 stated she documented all the details of the event which included information regarding the dominos box. Personnel #36 stated she clocked out and went home. Personnel #36 stated she was contacted by Personnel #7 approximately one hour later to return to work and re-write her note. Personnel #36 stated Personnel #7 informed her to use her original note and exclude the information regarding the dominos box. Personnel #36 stated Personnel #7 informed her that removal of the original note was not removing it from the medical record as the note was not in the chart yet as it was still on the clipboard. Personnel #36 stated she did as she was instructed even though she felt uncomfortable.

On 06/30/15 at 1202 Personnel #7 was interviewed by telephone. Personnel #7 was asked if she telephoned Personnel #36 to return to work. Personnel #7 stated she did. The surveyor asked Personnel #7 the reason Personnel #36 was asked to return to work. Personnel #7 stated she asked Personnel #36 to return and change her note. Personnel #7 was asked why by the surveyor. Personnel #7 stated "because of the recent safety issues identified by the State." Personnel #7 said she was not thinking at the time she did not feel like this was falsification of a medical record. Personnel #7 was asked if she spoke with anyone about the event. Personnel #7 stated she spoke with Personnel #2 regarding the note being changed. Personnel #7 stated she asked Personnel #2 if they could get the original note out of the shred box. Personnel #7 stated Personnel #2 did not say anything.

On 06/30/15 at 1315 Personnel #37 was interviewed by telephone. Personnel #37 stated she was present when Personnel #36 was instructed by Personnel #7 to return to work and to re-write her note excluding the information regarding the dominos box. Personnel #37 stated sometime later in the shift Personnel #3 telephoned her and wanted to know if Personnel #36 returned to work to change her note. Personnel #37 stated she informed Personnel #3 that Personnel #36 returned and changed her note. Personnel #37 stated the entire event put herself and the other nurse in a bad position.

The Clock in records for Personnel #7 reflected, "06/17/15 clocked in at 1218 and clocked out at 1724, clocked in at 1753 and clocked out at 2107."

The Clock in records for Personnel #36 reflected, "06/17/15 clocked in at 0544 and clocked out at 1946...clocked in at 2140 and clocked out at 2211."

The Clock in records for Personnel #37 reflected, "06/17/15 clocked in at 1745 and clocked out on 06/18/15 at 0515."