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The Condition of Participation: Patient's Rights was not met.

Findings included:

1.) The Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure restraints were effective to protect Patient #1 and Hospital Staff from harm in accordance with a written modification to Patient #1's plan of care, resulting in a reasonable contributing factor to Patient #1's death.

Refer to TAG: A-0166.

2.) The Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure effective restraint training for Medical Assistant #1 to monitor the condition of Patient #1 who was both chemically and mechanically restrained, resulting in a reasonable contributing factor to Patient #1's death.

Refer to TAG: A-0175.

State Scope of Practices and Federal Hospital Regulations; The Hospital provided no documentation to indicate that the Medical Staff recommended B.E.S.T. Team Clinicians to the Governing Body for the medical privilege to provide psychiatric evaluations for Emergency Department patients, and; The Hospital provided no documentation to indicate that the Governing Body granted B.E.S.T. Team Clinician the privilege to provide psychiatric evaluations for Emergency Department patients at the Hospital.

Based on records reviewed and interviews the Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure restraints were effective to protect Patient #1 and Hospital staff from harm in accordance with a written modification to Patient #1's plan of care, resulting in a reasonable contributing factor to Patient #1's death.

Findings included:

A.) The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, dated 3/31/2020, indicated the definitions of restraint as:

1.) a mechanical device attached to the patient's body that restricted movement was a restraint; and

2.) when a medication was used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and not a standard treatment for the patient was a restraint.

The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, indicated the treating physician was responsible for the care and treatment of the patient, or physician designee. The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, indicated restrained patient's condition were continually assessed, monitored, and re-evaluated.

The Emergency Department Record, dated 6/2/2021, indicated Patient #1 was brought to the Emergency Department, at 3:42 A.M., demonstrating psychotic behaviors, was in the Emergency department for nineteen hours, had six episodes of increasing psychotic, violent behaviors requiring both mechanical and chemical restraint, with periods of apnea and blood oxygen desaturation; prior to episode seven where Patient #1 was found by a Registered Nurse, unconscious and without a heartbeat when Emergency Department Staff initiated unsuccessful resuscitation and Patient #1 was pronounced dead at 10:26 P.M. on 6/2/2021.

Regarding restraint Episode #1:

The Emergency Department Record, dated 6/2/2021, indicated restraint Episode #1, at 4:09 A.M. Patient #1 received the first doses of medication as restraint (Haldol, an anti-psychotic medication; Zyprexa, an anti-psychotic medication and Versed, a benzodiazepine, an anti-anxiety, sedative medication; (reported side effects are apnea and tiredness). The Emergency Department Record indicated, at 4:18 A.M., an adverse reaction noted to the medication Haldol. The Emergency Department Record indicated no description of the adverse reaction to Haldol. The Emergency Department Record indicated during the timespan of Episode #1, at 4:09 A.M. Patient #1's heart beat was 107 beats per minute (tachycardic, fast) and at 4:29 A .M. Patient #1 had periods of apnea (potentially life-threating breathing that stops and starts).

Regarding restraint Episode #2:

The Hospital policy titled Emergency Code Policy, dated 10/20/2020, indicated a Code Gray was for Security Staff to immediately respond for intervention with a violent person.

The Emergency Department Record, dated 6/2/2021, indicated restraint Episode #2, at 10:15 A.M. a Code Gray was called. Patient #1 received a second medication restraint with the medications Zyprexa and Versed and Patient #1 was four point (both arms and both legs), mechanically restrained and a 1:1 Sitter (1:1 Observation) was ordered for Patient #1's safety; restraints were removed at 10:40 A.M.

The Emergency Department Record, dated from 10:35 A.M. through 1:13 P.M. on 6/2/2021, indicated around the time span of Episode #2, Patient #1 had a heartbeat of 105, 108, 110, 114, and 116 beats per minute.

The Emergency Department Record, dated 6/2/2021 at 11:52 A.M., Patient #1 required a non-rebreather mask (a life-saving device to deliver the highest concentration of supplemental oxygen prior to consideration of a breathing machine) to deliver 100% oxygen for decreasing blood oxygen levels to 80 (very low), and at, 1:13 P.M., Patient #1 required three liters of supplemental oxygen by nasal cannula (indicated a decreased oxygen requirement).

