HospitalInspections.org

Based on review of preadmission screening forms and interview with staff, the hospital failed to provide written documentation that the physician verified the patient met the criteria for admission after the preadmission screening had been completed and prior to admission to the hospital as evidenced by the physician not signing the form for 5 of 5 open medical records and 1 of 1 closed medical records in a total of 20 reviewed medical records. Findings:

Review of the open medical for patient #3, #9. #10, #13, and #14 revealed the preadmission screening form was completed prior to the admission date and time for each patient, but the physician had not signed the form verifying the patients met the criteria for admission. Review of the closed medical record for patient #4 revealed the prescreening admission screening form was completed, the patient was admitted, treated and discharged and the physician had not signed the form verifying that the patient met the criteria for admission.

Interview with S1 DON on 2/21/11 revealed the preadmission screening form should be signed by the physician after completion of the form and prior to admission of the patient. S1 confirmed that preadmission screening form for patients #3, #4, #9, #10, #13, and #14 were not signed by the physician prior to admission into the hospital.

Based on review of 11 open medical records (#1-#3, #8-#14, #18) and 9 closed medical records (#4-#7, #15-#17, #19, #20), review of Therapy Policies and Procedures (approved 5/2010) and interviews, the hospital failed to follow their own policies and procedures that described the scope of rehabilitation services offered by the hospital. This was evidenced by the failure to provide a Therapeutic Recreations/Activities Department for patients when this was a discipline listed under the scope of rehabilitative service the hospital offered. Findings:

Review of Therapy Policies and Procedures revealed the hospital provided a Therapeutic Recreations/Activities Department for patients to improve cognitive, social and emotional functioning. Further review revealed the director of the activities department "functions as an integral part of the interdisciplinary rehabilitation team".

In an interview on 2/21/2011 at 11:45 AM patient #11 reported she had been hospitalized for 4 days and staff had not provided any type of diversional activity other than TV. In an interview on 2/21/2011 at 12:35 AM, S1 DON stated the hospital had not provided a Therapeutic Recreations/Activities Department since 10/2010. S1 stated the staff assessed patient preferences and provided puzzles and books, but this could not be confirmed with patient interviews or documentation in the medical records.