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Based on staff interview, medical record review, governing body by-law review, and policy review the facility's governing body failed to establish a policy/procedure to ensure the timely response from the on-call medical provider on one (1) out of three (3) medical records reviewed during two (2) of two (2) days of survey.

Findings Include:

Interview with the Director of Nurses (DON) on 05/23/2023 at 3:20 p.m., confirmed the nurses should have notified the Emergency Medical Services (EMS) instead of waiting for the medical provider to call back. The DON confirmed the facility did not have a policy addressing the response time of the medical provider call back. The DON confirmed she expected medical providers to call back promptly when on call.

Review of Patient #1's Nurses' Note dated 04/24/2023 at 4:37 a.m., confirmed RN #1 attempted to notify the medical provider without success at 3:05 a.m., 3:07 a.m. and 3:17 a.m. and further reveals the Psychiatric Nurse Practitioner was called at 3:15 a.m. by RN #1 and orders were received to transfer Patient #1 to the emergency room in 15 minutes if provider has not returned call.

Review of Policy and Procedure Manual and Governing Body By-laws revealed there were no policy/procedures for the facility's on-call process.

During the exit conference on 05/25/2023 at 12:30 p.m. with Program Director, Director of Nurses, and Chief Administrator Officer, survey findings were discussed, and no further documentation was submitted for review.