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A review of 15 patient medical records revealed that the hospital staff failed to complete the psychosocial assessment for patients #11 and #12.

Patient #11 was admitted to the chronic hospital on 8/4/15. A psychosocial assessment of the patient was not found in her medical record when it was reviewed on 9/23/15. The unit case manager also reviewed the patient's record and could not find an assessment.

Patient #12 was admitted to the chronic hospital on 9/1/15. A psychosocial assessment of the patient was not found in his medical record when it was reviewed on 9/23/15. The unit case manager also reviewed the patient's record and could not find an assessment.

Within 48 hours of admission each patient has a psychosocial assessment performed by the social worker or case manager. The psychosocial assessment evaluates the patient's mental health, social status and functional capacity. Information is gathered from the patient and family. These initial assessments aid in determining baseline to help determine the next steps in the patient's care.

The hospital staff failed to meet the standard of care to perform and document the psychosocial assessments on two patients within 48 hours of admission to the chronic care hospital. Nor did the staff document justification for failure to complete the assessment.

A review of 15 medical records revealed that the hospital staff failed to complete the transfer form for patient #9.

Patient #9 was a 60 year old male who presented to the hospital in respiratory distress. The patient was stabilized and transferred to a higher level of care. Review of the patient's Transfer Form revealed that the physician had completed the form and the patient's daughter signed for the transfer, but the physician failed to sign the form. The space for the physician's signature was blank

Observation of the Hydrocollator Pak Unit on the 5C-Rehab Gym, review of the temperature logs and an interview of the Rehab Staff revealed that the Rehab Staff were not consistently monitoring the temperature readings to ensure patient safety.

The findings were:

A tour of the 5th floor Rehab Gym on 09/23/15 starting at 11:40 AM revealed that the gym was active with patients involved in therapy with staff. An interview of the Rehab Staff (Rehab Aide) revealed that the Hydrocollator Pak (HP) temperatures are taken and recorded on a monthly calendar kept on a clip board above the unit. A review of the temperature logs revealed that in 08/15 the temperature of the unit was checked 6 times in 31 days and noted as 160° F. The month of 09/15 had no temperature checks noted.

In addition, an interview of the Risk Manager on 9/23/15 confirmed that the hospital had no written policy and procedure for checking the Hydrocollator Unit.

Failure to assess, document, and perform temperature checks of the HP Unit (uses a high moist heat temperature) placed the patient at risk for injury.