HospitalInspections.org

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Based on unit tour, staff and patients interviews, the review of medical records, facility's policy and other documents, it was determined that the facility did not effectively and consistently inform each patient, or when appropriate the patient's representative, of his or her rights in advance of furnishing or discontinuing patient care. This deficiency was noted in ten (10) of eighteen (18) applicable medical records reviewed (MR #s: #18-27).

Findings include:

During the tour of Unit 8B (Medical/Surgical) on 11/29/11 at 10:35AM, several medical records were selected for review: - MR #18, MR #19, MR #20, MR #21, MR #22 & MR #27.

Review of MR #20 noted that this 90 year patient was transferred from Park Gardens Nursing Home on 11/23/11 with diagnosis of hyponatremia. The patient was sent to the hospital for an evaluation after she refused to take some of her medications. It was noted that the patient did not sign the copy of An Important Message from Medicare (IM) form dated 11/26/11. It was noted that the patient had a psychiatry evaluation on 11/28/11 at 1421. The psychiatrist noted "the patient appeared quite capable of participating in her own medical decisions". It was noted that the patient had a social work (SW) assessment on 11/28/11 at 1641. The SW noted that the patient was given the Medicare Important Message form but wouldn't sign a copy. There was no documentation that the information on the IM form was discussed with the patient or the patient's reasons given why she refused to sign the form.

Review of MR #19 noted that this 85 year old patient was brought to the facility by ambulance on 11/18/11 after he had two seizures at home. It was documented that the patient was non-verbal; the patient's daughter signed the General Consent for Treatment form on 11/18/11. There was no documentation why the IM form was not discussed and given to the patient's representative.

It was noted that there were no copies of IM forms located: in MR #18 and MR #21 for these Medicare beneficiaries who were admitted on 11/23/11 and the patient in MR #27 who was admitted on 11/20/11 and discharged on 11/29/11.

While on Unit 8B on 11/29/11 at approximately 11:00AM, staff nurse was interviewed regarding her understanding of IM form. After reviewing the form, the nurse stated that this was a financial document; she stated that she had nothing to do with this form. She also stated that it was social worker's responsibility to ensure that this document was given to the patient/representative.

The social worker (SW) assigned to the unit was interviewed on 11/29/11 at approximately 11:15AM. This staff reported that the IM forms were not in the medical records because she had them in her office and she was in the process of mailing them to the patients' representatives. This staff was unable to explain why the forms were not presented/given to the patients/ representatives within the required forty-eight (48) hours from admission.

The patient in MR #22 was interviewed in his room on 11/29/11 at approximately 11:30AM. The patient reported that he was not provided with a Patients' Rights package informing him of his rights. It was noted that a signed copy of the patient's IM form was on his night stand. The patient reported this document was just given to him to sign.

Review of MR #23 on 11/30/11 at 10:50AM noted that this 88 year old patient was admitted to the facility on 10/8/11 and discharged on 10/13/11. It was noted that this patient was transferred to the hospital from a skilled nursing facility on 10/3/11. The chief complaint was right sided chest pain and headache. It was noted that the patient signed the General Consent for Treatment form on 10/8/11. This Medicare beneficiary was not provided with the IM form. The CMS Social Work Notification documentation dated 10/12/11 at 1443 was reviewed. It was documented "Discharge IM given to patient: no". "DC IM mailed/given to patient rep/nok (next of kin): mailed". It was noted that the name of the person this form was mailed to was not listed. In addition, it was unclear why this document was mailed the day before discharge or why it was not given to the patient.

Review of MR #24 on 11/30/11 noted that this 76 year old patient was admitted on 10/9/11 with chief complaint of rectal bleeding. It was noted that this patient signed out AMA (Against Medical Advice) on 10/11/11. There was no evidence that the patient was presented with the IM form during this admission.

Similar findings were noted for Medicare beneficiaries in MR #25 & MR #26 who were not given IM forms.

Medicare Important Message Training Agenda October 28, 2011 and Attendance Sheet were reviewed on 12/1/11. It was noted that the staff who attended this training were from the Social Work Department.

The facility's policy subject: "Medicare Import Message" was reviewed. This policy indicated that "Social Worker reviews the daily admissions and gives the initial important message (IM) to Medicare Beneficiaries to all enrolled Medicare beneficiaries".