The Emergency Department Record, dated 6/2/2021 indicated at, 10:54 A.M., a physician documented that Patient #2's the episodes of hypoxia were likely secondary to airway obstruction, and at, 1:04 P.M., a Physician documented that Patient #1's transient hypoxia resolved with supplemental oxygen.

During an interview at 8:00 A.M. on 6/11/2021, Emergency Department Registered Nurse (RN) #2 said it was not common for patients to have a decreased blood oxygen levels following
chemical restraint; he had never seen respiratory distress after chemical restraint, never seen a decreased blood oxygen level below 90% and the need for a non-rebreather mask (to deliver 100% oxygen) was precursor to intubation (a breathing machine).

During an interview, at 11:30 A.M. on 6/11/2021, the Emergency Department Nurse Director said the need for supplemental oxygen for a restrained patient was not common and when blood oxygen levels drop that much the patient needs a higher-level response, possible intubation, or transfer to the Intensive Care Unit (for intensive monitoring).

Regarding restraint Episode #3:

The Emergency Department Record, dated 6/2/2021, indicated restraint Episode #3, at 1:45 P.M., Patient #1 attempted to elope (escape) from the Emergency Department, and Emergency Department Staff called a Code Gray, at 1:50 P.M. Patient #1 was four-point restrained (second mechanical restraint), removed after thirty-two minutes, at 2:22 P.M., and at 1:50 P.M., Patient #1 received the medication Versed (third chemical restraint). The Emergency Department Record indicated, at 2:22 P.M., Patient #1 required three liters of supplemental oxygen by nasal cannula, and had a heartbeat of 111 beats per minute, at 2:50 P.M., Patient #1 continued to require three liters of supplemental oxygen by nasal cannula, with a heartbeat of 112 beats per minute and, at 3:20 P.M., Patient #1's supplemental oxygen requirement decreased to two liters of supplemental oxygen by nasal cannula.

Regarding restraint Episode #4:

The Emergency Department Record, dated 6/2/2021, indicated restraint Episode #4, at 3:30 P.M., Patient #1 was four-point mechanically restrained (third time) for fifty minutes, and removed, at 4:20 P.M., and Patient #1 had a heartbeat of 107 beats per minute; at 3:51 P.M., Patient #1 was chemically restrained (fourth time) with the medications Zyprexa and Versed and at 4:00 P.M., documentation that Patient #1 attempted to elope, a Code Gray was called, and, at, 4:03 P.M., Patient #1 remained tachycardic with a heartbeat of 103 beats per minute.

Regarding restraint Episode #5:

The Emergency Department Record, dated 6/2/2021, indicated Episode #5, at 5:12 P.M., Patient #1 attempted to elope from the Emergency Department, and, at 6:33 P.M, Hospital Staff called a Code Gray. The Emergency Department Record indicated, at 6:35 P.M., Patient #1 was administered chemical restraints (fifth time) of the medications Zyprexa and Versed and Patient #1 was placed in four-point mechanical restraint (fourth time) with mechanical restraints removed, at 7:40 P.M., (one hour and five minutes later). The Emergency Department Record indicated, at 7:17 P.M., Patient #1's heartbeat remained tachycardic at 124 beats per minute and Patient #1 was in room air (supplemental oxygen was not needed) and, at 7:45 P.M., Patient #1's heartbeat remained tachycardic at 124 beats per minute and Patient #1 was snoring.

Regarding restraint Episode #6:

During an interview, at 9:00 A.M. on 6/10/2021, the Chief Administrative Officer said Patient #1 sustained a head laceration from a "head-but" (an aggressive and forceful thrust with the top of the head into the face or body of another person) to a Security Officer.

The Emergency Department Record, dated 6/2/2021, indicated Episode #6, from 8:12 P.M. though 8:33 P.M.; Patient #1 exposed his/her genital area, the Physician determined not to suture Patient #1 head laceration (from the earlier head-but event), Patient #1 continued with a tachycardic heartbeat at 105 beats per minute, Patient #1 was yelling, "help"; at 8:28 P.M., Patient #1 was 4-point mechanically restrained (fifth time) and, at 8:33 P.M., Patient #1 was chemically restrained with the medications Zyprexa and Versed (sixth time).

During an interview at, 12:45 P.M. on 6/10/2020, Emergency Department Registered Nurse (RN) #1 said Patient #1 said "help me", "help me" as they proceeded to a bathroom, as Patient #1 swung his/her arms and they walked back to Patient #1's room.

