Tyslii is a 32-year-old AA female who presents to CRU from UPC. She is SMI designated with SWN as the OP treatment agency. She is on ACOT for non-compliant with COT plan. Per amendment letter, client missed her court appointment, and believes that her group home staff poisoned her food. She has called Police multi times. Upon admission, she is calm, appropriate. She denies DTO/DTS and AVH. Her vitals are within WNLs. Tyslii will benefit from meeting with the provider to discuss medication stabilization.…
CCIB Intake received SOC 341 from co-complainant for complaint control # 27-SC-20170104121605. The reporting party is Michelle Allie, RN Case Manager with Mercy Hospice 9912 Business Park Dr., Sacramento 95827 (916) 281-3900. The SOC 341 is regarding resident Shirley Pond. The reporting party (RP) stated the home health aide Ramona was preparing to leave when the caregiver Lidia stated "aren't you going to make the bed!" Ramona replied the resident stated she was tired and wanted to lie back down after her shower. Lidia then went into the resident's room where the resident was sitting on the side of her bed and in the presence of the RP and the home health aide, yelled "why did you tell the nurse not to make your bed?" She then told the resident…
On September 27, 2016, CPT Porter, Derek came in for his appointment; however, he did not have his ID card with him. At that moment, I informed him that I could not check him in unless he has his ID card. He replied, “Even if they already know who I am”, I said “yes, even if they know who you are, I cannot check you in without your ID it is protocol”. I proceeded to inform him that if he had another form of identification he can go to medical records and get a promissory note. At which time he became upset and stated he wanted to speak to someone. I immediately, asked Major Stackhouse for assistance, I explained to him the situation and also informed CPT Porter that he had to obtain a promissory note. In addition, Major Stackhouse offered to inform the provider of the situation.…
4 years after admission). The resident reports never receiving a copy of a signed admission agreement; resident reported receiving an envelope of blank pages and miscellaneous pharmacy forms left by his bed. Resident stated that he was not made aware of "code of conduct or house rules/policies"; even after any of the alleged incidents occured. On 12/14/16, staff Samantha Byers told the resident to sign an updated care plan ofr Jewish Family Services but refused to let hime review a copy beforehand. The care plan alleged resident was "agitated and disruptive 1-3 times per week and resident refused to sign it. Resident spoke with Jewish Family Services who denied having updated any care plans that would have had this language. The administrator refused to honor Ombudsman's request to reissue the notice or produce a written copy of the code of…
SC, Jennifer Stoker contacted provider, Anita Baker via telephone. SC introduced herself and told provider that she was Terry Williams’s SC. SC asked has she spoke to Terry over the weekend. Anita Baker stated yes. She noted Terry called her told that he don’t have his medication and his blood pressure was high. Anita stated that she got his medication from his Aunt Earnestine and give it to Terry nurse. SC asked if she know if the nurse give him or his host home the medication. Anita sated she don’t know if the nurse give them the medication. SC informed Anita, Terry call is old provide and stated that he was hungry and need food. Anita noted Terry tell her he is happy at his new home and they cook was great. Anita then noted Terry never…
In the process of completing an internal audit. Within that internal audit, they pulled a patients bill and medical records and traced everything back to make sure orders, charges and within that they found one discharge summary and psych evaluation that were missing diagnosis on both documents. We were cited for that and we told them that we notified medical staff and a reminder was sent by Becky Daniels. They pulled 20-25 records and only found 2.…
Potential solutions should be identified for as many causes on the map as possible. Once the potential solutions have been identified, the next step is to identify the solutions that will best reduce the risk for the organization involved. These solutions become action items. Following are some action items that have been put into place by various organizations in order to reduce the risk of medication errors (IMNAP, 2000).…
What do you think is the reasoning for not filing incident reports in medical records? Provide examples of three incidents and explain why they could be problematic in patients’ files.…
The managers or the care staff did not report to the Care Quality Commissions as required, and if they did report it to someone within the company they should have followed the report up for progress as to why nothing had been done.…
The administration at St. John’s Hospital takes pride in their sound policies and procedures for the protection of confidential client information. In fact, they serve as a model for other institutions in the area. However, printouts discarded in the restricted-access IS department are not shredded. On numerous occasions, personnel working late observed the cleaning staff reading discarded printouts. What actions, if any, should these…
This article was about a case implicates the Georgia Regional Hospital, Atlanta. In January of 2009, a patient, Na Young, this patient has a history of psychotic episodes. This patient was released form the psychiatric hospital. On a Friday evening in January at the Regional Hospital in Atlanta, Na Yong, refused to sign the release paper. The patient go valance with the nurse and told her that she will now longer take the antipsychotic medication. The patient family pleaded the doctors and nurses to reconsider discharging her from the hospital. The patient prior to been admitted into the hospital had physically abused her mother on several occasion. Na Yong told physician and nurses that if she were discharge from the hospital she would kill her mother, which was the target of her schizophrenia-fueled rage. The hospital staff still…
The agencies that are in charge of monitoring health care facilities and practitioners are known as health care regulation agencies. These agencies also provide the organizations with information about changes in the industry. At the federal, state, and local level the agencies establish rules and regulations that health care organizations have to follow mandatorily. Some agencies, especially those that provide accreditation for health care professionals, require no mandatory participation. The objective of this paper is to examine one of those health care regulatory agencies; the Centers for Disease Control and Prevention.…
In the case presented for discussion described above, it was imminent that Dr. Yarnell had a justifiable medical history that supported his symptoms. Nonetheless, it can be argued the way PA Brian decided to evaluate and treat Dr. Yarnell was biased or based on personal interests. PA Brian’s medical judgment was compromised. Mutual personal motivations existed between Dr. Yarnell and PA Brian. However, as a clinician PA Brian should have impartially evaluated Dr. Yarnell by properly and examining and documenting his findings or properly redirecting Dr.Yarnell to a different clinician. If the patient (Dr. Yarnell) was never appropriately examined, how can PA Brian as a health care provider substantiate that the medication prescribed was adequate and beneficial for the…
The first case of the day was will be referred to as T.O. This female registered nurse employed in Eureka, Missouri works overnight shifts. On August 20, 2014 to August 21, 2014 at approximately 1:15 am the Director of Nursing of the facility T.O works at was contacted by another Licensee’s coworker who reported that T.O was not acting right. T.O was reported of having slurred speech, was confusing coworkers’ names, appeared disoriented and staggered while working. The DON of the facility came in to evaluate the situation at which time found T.O to be impaired and requested that T.O submit a sample for a drug screen. The results of this drug screen returned positive for Benzodiazepines and opiates. T.O provided her prescription information…
* An individual may have a concern which they feel they need to discuss but will only tell the staff member if they promise not to tell anyone else. The conflict here is that the individuals rights is that he wants you to keep it secret and only wants to tell you, but as a duty of care we must report anything that may be a danger or harm to that individual.…