The Administrator interviewed on 12/1/11 reported that the facility does not have social work coverage on weekends. The facility is required to provide each Medicare beneficiary inpatient with a standardized notice "An Important Message from Medicare" (IM) within two (2) days of admission. It was concluded that since Social Work staff is responsible to distribute "An Important Message from Medicare" (IM) forms to all inpatient Medicare Beneficiaries, not all patients with short length of stay will be provided with this essential Patient Rights information.
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Based on review of grievance records, procedures, and interviews, it was determined the facility did not consistently provide complainants with written notice of findings that include the results of the hospital's grievance investigation in accordance with the facility time frames.

Findings include:

Four (4) of nine (9) patient grievance files reviewed on 12/1/11 found that there was no record enclosed of a written response provided to the complainant which detailed the results of the facility's investigation of the complaints.

The facility did not adhere to its policy entitled "Grievance Mechanism" which requires that investigations must be completed in thirty (30) days and that upon completion, the patient representative investigating the issue will provide a written response.

Specific examples include:

MR #10: Complaint dated 10/4/11 by a patient who perceived the physician was rude and refused to provide services for timely TOP during a visit on 9/26/11. The patient felt the appointment given for 10/17 would result in delay.

An e-mail from a different physician noted the TOP was performed on 10/19/11 and noted the reasons for the scheduling including need for cardiology clearance for anesthesia. The patient representative file noted interventions taken on 10/4/11 including contact with staff for rescheduling and patient reassurance. The file notes the complaint was received on 11/30/11 (date during the survey). No written response provided was evident.

MR #11: Complaint dated 8/29/11 filed by the patient's daughter who complained of delay in biopsy pending a change of insurance. A review conducted indicated no evidence of treatment delay on 9/22/11. However, follow up dated 11/30/11 indicated that since April 2011 the insurance had changed in May; the insurance was switched to a provider that is contracted. The facility's report indicates no delay in care due to insurance and recommended that the financial counselor must provide clear explanation regarding no interruption in care. A stamp on the record was dated "received 12/1/11" yet there was no evidence of any written response provided to the complainant.

MR #12: Complaint was received from a patient on 10/31/11 who alleged violation of confidentiality in that a physician allegedly screamed out private medical information to another staff member across a room in the Emergency Room. The file contained three (3) inconsistent dates of receipt of the complaint, noted as 10/12/11, 10/31/11, and 11/30/11. The investigation page indicated the complaint was received one (1) month later after the incident, on 11/30/11, and indicated a prospective plan to counsel the physician. There was no documented evidence the physician counseling had been implemented. No evidence of a written response issued to the complainant was noted.

MR #7: Complaint was received on 7/26/11, from the niece of a patient who alleged the patient, an elderly woman with dementia, was inappropriately discharged without home care. The investigation revealed that the staff did not complete the referral form for home care correctly. While verbal contact was made with the complainant in effort to correct the problem, there was no evidence a written response was provided. Interview with the administrator on 11/30/11 confirmed that no letter was sent because the facility felt they had resolved the issue.

Interview with the Director of Patient Relations on 12/1/11 indicated that the delays were attributed to the finding that the complaints were not received until 11/30/11 (during the survey). It was stated that there is a process in place to monitor the timeliness of responses from departments when there is a delay beyond seven (7) days.
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Based on record review and interview it was evident that the hospital did not formulate and implement policies and procedures to ensure patient safety on the psychiatric units.

A) Based on record review and interview it was determined that the hospital did not formulate and implement policies and procedures to ensure that patients were protected from excessive force from outside law enforcement personnel.

Findings include:

On review of MR #1 on 11/30/11 it was found that that Hospital Police, with the approval of the Network Administrator, called the NYC Police Department to assist them in the management of a violent psychiatric patient. Specifically, the patient had barricaded himself in his room, where he was storing instruments which included broken hospital equipment (potential weapons) and that he needed to be extricated and placed in seclusion and restraints.

Further review of the record under miscellaneous nursing note stated "It took up to ten (10) Police Officers to get him (the patient in MR #1) placed on seclusion and restraints that was commenced at 12:10PM.

Review of hospital policy (restraints, hospital police, and nursing) did not find any policy
governing the use of outside law enforcement personnel to assist with implementation of restraint, seclusion or extrication of any patient. There was no evidence as to the role and supervision of outside law enforcement agencies when they are called to assist clinical staff in non-criminal issues.

Review of the NYC-HHC Incident Reporting Form on 11/30/11 found under the section titled "Notification Details" read "HP (Hospital Police) called NYPD (New York City Police Department) due to the acuity of the situation. The outcome was the NYPD stood by and did not need to intervene. A special review will be convened to discuss the protocol in the event that NYPD is called to the unit."

