Initial Comments:
This report is the result of an unannounced onsite complaint investigation (JAC10C062P) completed on July 19, 2010, at Southwood Psychiatric Hospital. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.13(a)(2)(iii) STANDARD
PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION
Name - Component - 00
At a minimum:
In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Observations:
Based on review of facility documents and staff interview(EMP), it was determined that the facility failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 11 of 18 complaints/grievances reviewed.
Findings include:
Review of policy "Child/Adolescent/Family Grievance and Appeal" dated 2009, revealed "2.2 The Program Manager shall immediately inform the Patient Advocate of all Formal Grievances. 2.3 The program Manager/Patient Advocate shall immediately begin an investigation into the compliant[sic] and provide a written response to the person filing the complaint within 48 hours of receiving the complaint. If the investigation is unable to be completed within 48 hours due to extenuating circumstances (employees being off duty, etc.), the person filing the complaint will be contacted with updates and an estimated time for a resolution."
1) Review of facility documentation "Southwood Psychiatric Hospital Patient/Family/Other Complaint Or Grievance" for the months of February thru June 2010, revealed 11 grievances. Further review revealed no documentation of a written response to the person filing the complaint within 48 hours of receiving the complaint as per facility policy.
Interview with EMP5 on July 19, 2010, at approximately 2:00 PM confirmed there was no documentation of a written response to the person filing the complaint within 48 hours. EMP5 further stated "No, no letters were sent. I only remember one letter I ever sent out."
Interview with EMP6 on July 19, 2010, at approximately 3:00 PM confirmed the above findings and revealed "I don't think we ever sent a letter out."
Plan of Correction:When a complaint/grievance is filed with the Patient Advocate, the Patient Advocate shall immediately begin an investigation into the compliant, and provide a written response to the person filing the complaint within 48 business hours of receiving the complaint. If the investigation is unable to be completed within 48 hours due to extenuating circumstances (employees being off duty, etc.), the person filing the complaint will be contacted via telephone call, which shall be documented ion final written response, with updates and an estimated time for a resolution.
To further ensure this issue does not occur again the Patient Advocate will submit a Variance Report for every grievance or complaint filed with them to include an attached copy of "Patient/Family/Other Compliant or Grievance" form to the Director of Performance Improvement for processing through the Performance Improvement System. This system will include review of complaints/grievances during Performance Improvement Committee, Medical Staff and Governing Body meetings with the inclusion of this review in said meetings' minutes. The Director of Performance Improvement will audit the Patient Advocate's complaints/grievances monthly to ensure all filings were submitted through the Performance Improvement process. All Program Directors and Patient Advocate will be educated on this standard by 9/01/10. All aspects of this plan will be finalized by 9/01/10.
482.24(c)(1) STANDARD
ORDERS DATED AND SIGNED
Name - Component - 00
(i) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, except as noted in paragraph (c)(1)(ii) of this section.
(ii) For the 5 year period following January 26, 2007, all orders, including verbal orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to write orders by hospital policy in accordance with State law.
Observations:
Based on review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that all orders, including verbal orders, were dated, timed, and authenticated promptly by the ordering practitioner for two of two medical records with verbal orders (MR1, MR5).
Findings include:
Review of the facility policy "Special Procedure-Physical Restraint" revised 7/09, revealed "16. The physician as permitted by the state and the facility to order restraint, must verify the verbal order in a signed written form in the resident's record."
1) Review of MR1 on July 19, 2010, at 2:00 PM revealed four preprinted "Physician Order Restraint Orders" dated April 15, 2010, July 11, 2010, July 13, 2010, and July 17, 2010 with no physician signature, date or time.
2) Review of MR5 on July 19, 2010, at 3:00 PM revealed a preprinted "Physician Order Restraint Orders" dated June 24, 2010, with no physician signature, date or time.
3) Interview with EMP2 on July 22, 2010, at approximately 2:30 PM stated, " I have reviewed the five questioned verbal orders and they were not authenticated."
Plan of Correction:In our acute care program verbal or telephone orders will be immediately flagged by the nurse taking the order to help identify need of physician authentication with date and time. All active medical records will be audited daily to ensure all orders in need of physician authentication with date and time are flagged; this will be the responsibility of the overnight Nursing Supervisor. Each shift the nurse supervisor is responsible for reviewing all needed instances, of physician authentication with date and time, with the physician for completion. The Medical Records Manager will review all active medical records to ensure all needed physician authentication with date and time have been completed. Should the Medical Records Manager identify any unresolved need for physician authentication with date and time, the medical record will be taken to the physician for immediate resolution. The Medical Records Manager will inform the Director of Performance Improvement, DON and CEO of any instance of process failure resulting in delinquency. These process failures will then be discussed and communicated through the Performance Improvement System which includes review during Performance Improvement Committee, Medical Staff and Governing Body meetings with the inclusion of this review in said meetings' minutes. All medical staff will be educated on this standard by 9/01/10. All aspects of this plan will be finalized by 9/01/10.
|