Regarding restraint Episode #7:

The Emergency Department Record, dated 6/2/2021, indicated, at 9:50 P.M., a Registered Nurse noted Patient #1 was unconscious and without a heartbeat; cardiopulmonary resuscitation was initiated and, at 10:26 P.M., a Physician pronounced Patient #1's death.

B.1.) The Hospital policy titled Sepsis (life-threatening infection): Early Recognition, Initial Treatment and Ongoing Management Protocol, dated 11/17/2020, indicated the scope of the policy applied to adult patients in the Emergency Department and inpatient areas except for adult psychiatry. The Hospital policy titled Sepsis indicated the Emergency Department physician would determine if the patient met the criteria for sepsis and if the patient met the criteria the Emergency Department physician would initiate treatment. The Hospital policy titled Sepsis indicated if the patient did not meet the sepsis criteria the Emergency Department nurse would reassess the patient and notify the Emergency Department physician of changes in condition.

The Emergency Department Record, dated 6/2/2021 and during the time span of Episode #2, indicated Patient #1 triggered for sepsis at 3:53 A.M. and at 2:22 P.M. the physician was notified. The Emergency Department Record indicated no documentation that Emergency Department physicians evaluated Patient #1 for sepsis considering Patient #1 triggered for sepsis and demonstrated changes in the condition of his/her behaviors.

B.2.) The Emergency Services Program (ESP) Adult Comprehensive Assessment, dated at 9:00 A.M. on 6/2/2021, indicated Patient #1 said he/she thought he/she was having a heart attack and for some reason they committed me, when the B.E.S.T. Team Clinician (local area ESP behavioral health contracted service clinician) asked why Patient #1 was hospitalized at another psychiatric hospital.

The Emergency Department Record, dated on 6/2/2021, indicated a physician documented, at 1:04 P.M., Patient #1 had transient episodes of hypoxia that resolved with supplemental oxygen, and at, 10:54 P.M., the episodes of hypoxia were likely secondary to airway obstruction.

The Emergency Department Record, dated on 6/2/2021, indicated, at 4:35 A.M., the Laboratory resulted that Patient #1 had an AST level of 63. (An AST is a liver function test where the normal blood AST is 14-20, however a high AST can also be a sign of or mean damage to other organs, heart, or kidneys.

The Emergency Department Record, dated on 6/2/2021, indicated from presentation and triage in the Emergency Department, at 4:09 A.M. through 8:22 P.M., Patient #1 remained tachycardic with heart beats ranging from 103 to 124 beats per minute.

The Emergency Department Record, dated 6/2/2021, indicated no medical written modification to the Patient #1's plan of care regarding Patient #1's: escalating psychotic, violent behaviors; AST level of 63; tachycardia; trigger for sepsis; continued need for supplemental oxygen surrounding episodes of chemical and mechanical restraint, "Head-but" event at approximately 8:30 P.M. and Patient #1, at 9:50 P.M., was found unresponsive and pulseless (approximately one-hour and twenty minutes later).

Emergency Department Registered RN #1 said the Emergency Department needed a better plan for Patients requiring sedatives and restraints.

During an interview, at 2:30 P.M. on 6/11/2021, the Chief Medical Officer said talks were happening regarding psychiatric patients in the Emergency Department and the protocol for physicians was not in place.

The Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure effective restraint training for Medical Assistant #1 to monitor the condition of Patient #1 who was both chemically and mechanically restrained, resulting in a reasonable contributing factor to Patient #1's death.

Findings included:

The Hospital policy titled Patient Observation for Prevention of Harm (Non-Behavioral Health Units, dated 10/19/2021, indicated Clinical Indications for One to One (1:1) Observation was implemented for patients with a high-risk for suicide and for Patients in restraint for violent or self-destructive behavior to refer to the policy on restraints.

The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, dated 3/31/32020, indicated a mechanical device attached to the patient's body that restricted movement was a restraint; and when a medication was used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and not a standard treatment for the patient was a restraint. The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, indicated Trained Staff were Hospital clinical staff members who had documented competencies and training. The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, indicated no clear One to One (1:1) Observation responsibilities for assigned staff, for Patients in restraint for violent or self-destructive behavior.

The Emergency Department Record, dated at 3:32 P.M., 6:33 P.M., 8:12 P.M. & 10:39 P.M. on 6/2/2021, indicated a physician ordered Patient #1 placed with a 1 to 1 Sitter [One to One (1:1) observation] for the duration that the physical restraint was in place.