At interview with the Assistant Director of Security on 11/30/11, it was reported that calling NYPD officers to assist with management of psychiatric patients was unprecedented.


B) Based on review of policies and interview, it was evident that the facility did not formulate and implement a policy to govern the actions of Hospital Police in the management of psychiatric patients.

Findings include:

Review of hospital policy regarding the use of "holds" by Hospital Police does not reference the use of handcuffs prior to the placement of hospital restraints.

Findings include:

At interview with the Associate Director of Hospital Police on 11/29/11 it was reported that Hospital Police use handcuffs in circumstances where the patient is violent and requires handcuffs to control him/her prior to the initiation of hospital approved restraints.


C) Based on record review it was determined that a patient who was in seclusion, in 5 point restraints and who was alleged to be on a 1 to 1 was able to escape the restraint and run out of the seclusion room and into his own room where he was able to threaten staff and other patients with dangerous weapons made out of hoarded and destroyed hospital equipment.

Findings include:

Review of MR #1 on 11/30/11 and incident reports, it was evident that the patient was able to escape from a 5 point restraint and seclusion while on a 1 to 1 observation and to run to his room where he had stored implements to use as dangerous weapons.

The patient was able to break hospital equipment (tables and chairs) as well as a sharp object taken off a light fixture in the seclusion room as well as a sharp object in his shoes without staff being aware of his sequestering the dangerous weapons.

There was no evidence that the staff ensured that when tables, chairs and other objects were broken by the patient that those pieces of such furniture were removed from his possession and that any missing items were recovered. No search of his room for such contraband was done. When the patient removed sharp ceiling tiles in the hall, the facility did not ensure that all such materials were inventoried and the patient and his room searched.

The fact that the patient was able to remove a sharp object from the light fixture in the seclusion room while on a 1 to 1 as hospital policy dictates was not properly supervised while on that 1 to 1.

At interview with the Director of Psychiatry on 11/30/11 it was stated that a patient is not restrained and in seclusion simultaneously. Review of MR #1 found that there was an order for both at the same time.


D) Based on record review it was determined that the facility staff did not ensure that a patient was protected from assault by other patients.

Based on record review it was evident that a violent patient was placed in a choke hold by other patients and lowered the patient "to the ground".

This was found in MR #1 and an incident report associated with this event.
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Based on interviews and the review of medical records and other documents, it was determined that the facility failed to provide adequate assessment and interventions to ensure prenatal patients' nutritional needs were met. These finding were noted in five (5) of five (5) applicable records.

Findings include:

The following records were noted to lack evidence that these prenatal patients were provided with nutritional education and or nutritional assessments by the dietitian as required.

1. Review of Patient MR #13 on 11/30/11, it was noted that this 19 year old pregnant mother presented to the prenatal clinic for her first visit on 7/13/11. On 8/15/11 the midwife noted weight loss, small size fetus and referred the patient to the nutritionist. There was no evidence in the record showing that the patient's nutritional needs were assessed by the dietitian or that she provided the patient with prenatal nutrition education. It was noted that the patient had four (4) prenatal clinic visits after the nutritional referral was made.

2. Review of MR #14 on 12/1/11, noted that this 18 year old mother had her first prenatal visit on 6/22/11. She was screened at high nutrition risk for BMI of 18 and hematocrit/hemoglobin (H/H): 29.3/9.8 and referred to nutritionists. Patient's nutritional status was assessed by the dietitian and she was provided with nutrition education. The nutritionist recommended iron rich diet and vitamin C. No nutrition follow-up care or counseling was provided to patient during her subsequent prenatal visits. Patient had laboratory work done and her H/H of 11/9/11 was noted as 36/12. Patient was seen in clinic on 11/14 for her laboratory results and on her 11/30/11 visit the midwife noted hydration encouraged and to increase iron. No nutritional referral was noted at this time.

3. Review of MR #15 on 12/1/11, noted that this 37 year old pregnant mother with history of depression, anxiety, mood swings and followed by psychiatrist had her first prenatal visit on 8/10/11. Patient was not referred to the nutritionist; she had six (6) prenatal visits and has yet to be seen by the dietitian to have her nutritional needs assessed and provided with prenatal nutrition education.

