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Based on medical record review, document review and staff interview it was determined the facility failed to follow and enforce the "Medical Staff Bylaws" by not documenting progress notes per the frequency required in such Bylaws in three (3) out of ten (10) patients (patients #2, 4, and 10). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A record review was conducted for patient #2. The patient was admitted to the facility on 08/11/21 as a Probable Cause status, for competency restoration with a diagnosis of schizoaffective disorder. The medical record revealed only one (1) physician progress note for the calendar week of 02/20/22, dated 02/23/22, and no progress notes for the calendar week of 02/28/22.

A record review was conducted for patient #4. The patient was admitted to the facility on 02/02/22 as a Probable Cause status with a diagnosis of schizoaffective disorder. The provider and/or physicians did not see the patient, as required, three (3) times a calendar week. Only two (2) provider notes were documented the week of 02/06/22, on 02/07 and 02/08/22, and one (1) provider note the week of 02/20/22, dated 02/22/22.

A record review was conducted for patient #10. The patient was admitted to the facility on 02/21/22 as a Probable Cause status with a diagnosis of bipolar disorder. The provider and/or physicians did not see the patient, as required, three (3) times a calendar week. Only two (2) provider notes were documented the week of 02/27/22, dated 02/28 and 03/04/22, one (1) provider note the week of 03/06/22, dated 03/09/22, two (2) provider notes the week of 03/13/22, dated 03/14 and 03/18/22, and two (2) provider notes the week of 03/20/22, dated 03/22 and 03/24/22.

A review conducted of the "Medical Staff Rules and Regulations," effective 11/04/19, stated in part: "... Article II ... 2.3 Progress Notes: ... Progress notes documenting interactions with the patient, relevant observations, and plans for continued care will be completed weekly. Progress notes should be completed as frequently as a patient's status or treatment requires, but a minimum of three (3) times per week for the first month of hospitalization. The frequency of the Progress note will decrease to twice weekly for one month after the first month of hospitalization, then weekly thereafter, unless more frequently is clinically indicated, throughout the course of the hospitalization. The frequency of the Progress note for a forensic patient that has been adjudicated is a minimum of two (2) times a week for the first month of hospitalization then weekly thereafter. The frequency of the Progress note for a forensic patient that has not been adjudicated is a minimum of two (2) times a week for the duration of the hospitalization ..."

An interview was conducted with the Chief Medical Officer (CMO) on 03/28/22 at 1:09 p.m. Regarding physicians seeing patients on the units, the CMO stated, "Practitioners will see the patient if nursing asks, or the patient themselves asks to see the physician. The physician either gets a schedule from the unit clerk or makes one themselves to ensure all the patients get seen as required and documents in the progress notes." Regarding patients #2 and 4, the CMO concurred progress notes were not documented as required.

An interview was conducted with Nurse Practitioner (NP) #1 on 03/28/22 at 2:36 p.m. Regarding patient #1, the NP stated, "The visits were made as required, within the calendar week." Regarding patient #2, the NP stated, "The unit clerk makes the schedules, and must have left the patient off the schedule on those instances."

An interview was conducted with the Certified Physician Assistant (PA-C) on 03/29/22 at 11:19 a.m. Regarding the practitioners seeing patients as per schedule, the PA-C stated, "The unit secretary prints a list of the patients with their status. I then make myself a schedule to see the patients. If the documentation isn't in the medical progress note, it could also be in the suicide risk assessment note. If there is a missed note, it is probably due to receiving the wrong status on the patient."

An interview was conducted with the Chief Nursing Officer (CNO) on 03/30/22 at 11:00 a.m. Regarding patients #2, 4 and 10, the DON concurred no additional physician documentation could be found, and the physicians did not document on the patients as required.