During an interview, at 9:00 A.M. on 6/10/2021, the Chief Administrative Officer said that a 1:1 Sitter (1:1 Observation) was ordered at 10:15 A.M. on 6/2/2021, and implemented (for Patient #1's safety).

During an interview at, 12:45 P.M. on 6/10/2020, Emergency Department Registered Nurse (RN) #1 said Patient #1 had a 1:1 Sitter (1:1 Observation by Medical Assistant #1) that was watching Patient #1 and other patients. RN #1 said she did not know why Patient #1 was not receiving 1:1 Observation, this happened a lot and that they (the Emergency Department) were not able to get staff.

During an interview, at 10:00 A.M. on 6/11/2021, Medical Assistant #1 said she was a new employee with the Hospital, and this was the first time she was assigned to be a Sitter (perform 1:1 Observation). Medical Assistant #1 said the Emergency Department Nurse Director told her in an informal conversation, that she received the (1:1 Observation) training during orientation, and was able to sit (perform the responsibilities of 1:1 Observation). Medical Assistant #1 said she forgot she had taken the course and did not know the role of the Sitter (1:1 Observation). Medical Assistant #1 said the Emergency Department Nurse Director did not provide re-training and no-one reviewed the details (of 1:1 Observation) with her. Medical Assistant #1 said she relieved another Sitter who was watching three patients, did not know that 1:1 Observation was necessary for Patient #1 and assumed the RN (RN #1) caring for Patient #1 knew she was watching three patients. Medical Assistant #1 said she wrote "unresponsive" (on the Patient Observation Monitoring Tool at 9:45 P.M. and 10:00 P.M.) because she did not know what to write, and did not know that she needed to sign the bottom of the sheet. Medical Assistant #1 said she wished someone had checked in with her and told her about Patient #1.

The Job Description titled Medical Assistant, dated 8/11/2016, indicated no job responsibility to perform in the responsibilities of 1:1 Observation.

The document titled Competency Assessment For Restraints (Nurse Aide), undated, indicated competency for Medical Assistant #1. The Competency Assessment For Restraints (Nurse Aide) indicated it was designed to document competency assessment of a Nurse Aide; the Competency Assessment For Restraints indicated no indication the document was designed for competency assessment of Medical Assistants.

Medical Assistant Orientation Checklist, dated 4/26/2021, indicated a competency for Medical Assistant #1, that identified 1:1 Observation for patients in restraint or self-destructive behavior with illegible preceptor initials. The Medical Assistant Orientation Checklist indicated no documentation of signatures in the spaces provided for a preceptor's name, the orientees's name or the Director's name to validate Medical Assistant #1's competency in the provision of 1:1 Observation for Hospital patients.

The Condition of Participation: Emergency Services was not met.

Findings included:

1.) The Medical Staff failed to ensure for one patient (Patient #1) in a sample of ten patients that the Emergency Department had policies and procedures governing medical care to meet the needs of violent, aggressive, psychotic, psychiatric patients in the Emergency Department, resulting in a reasonable contributing factor to Patient #1's death.

Refer to TAG: A-1104.

2.) The Hospital failed for two patients (Patients #1 & #2) in a sample of ten patients to ensure adequate medical and Hospital personnel qualified in emergency care to meet to meet the acuity needs and psychiatric evaluation needs of patients cared for in the Emergency Department consistent as non-physician practitioners.

Refer to TAG: A1112.

Based on records reviewed and interviews the Medical Staff failed to ensure for one patient (Patient #1) in a sample of ten patients that the Emergency Department had policies and procedures governing medical care to meet the needs of violent, aggressive, psychotic, psychiatric patients in the Emergency Department, resulting in a reasonable contributing factor to Patient #1's death.

Findings included:

The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, dated 3/31/32020, indicated a mechanical device attached to the patient's body that restricted movement was a restraint; and when a medication was used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and not a standard treatment for the patient was a restraint. The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, dated 3/31/32020, indicated the treating physician was responsible for the care and treatment of the patient, or physician designee.