4. Review of MR #16 on 12/1/11, noted that this 28 year old pregnant mother had her first prenatal clinic visit on 5/31/11 and eight (8) prenatal clinic visits since. There were no evidence in her record showing that her nutritional needs were assessed and prenatal nutrition education provided by the dietitian.

5. Review of MR #17 on 11/30/11 noted that this 31 year old pregnant mother had her first prenatal visit on 9/7/11 and was not provided with nutritional education as required.
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Based on observation, document review and staff interview, it was determined that the facility did not maintain the hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include:

Kitchen Area:
On 11/28/2011, during a tour of the Kitchen, it was observed that the washing area did not have a readily visible exit sign to direct the staff to the exit door.

Also, the second mean of egress to the kitchen near the dish washing area lacked an illuminated exit sign.

Psychiatric Unit 11-B:
During a tour of Psychiatric Unit 11-B on the afternoon of 11/28/11, the following were identified and brought to the attention of the Associative Executive Director of Environmental Care and Safety who accompanied the surveyor during the hospital tours:

1- The seclusion room had a stretcher that had side rails; two restraint beds and other features that could be used for looping hazard. When, asked the staff said that the stretcher will be used in the presence of a staff member who would be sitting outside the open door of the seclusion room. The presence of the stretcher in the seclusion room constitutes a looping hazard, especially when patients are kept in the room for seclusion purpose only.

2- All the bathrooms of the patient bedrooms had gaps between the drain pipes under the hand-wash sinks and the sinks (about ½-1 inch), that imposed a looping hazard.

3- There were some mattresses observed to be torn and had broken surfaces, which make it difficult to clean and or disinfect them and imposed a risk of infections. Examples included but were not limited to: mattresses in Rooms 1106 and 1103.

4- The glass window of Room 1114 was observed to be shattered at its perimeter.

5- The mirror's frame and the metal towel dispenser of the bathroom of Room 1125 were observed to be loose and were not affixed to the wall, which make them a looping hazard.

Emergency Department (ED):
During a tour of the Emergency Department on 11/29/11, the following was noted:

1- The faucet of Bathroom 1C-06B of the ED was leaking water.

2- The nursing call bell of Patient Bathroom 1C-06B of the ED was pulled at 11:05AM. No staff members responded to that nursing call bell. When asked, the nurse at the nurse station said that she heard the call bell but she did not know what to do as she is new to the institution and that she did not receive training regarding the nursing call bell system.

The Same Day Surgery Suite:
The chute of the ice machine in the Same Day Surgery Suite next to Room 4F19G, was observed to have dirty surfaces in its inside and outside surfaces. Also, that ice machine was leaking water and the surface of the filter of that machine was dust laden.

Intensive Care Unit:
The wall of the bathroom of Isolation Room 10-B05 was observed to have signs of water leaks behind the stall.

Fire Dampers:
Review of the fire damper testing of November 3-6, 2010 showed the following:

1- Nine (9) of the fire dampers on the fifth, fifteenth, sixteenth and seventeenth floor were not tested due to lack of access. Those dampers are: 5-FD-032, 5-FD-035, 5-FD-047, 5-FD-048, 5-FD-049, 5-FD-084, 5-FD-284, 5-FD-313, 5-FD-254.

2- The smoke damper on the second floor, 2B-SD-433, had failed the test due to an inoperable actuator and there was no documented evidence to ensure its repair.

3- The fire damper, 5-FD-002, at the fifth floor failed the test of November, 2010 because of a broken spring on one side.

4- The fire damper, 5-FD-051, at the fifth floor failed the test of November, 2010 because of no fusible link.

5- The fire damper, 5-FD-088, at the fifth floor failed the test of November, 2010 because of no fusible link.

6- The fire damper, 5-FD-151, at the fifth floor failed the test of November, 2010 because of no fusible link.

During a tour of the basement and subbasement floors on the afternoon of 11/30/11, the following was observed:

1- At least six (6) of the sprinkler heads in the medical record area were loose.

2- The majority of the file cabinets of the medical records were fourteen (14) inches below the ceiling of the sprinklered area. In sprinklered space no storage should be within eighteen (18) inches of the sprinkler heads.

3- Two ceiling tiles were missing in the corridor near the Environmental Department in the basement and many ceiling tiles were stained and had signs of leaks.

4- No illuminated exit signs were provided in the Paint Shop area.

5- No exit signs were provided at the space of the mechanical area on the 3B Mechanical Floor.

During a tour of the radiology area on 12/1/2011, the following was identified:

1- The safety pin of the fire extinguisher of the MRI Suite was found to be from ferrous material.

