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Based on record review, interview, and observation, the facility failed to ensure that psychiatric evaluations were performed by a physician. This was evidenced by 1 of 7 psychiatric evaluations (Patient #1) being completed by a nurse practitioner.

Findings included:

Record review of the Psychiatric Evaluation, by Staff B, a Nurse Practitioner, dated 7/23/2019 at 8:41pm - 8:56pm, for Patient #1 showed: 15yo male with a history of depression, self-harm, and suicidal behaviors. Diagnostic Impression: Disruptive mood dysregulation disorder; attention deficit hyperactivity disorder, combined type; oppositional defiant disorder. Attending: Staff G [DO - Doctor of Osteopathic Medicine].

Record review of Progress Note by Staff G [DO], dated 8/6/2019 at 8:54pm, showed: "I discussed the case with the NP. I agree with her assessment and plan." The time between the completion of the Psychiatric Evaluation performed by the nurse practitioner and the documented approval by the physician was fourteen (14) days.

In an interview with Staff B on 9/10/2020 at 12:00pm, she stated she had not been credentialed by the facility to perform psychiatric evaluations.

Record review of Medical Staff Bylaws, accepted and approved by Staff O [Executive Medical Director], Staff A [Executive Director] and Staff P [Senior Vice President and Chief Clinical Officer] on 8/20/2019 showed:
"Allied Staff consist of physician assistants, nurse practitioners and other professional staff who are certified or registered to provide specific clinical interventions and are not licensed to practice independently, or who function under the supervision of a member of the Medical Staff in the exercise of assigned clinical privileges.
Allied Staff are granted privileges as recommended by the Executive Committee of the Medical Staff to the Board according to the procedures provided by these bylaws and are subject to Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation as described in Admin. 1196-L. Allied Staff are non-voting members of the Medical Staff ...
"All LIPs shall abide by the principles of ethics established by their respective national and/or, professional organization ... "

Record review of the Medical Staff Rules and Regulations, agreed to and accepted by Staff O [Executive Medical Director], Staff A [Executive Director] and Staff on 6/2/2016 and by Staff Q [MD, Senior Vice President], on 6/7/2016 showed:
"ADMISSIONS ... 5. The admitting physician shall care for the client until the time when an attending physician or a physician designee, if different from the admitting, can assume responsibility for that client. Regardless, the admitting physician shall be privileged according to the Bylaws. 6. On a hospital-licensed unit, a physician shall see the client within twenty-four (24) hours after admission and shall write an admission note which shall include a report on the mental status of the client, any special considerations of care and a preliminary plan of care ...
"MEDICAL RECORDS ... The attending physician shall be responsible for timely, pertinent and legible documentation for each patient - Initial Psychiatric Evaluation: required to be completed and signed at the time of admission ... "

Based on record review, interview, and observation, the facility failed to ensure that an estimate of the intellectual function was included in the psychiatric evaluation. This was evidenced by 1 of 7 patients (Patient #1) not having an estimate of intellectual functioning in the psychiatric evaluation.

Findings included:

Record review of the Psychiatric Evaluation, by Staff B, a Nurse Practitioner, dated 7/23/2019 at 8:41pm - 8:56pm, for Patient #1 showed: "Current Mental Status ... Intelligence
O Below Average
O Average
O Above Average"
None of the options had been assigned in the assessment of intelligence.

In an interview with Staff B on 9/10/2020 at 12:00pm, she stated that all elements of the mental status are to be completed. She further explained that the clinician completes the Psychiatric Evaluation from an electronic template.

Record review of the Psychiatric Evaluation from the electronic template showed: "Current Mental Status ... Intelligence
O Below Average
O Average
O Above Average"
The clinician is prompted to choose one of the options for "Intelligence."