The Emergency Department Log, dated 6/2/2021, indicated Patient #1 was brought to the Emergency Department, at 3:42 A.M., demonstrating psychotic behaviors, was in the Emergency department for nineteen hours, had six episodes of increasing psychotic, violent behaviors requiring both mechanical and chemical restraint, with periods of apnea and blood oxygen desaturation; prior to episode seven where Patient #1 was found by a Registered Nurse unconscious and without a heartbeat when Emergency Department staff initiated unsuccessful resuscitation and Patient #1 was pronounced dead at 10:26 P.M. on 6/2/2021.

During an interview at 1:45 P.M. on 6/10/2021, Risk Manager #1 said the Hospital investigation was not completed and that two more meetings were to be done.

During an interview, at 2:30 P.M. on 6/11/2021, the Chief Medical Officer said talks were happening regarding psychiatric patients in the Emergency Department and the protocol for physicians was not in place.

The Hospital provided no documentation, policy, procedure, guideline, algorithm, governing medical care provided to violent, aggressive, psychotic, psychiatric patients in the Emergency Department prior to the death of Patient #1.

Based on records reviewed and interview the Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure adequate medical and Hospital personnel qualified in emergency care to meet to meet the acuity needs and psychiatric evaluation needs of patients cared for in the Emergency Department.

Findings included:

Regarding Provider Staffing:

Based on records reviewed and interviews the Hospital failed to adequately staff the Emergency Department with Licensed Independent Practitioners (Physicians, Physician Assistants) on 6/2/2021.

During an interview, at 11:15 A.M. on 6/10/2021, Emergency Department Physician #1 said it was a usual busy day from 3:00 P.M. through 11:30 P.M. on 6/2/2021.

During an interview at, 12:45 P.M. on 6/10/2021, Emergency Department Registered Nurse (RN) #1 said that the Emergency Department needed proper Doctor (Physician) coverage to manage discharges and Emergency Department volume.

During an interview, on 6/10/2021 at 1:45 P.M., Risk Manager #1 said the Hospital investigation (Regarding Patient #1's death) determined that Provider (Physician) coverage was not an issue and the determination was made by (patient) volume.

During an interview, on 6/11/2021, at 11:30 A.M., the Emergency Department Nurse Director said between 7:00 P.M. through 12:00 P.M. the Emergency Department was busy, there were twenty-seven patients, five patients were triaged, five patients were discharged, five patients were transferred, or in the process of transfer (to a hospital with a higher-level of care) with one physician, one physician assistant, seven registered nurses and four medical assistants.

Emergency Department Records regarding Patient's #1, #2, #3, #4, & #5 indicated emergency medical management for various, complicated patient care acuity needs.

Regarding Patient #1:

The Emergency Department Record, dated 6/2/2021, indicated Patient #1 was brought to the Emergency Department, at 3:42 A.M., demonstrating psychotic behaviors, was in the Emergency department for nineteen hours, had six episodes of increasing psychotic, violent behaviors requiring both mechanical and chemical restraint, with periods of apnea and blood oxygen desaturation; prior to episode seven where Patient #1 was found by a Registered Nurse unconscious and without a heartbeat when Emergency Department staff initiated unsuccessful resuscitation and Patient #1 was pronounced dead at 10:26 P.M. on 6/2/2021.

Regarding Patient #2:

The Emergency Department Record indicated Patient #2 was transferred to another hospital at 8:00 P.M on 6/2/2021 for an acute (developed quickly) on chronic (long-lasting) intracranial subdural hematoma (brain bleed), end stage renal disease (kidney failure), elevated troponin blood level (can indicate a heart problem), altered mental status and Congestive Heart Failure (CHF), for a higher-level of care.

Regarding Patient #3:

The Emergency Department Record, dated at 5:14 on 6/2/2021, indicated Patient #3 was transferred to another hospital for an Endoscopic Retrograde Cholangiopancreatography (ERCP, procedure to diagnose and treat liver, gallbladder problems) after Patient #3 presented to the Emergency Department for right upper quadrant abdominal pain.

Regarding Patient #4:

The Emergency Department Record, dated at 5:02 P.M. on 6/2/2021, indicated Patient #4 was transferred to a trauma center hospital for treatment of gun-shot wounds.

Regarding Patient #5:

The Emergency Department Record, dated at 11:46 P.M. on 6/2/2021, indicated Patient #5, was transferred to another hospital with a trauma service for management of bleeding following a fall on the right hip and sustaining a hematoma while on Eliquis (blood thinner medication). The Emergency Department Record indicated diagnostic imaging revealed a very large hematoma that was active and expanding (bleeding), and Patient #5 had decreased hematocrit and hemoglobin (blood levels).

