HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by failing to ensure hospital policy for elopement precautions was implemented for 1 (#1) of 2 (#1, #2) patients that eloped from the hospital.
Findings:

Review of hospital policy titled "Elopement Precautions Function: Care" Reviewed: 12/2024, Revised: 10/2024 revealed, in part:
"Policy: It is the policy of River Oaks Hospital to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur.
Procedure: Elopement Precautions. All patients deemed as elopement risks should be placed on Elopement Precautions according to the severity of the risk of elopement. Patients most frequently at high risk for elopement are adolescents, chemical dependency patients and patients under involuntary admission status. The decision may be based on the following: Patient's self-disclosure.
Risk factors or warning behaviors, which may influence and/or predict elopement, can include:
Patients who sign a Request for Release From Formal Voluntary Status ("72")-if a patients signs a "72" the Physician will be notified of such and of any other elopement risks present to determine if high risk for elopement is present and/or elopement precautions are indicated, document in medical record."

Review of Patient #1's medical record revealed the patient voluntarily admitted to the hospital on 12/25/2024 at 12:19 PM. Further review of Patient #1's medical record revealed documentation Patient #1 verbalized a desire to leave the hospital.

Review of Patient #1's medical record revealed a signed "Request for Release Formal Voluntary Status" form dated 12/27/2024 at 8:49 AM that read, in part: "I, (Patient #1's name) having been hospitalized at River Oaks Hospital on a formal voluntary status, now request that the Administrator release me within 72 hours."

Review of Patient #1's medical record revealed no evidence Patient #1's physician was notified that the patient signed a "Request for Release Formal Voluntary Status" form as indicated in hospital policy.

Review of Patient #1's medical record revealed Patient #1 eloped from the hospital on 12/27/2024 at 11:18 AM.

In an interview on 01/14/2025 at 2:39 PM, S1DRM confirmed Patient #1's medical record contained no evidence the physician was notified that the patient signed a "Request for Release Formal Voluntary Status" form. S1DRM confirmed Patient #1 eloped from the hospital on 12/27/2024 at approximately 11:18 AM.

Based on record review and interview, hosptial nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficient practice is evidenced by failure of the nursing staff to monitor the therapeutic effects of PRN medications in 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy titled, "PRN Orders" missing effective date and review date, revealed in part: "PROCEDURE: F. Efficacy or PRN medication must be documented within one hour after administration."

Patient #2
Review of Patient #2's medication administration record revealed the following PRN medications were administered:
Tizanidine (Zanaflex) 4mg oral tablet four times a day PRN for Muscle Spasms:
Administered on 12/25/2024 at 12:16 PM. Effectiveness evaluated at 7:13 AM on 12/26/2024.
Administered on 12/26/2024 at 8:51 AM. Effectiveness evaluated at 10:38 AM on 12/26/2024.

Hydroxyzine (Vistaril) 50mg oral tablet four times a day PRN for Anxiety:
Administered on 12/28/2024 at 8:10 AM. Effectiveness evaluated at 2:39 PM on 12/28/2024.

In an Interview on 01/14/2025 at 11:35 AM, S1DRM confirmed that the therapeutic effects of the PRN medications listed above were not re-evaluated within one hour of administration.

Based on record review and interview, the hospital failed to ensure that all medical record entries were dated and timed by the person responsible for providing the treatment or service provided. This deficient practice is evidenced by failing to assure all pages in the medical record contained the date and time of treatment or service provided for 1 (#2) of 3 (#1-#3) records reviewed for completeness of documentation.
Findings:

A review of Patient #2's medical record revealed an AMA form titled, "Release From Responsibility For Discharge" signed by the patient and witnessed by hospital staff. Further review failed to reveal a date or time the document was completed.

In an interview on 01/14/2025 at 9:26 AM, S1DRM confirmed the AMA form for Patient #2 was not complete and was missing the date and time.

Based on record review and interview, the hospital failed to ensure all hospital orders were promptly signed, dated, and timed by the physician. This deficient practice is evidenced by verbal/telephone orders not being authenticated by the physician within the timeframe stipulated by the hospital policy for 2 (#1, #2) of 3 (#1-#3) medical records reviewed.
Findings:

Review of Medical Staff Bylaws, last revised 04/2024, revealed in part: "Medical Records: 6. Telephone orders of authorized physician practitioners shall be accepted and transcribed by Registered Nurses or Licensed Practical Nurses. The responsible physician practitioner shall sign such orders at the next visit, not to exceed forty-eight (48) hours."