2- There were two (2) wheeled stands of sharp containers that were stored outside the MRI door (about five (5) feet from the door of the MRI Room) and they were from ferrous material. This is especially dangerous if these stands were accidentally rolled to the MRI Room.

3- No exit sign was provided in the CT scan and MRI suite.

4- The handle and the squeeze control parts of the housekeeping mop were from ferrous material that should not be used in the MRI Suite.

5- The door of the electric panel in the storage room of the MRI Suite was removed and the panel with its electric wiring was left without its door.

6- No hand washing sink was provided in the soiled utility room of the MRI Suite as required for this type of room. This in an infection control concern.

7- The nursing call bell of Patient Bathroom 2G07T next to the mammography area was activated but no staff responded to the nursing call even after long time of waiting (>five (5) minutes). Per the Radiology Supervisor, that nursing call bell does not annunciate at the nursing station or anywhere else.

8- There was no nurse call bell was provided in Women's Dressing Room 2G-24.

9- There was a missing ceiling tile in Radiology Room 2G-27.
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A. Based on review of records, procedures, and staff interviews, it was determined that the facility did not consistently provide mandatory social work/discharge planning assessments to inpatients hospitalized on the psychiatry units.

Findings include:

During tour of inpatient psychiatric units conducted on 11/28/11 (12A and 11B) and 11/29/11 (Unit 11B) it was noted during document review that social work/discharge planning assessments were missing from five (5) of eight (8) concurrent inpatient psychiatric records reviewed.

The hospital did not adhere to it's Behavioral Health/Inpatient Policy and Procedure entitled "Assessment, Treatment, and Aftercare Planning" which notes that the social work assessment must be initiated by the Emergency Room staff and then completed by the social worker within seventy-two (72) hours of admission.

The following records did not meet the requirements for timely social work/discharge planning assessments as required by hospital policy for the following cases:

MR #2: Patient was admitted on 11/21/11 to Unit 12A for violent behavior in setting of diagnosis of schizoaffective disorder, bipolar type with psychosis. Review of the record on 11/28/11 found there was no evidence of documented social work assessment. On Interview of the social worker assigned to Unit 12A on 11/28/11, it was indicated there was a staff shortage during the previous holiday week.

MR #3: Patient was originally admitted to the facility on 10/25/11 for violent behavior towards a peer in the community and had been transferred to medical unit for treatment of seizure disorder. The patient was re-admitted to inpatient psychiatry on 11/1/11 for continued treatment of schizoaffective disorder. Review of the record on 11/28/11 found there was no evidence of documented social work assessment.

MR #4: Patient was admitted on 11/7/11 to Unit 12A for aggressive behavior in setting of diagnosis of schizoaffective disorder. Review of the record on 11/28/11 found there was no evidence of documented social work assessment.

MR #5: Patient was admitted on 11/14/11 to Unit 12A for behavioral disturbance in the setting of dementia with depressed mood. Review of the record on 11/28/11 found there was no evidence of documented social work assessment despite supporting documentation in the record that the patient's nursing home where she resided prior to arrival had refused to take her back.

MR #6:18 year old patient was admitted on 11/22/11 to Unit 12B for assessment of psychosis NOS. The hospital had received a report from the patient and from the sister that the patient had been sexually assaulted by two (2) men prior to arrival. The record also indicated that the patient was unable to state what took place at time of assessment on 11/22/11. However, at a subsequent interview on 11/25/11, the patient had denied being assaulted and reported the sex was consensual. During review on 11/29/11, the record did not contain social work assessment despite presumptive needs.




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B. Based on medical record review, it was determined that the facility did not consistently ensure that each patient identified as likely to suffer adverse health consequences without adequate discharge planning had completed an evaluation.

Findings include:

Review of MR #26 on 11/30/11 noted that this 72 year hearing impaired patient was admitted to the facility on 9/16/11 and discharged on 9/20/11. The reason for admission was hand cellulites and foot pain. Medical history included: hypertension & MI. It was documented that the patient was unable to speak due to impaired communication/deaf. During the initial nursing assessment, the nurse noted "probable need for placement or supportive service upon discharge". The discharge concerns: "coping with disease process/condition". There was no documentation that the patient had a social work assessment. There was no bio-psychosocial needs assessment located in this record presented for review.
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Based on review of records and staff interviews, it was determined that the facility did not validate implementation of referrals prior to discharge or ensure follow-up for necessary services for three high-risk patients, in order to ensure continuity of care.

