HospitalInspections.org

Based on interview and record review the hospital failed to ensure a four hour written request for discharge by the legal guardian for 1 of 3 patients (Patient #1) was provided. The hospital did not have a written physician's order to legally hold the minor patient.

Findings included:

The Behavioral Health Integrative Psychiatric Assessment dated 04/28/15 timed at 1322 reflected, "Patient aggressive towards teacher at school...is not remorseful...mother states ...patient threatened to run away...mood swings...I'm just gonna go away..."

The Discharge Against Medical Advice (AMA) form dated 05/01/15 timed at 1639 reflected, "I understand that I will be released within four (4) hours from the time of my request unless...I withdraw my Demand for Release, or...my doctor feels I am likely to cause serious harm to myself...(signed by legal guardian)...physician notification...1842...physician decision...detain patient/intent to evaluate for court ordered treatment...note...physician must be notified and respond within four hours...a separate order must be written in the patient file to reflect the order and disposition received from the physician..."

The Nursing Shift Assessment and Progress Note dated 05/01/15 timed at 1640 reflected, "Mom here to sign AMA informed Mom of AMA process...1840 Dr...informed of AMA placed on 24 hour hold."

The physician orders dated 05/01/15 through 05/02/15 revealed no physician order which indicated the minor adolescent was being physician ordered held.

The 05/02/15 physician daily progress note dated 05/02/15 timed at 1000 reflected, "Patient is doing ok today and is without complaints...mood is better, no suicidal ideations...patient is stable and appropriate for discharge to home today..." No documentation was found which addressed the legal guardian's written request for discharge signed 05/01/15.

On 09/25/15 at 1250 Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record. Personnel #2 stated no physician order to hold the minor was written and the physician did not document anything about the legal guardian's four hour request to discharge the patient and the reason for holding the patient.

Based on interview and record review the hospital failed to ensure 2 of 3 patients' (Patient #1's and Patient #2's) physician discharge summaries recapitulated the patients' hospitalization.

1) Patient #1's physician discharge summary did not reflect documentation that (Patient #1's) legal guardian requested a four hour request for( Patient #1's) discharge.

2) Patient #2's physician discharge summary reflected a medication (Patient #2) did not receive in the hospital and did not reflect the patient's discharge against medical advice.

Findings included:

1) Patient #1's Behavioral Health Integrative Psychiatric Assessment dated 04/28/15 timed at 1322 reflected, "Patient aggressive towards teacher at school...is not remorseful...mother states ...patient threatened to run away...mood swings...I'm just gonna go away..."

Patient #1's Discharge Against Medical Advice (AMA) form dated 05/01/15 timed at 1639 reflected, "I understand that I will be released within four (4) hours from the time of my request unless...I withdraw my Demand for Release, or...my doctor feels I am likely to cause serious harm to myself...(signed by legal guardian)...physician notification...1842...physician decision...detain patient/intent to evaluate for court ordered treatment...note...physician must be notified and respond within four hours...a separate order must be written in the patient file to reflect the order and disposition received from the physician..."

Patient #1's Nursing Shift Assessment and Progress Note dated 05/01/15 timed at 1640 reflected, "Mom here to sign AMA informed Mom of AMA process...1840 Dr...informed of AMA placed on 24 hour hold."

Patient #1's physician orders dated 05/01/15 through 05/02/15 revealed no physician order which indicated the minor adolescent was being physician ordered held.

The 05/02/15 physician daily progress note dated 05/02/15 timed at 1000 reflected, "Patient [#1] is doing ok today and is without complaints...mood is better, no suicidal ideations...patient is stable and appropriate for discharge to home today..." No documentation was found which addressed the legal guardian's written request for discharge signed 05/01/15.

Patient #1's (physician) Discharge Summary dated 06/01/15 reflected, "Admit 04/28/15...14 year old admitted as a result of increased mood instability to include aggressive behaviors...increased anxiety...admitted to inpatient...hospital course...Seroquel initiated for better results...patient having difficulty contracting for safety...level of anxiety continued to decrease...discharged 05/02/15...affect mood more stable..." No documentation was found regarding the legal guardian of the patient request to discharge the patient AMA (against medical advice).

On 09/25/15 at 1250 Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record. Personnel #2 stated the physician discharge summary did not address the legal guardian's request for her child to be discharged and the physician did not document anything about the legal guardian's four hour request to discharge the patient and the reason for holding the patient.

2) Patient #2's physician orders dated 06/27/15 at 11:07 reflected Seroquel 25 milligram (mg) was ordered "for mood" to be administered at bedtime. Eight hours later, before the first dose of the medication was due to be administered, physician orders dated 06/27/15 at 19:05 reflected Seroquel to be discontinued.

Medication Administration Record dated 06/27/15 and 06/28/15 reflected Patient #2 did not receive the Seroquel medication.

The Demand for Release document was dated 06/27/15 at "3:15 [not stated AM or PM] and discharge orders dated and signed by Personnel #11 on 06/28/15 at 09:00 reflected to discharge Patient #2 against medical advice.

Patient #2's physician discharge summary dated and timed by Personnel #11 on 07/29/15 reflected Patient #2 was hospital admitted on 06/26/15 and transferred on 06/28/15 to another hospital. The document noted that Patient #2 received Seroquel 25 mg at bed time.

Personnel #11 was interviewed on 09/25/15 at 14:45 and acknowledged that the discharge summary "was not right."