Review of hospital policy titled "Telephone/Verbal Orders," last reviewed 01/2024, revealed in part: "PROCEDURE: 1) The licensed nurse receiving the verbal/telephone order shall promptly enter the order into the electronic medical record, indicating the order in the following manner: Choose telephone order and the ordering physician in the drop down in the electronic record. The licensed nurse receiving the verbal/telephone order will repeat the order back to the physician to ensure accuracy of the order. The physician will authenticate orders electronically within 48 hours of the verbal/telephone order. A covering physician/LIP may authenticate the attending physician/LIP's telephone orders."

Review of Patient #2's medical record revealed an admission date of 12/24/2024. Review of Patient #2's admission and medication orders revealed the orders were obtained by telephone from the physician and entered by the nurse on the following dates:
12/24/2024 at 5:10 PM
12/25/2024 at 9:30 AM
12/27/2024 at 11:40 PM
12/29/2024 at 10:23 PM
12/29/2024 at 10:24 PM
Further review revealed that the physician did not authenticate the orders listed above until 01/02/2025 at 10:09 AM.

In an interview on 01/14/2025 at 1:15 PM, S1DRM confirmed that the orders entered by the nurse for Patient #2 were not authenticated by the physician within 48 hours of the verbal/telephone order as per policy.

Review of Patient #1's medical record revealed an admission date of 12/26/2024. Review of Patient #1's admission and medication orders revealed the orders were obtained by telephone from the physician and entered by the nurse on the following dates:
12/26/2024 at 12:42 PM
12/27/2024 at 6:17 AM
12/27/2024 at 6:21 AM
Further review revealed that the physician did not authenticate the orders listed above.

In an interview on 01/14/2025 at 1:19 PM, S1DRM confirmed that the orders entered by the nurse for Patient #1 were not authenticated by the physician within 48 hours of the verbal/telephone order as per policy.

Based on record review and interview, the hospital failed to ensure the discharge summary contained the relevant information about the condition of the patient on the day of discharge. This deficient practice is evidenced by the discharge summary not including an accurate description of the clinical course for 1 (#2) of 3 (#1-#3) medical records reviewed.
Findings:

Review of the hospital Medical Staff Bylaws, last revised 04/2024, revealed in part: "Medical Records: 8. (K) a discharge summary, entered within (30) days following discharge and including: (1) the reason for hospitalization; (2) the significant findings; (3) the course and progress of the patient with regard to each identified clinical problem; (4) the clinical course of the patient's treatment; (5) the final assessment, including the general observations and understanding of the patient's condition initially, during treatment and at discharge; (6) the specific appointment arrangements for further treatment, including prescribed medications and after, specific instructions to the patient and family as necessary; (7) the final primary and secondary diagnosis."

Review of Patient #2's medical record revealed the patient was admitted on 12/24/2024 for Opiate and sedative detoxification.
Review of incident report provided involving Patient #2, revealed that Patient #2 eloped from the facility on 12/30/2024 at 4:10 PM and the provider was notified of elopement.
Further review of Patient #2's medical record revealed an additional note stating the patient returned on 12/30/2024 at 5:10 PM to collect his cell phone. MD notified. Discharge AMA order obtained. Patient signed out AMA. Returned cell phone. Left agitated, yelling about MD not discharging him prior.

Review of the discharge summary for Patient #2 revealed in part:
2. Safety: No major behavioral problems were reported during the hospitalization.
10. The patient tolerated medications without side effects and was successfully detoxed with no acute events. Patient was more cooperative and responded positively to redirections and limits set by the staff. The patient requested discharge and was discharged AMA.
11. On date of discharge, the patient was evaluated and patient denied withdrawal symptoms, suicidal/homicidal ideation, intention or plan and there was no evidence of manic or depressive symptoms. Patient was discharged from the hospital in stable condition.
Condition at Discharge:
Psychiatric Functioning to include Mental Status: The patient is felt to have improved in their psychiatric condition to the point where they may be discharged to outpatient care for follow-up at this time, having reached maximal hospital benefit.
Social Functioning: The patient is felt to have improved in their level of functioning, so that they may function in an unstructured environment.
Dated/timed by physician on 12/31/2024 at 9:50 AM.

In an interview on 01/14/2025 at 3:27 PM, S1DRM confirmed that the discharge summary did not contain documentation that the patient eloped from the facility on 12/30/2024. S1DRM also confirmed that based on the hospital bylaws, the discharge summary did not contain all relevant information regarding the patient condition on the day of discharge.