Findings include:

Three (3) of nineteen (19) inpatient postpartum/newborn and adult medical records reviewed on 11/29/11 and 11/30/11 found that referrals for necessary post-discharge services or home care were not validated before discharge. In addition, necessary follow up was not evident to ensure continuity of care for high-risk social or medical needs.

Specific reference is made to three (3) patients, two (2) post-partum adolescents and one (1) elderly patient with functional impairments, referred for home care services, in which the records failed to document confirmation of acceptance of referrals or timely follow up to ensure services were received for continuity and patient safety.

Examples include:

MR #7: This 78 year old female was admitted to the hospital on 7/19/11 for neck and shoulder pain and discharged on 7/25/11 without evidence that a safe discharge plan was in place. There was no documentation in the record that a home care referral had been implemented or that services were approved before departure.

The patient had significant co-morbidities including Potts disease, hypertension, diabetes mellitus, and spinal stenosis. The patient was dependent on a walker for ambulation and though alert and oriented x 3, she was at times having difficulty recalling information for home care or information for date, month, or year.

Social work assessments on 7/19, 7/21, and 7/22 indicated the patient had been receiving twenty-four (24) hour home care prior to arrival but the agency refused to re-accept her secondary to reported behavioral issues including verbally abusive behavior and reportedly had a friend that steals from her. The patient also threatened the niece who refused to be her health care proxy secondary to threats made against her. The patient also refused nursing home placements due to previously being placed in a nursing home against her will.

A referral was made by the social worker to Alpine Home Care on 7/22/11 but there was no follow up documented in the record by the staff to confirm acceptance of the new home care referral. The patient was discharged on 7/25/11 with an ambulette attendant to home. The physician discharge information summary noted "home with services from HHA" but there was no evidence the services were validated and accepted. The record did not explore the viable safety of the plan, given the social situation as noted and including the patient's physical impairment, mental, and behavioral issues as noted.

Following discharge the hospital received a complaint from a relative and the Patient Relations complaint investigation file noted the home care referral forms were incomplete. However there was no indication why the staff did not confirm the patient's acceptance before departure. It was stated on 11/30/11 by administrative staff at interview that the discharge planning referral home care file would reflect this information, but it was never provided nor any information incorporated into the medical record.

MR #8: This 15 year old female delivered a baby boy via c-section on 10/26/11. The patient reported the pregnancy was the result of a rape. She had been referred in prenatal clinic on 8/1/11 to a special victims unit and SATP agency for counseling. She was seen by social services post-delivery at which time it was confirmed the grandmother would provide support and that the mother was bonding with the infant. It was reported the patient was engaged in counseling at her school and the adolescent mother denied depression on interview. The mother and infant were socially cleared and referred for visiting nurse post-discharge assessment. While the mother's records noted bonding was evident, the assessment failed to include detailed exploration of the clinical aspects of the patient's adjustment, feeling, attitude, and behavior toward the infant. The assessment did not consider need for obtaining consent for validated collateral contact with the responsible counselor/agency to confirm the patient's functional state.

Review of the electronic record on 11/30/11 found the mother did come to clinic for wound check on 11/9/11 but that the infant's pediatric appointment was not kept.

There was no evidence the referral for visiting nurse was implemented or any follow up documented in the mother's or infant's record to assess the results of the nursing home care assessment. Given the high risk nature of the adolescent's history of rape and pregnancy, follow up was warranted.

MR #9: 16 year old adolescent delivered a newborn on 10/25/11 in which a referral made for visiting nurse assessment was not confirmed for acceptance. In addition, the assessment did not consider follow up referrals for presumptive psychosocial needs.

This adolescent mother was evaluated prenatally on 8/11/11 at which time it was reported that she had conflict at home with the stepmother and exhibited symptoms of anger during the assessment. The patient also reported school difficulty and past use of excessive alcohol when missing school.

The social work assessment post-delivery dated 10/26/11 confirmed with the patient's father the provisions and support of the infant. During the assessment the patient reported no feelings of depression but had received past counseling. She reported no substance abuse, but the assessment did not include reassessment of the recent problems reported at home. The mother and infant were socially cleared and a Visiting Nurse post home evaluation was ordered, but the referral was unconfirmed. No follow up of the nursing post-home visit results were evident nor were counseling referrals considered. A pediatric appointment for the baby for 11/2/11 was not kept, however, no follow up was evident.