Regarding Psychiatric Evaluations for Emergency Department Patients:

The Hospital failed to establish criteria, in accordance with State law and regulations and acceptable standards of practice delineating the qualifications required for B.E.S.T. Team Clinicians (local area Emergency Service Program (ESP) behavioral health contracted service clinician) to provide psychiatric evaluations for Patients in the Emergency Department consistent as non-physician practitioners.

Regarding Patient #1:

The Emergency Services Program (ESP, behavioral health contracted service) Adult Comprehensive Assessment: Revision date 11/10/2016, indicated Patient #1's psychiatric evaluation. The Adult Comprehensive Assessment indicated Patient #1 presented disorganized with tangential (incoherent) thought. The Adult Comprehensive Assessment indicated Patient #1's mental status and risk assessment was abnormal for mood, affect and thought content. The Adult Comprehensive Assessment indicated Patient #1's medical necessity for further treatment and clinical formulation was that Patient #1's affect was incongruent to mood, disorganized to time and Patient #1's judgement was poor. The Adult Comprehensive Assessment indicated a diagnosis of schizophrenia, unspecified. The Adult Comprehensive Assessment indicated treatment recommendations as medical admission. The Adult Comprehensive Assessment indicated that B.E.S.T. Team Clinician #1 (local area ESP behavioral health contracted service clinician) consulted with a Licensed Independent Clinical Social Worker (LICSW), a B.E.S.T. Team Supervisor, who agreed with the disposition of Inpatient Level of Care due to Patient #1's bizarre behaviors, lack of insight, recent discharge from an inpatient level of care hospital and unknown medication compliance. The Adult Comprehensive Assessment indicated the name of the B.E.S.T. Team Clinician with the letters MSW (undefined) following the name; to indicate that the B.E.S.T. Team Clinician completed the Adult Comprehensive Assessment.

During an interview, at 10:55 A.M. on 6/11/2021, Risk Manager #1 said the B.E.S.T. Team Clinicians did not have a credential file (at the Hospital), the B.E.S.T. Team Clinicians were not Hospital employees, and the Hospital had no choice to have the B.E.S.T. Team Clinicians come here (to the Hospital).

During an interview, at 11:00 A.M. on 6/11/2021, B.E.S.T. Team Clinician #1 said she completed Patient #1's psychiatric evaluation, identified a diagnosis, determined Patient #1 required an inpatient level of care hospital and the B.E.S.T. Team Supervisor agreed with her evaluation and determination of care. B.E.S.T. Team Clinician #1 said she did not discuss her psychiatric evaluation or determination of level of care with Patient #1's Emergency Department Physician.

During an interview, on 6/11/2021 at 11:30 A.M., the Emergency Department Nurse Director said the B.E.S.T. Team provided psychiatric evaluations and determined the patient's level of care needed. The Emergency Department Nurse Director said the B.E.S.T. Team Clinicians spoke with the Charge Nurses and sometimes the Emergency Department Physicians and there was no formal process to speak with the Medical Staff (Emergency Department Physicians).

Regarding Patient #8:

The Emergency Department Record, dated at 12:56 P.M. on 6/7/2021, indicated Patient #8 presented to the Emergency Department with a history of psychiatric disease, alcohol abuse and suicidal ideation. The Emergency Department Record indicated laboratory analysis was pending for medical clearance prior to psychiatric evaluation.

Review of Patient #8's Emergency Department Record indicated no documentation of a psychiatric evaluation.

During an interview, Risk Manager #1 said that the B.E.S.T Team did not forward a copy of Emergency Services Program Adult Comprehensive Assessment to the Emergency Department for physician review (this resulted in the Hospital maintaining Patient #8's medical record incomplete).

The Hospital provided no documentation to indicate B.E.S.T. Team Clinicians were qualified to perform psychiatric evaluations for Emergency Department patients in accordance with State Scope of Practices and Federal Hospital Regulations; The Hospital provided no documentation to indicate that the Medical Staff recommended B.E.S.T. Team Clinicians to the Governing Body for the medical privilege to provide psychiatric evaluations for Emergency Department patients, and; The Hospital provided no documentation to indicate that the Governing Body granted B.E.S.T. Team Clinician the privilege to provide psychiatric evaluations for Emergency Department patients at the Hospital.