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Based on a review of hospital contracts and staff interviews, it was determined the hospital failed to ensure the medical staff had written procedures for appraisal of emergencies, initial treatment and referral when appropriate. This had the potential to result in delayed assessment and treatment of patients' emergent medical needs. Findings include:

A Registered Nurse was interviewed on 7/22/15 at 10:45 AM. The RN stated in the event of a patient emergency requiring potential further treatment, the hospital medical director would be called during daytime hours. The RN stated if the emergency occurred after 5:00 PM, he may attempt to call the medical director, however he confirmed there was no physician or other provider on-call list. The RN stated the hospital had a contract with a medical services provider, however, the services were unavailable after 5:00 PM.

A review of the contract between the hospital and the medical services provider was made on 7/22/15. The contract stated the medical services provider will provide, seven days per week from 8:00 AM to 5:00 PM, access to a physician led medical team able to provide histories, physicals and basic medical care to patients at the hospital. The contract did not include an agreement for appraisal of emergencies, initial treatment, and referral, if necessary. In addition, the agreement did not include provision of medical services from 5:00 PM to 8:00 AM daily.

The CNO/Acting Administrator was interviewed on 7/22/15 at 11:15 AM. She stated the hospital did not provide emergency services and, in the event of a patient emergency, the staff did not have access to qualified medical services to perform an appraisal of a patient's emergency needs. The CNO/Acting Administrator confirmed the agreement between the hospital and the medical services provider did not include emergency services.

The hospital did not have policies and procedures in place that provided for an appraisal of patient emergencies, initial treatment, and referral.

Based on staff interviews and a review a review of QAPI documents, incident logs, and occurrence reports, it was determined the hospital failed to ensure a clear process was established and implemented for reporting adverse events. This had the potential to result in missed, delayed, and/or inaccurate reporting of adverse events. Findings include:

The hospital's incident report log was reviewed. The log included a Patient Occurrence Report, dated 7/08/15 at 8:30 PM, completed by the CNO/Acting Administrator. An Occurrence Report dated 7/08/15, stated Patient #2 cut his throat with a piece of broken mirror. An investigation of the cause of the event and actions taken were not documented.

The CNO/Acting Administrator was interviewed on 7/21/15 at 8:00 AM. She stated the incident involving Patient #2 occurred on 7/08/15 at approximately 7:45 PM, when Patient #2 was visited by his sister and brother-in-law. She stated Patient #2 had allegedly been calm during the day, however, during the visit, he threw a chair at the mirror in his room, broke the glass and used a piece of broken glass to cut his neck. She stated Patient #2 was restrained by the psychiatric technician responding to the sister's scream. The CNO/Acting Administrator stated Patient #2 was restrained after sustaining self inflicted lacerations on his hand, forearm and neck. She stated Patient #2 was attended to by the physician and transferred by ambulance to the ER of an acute care hospital for evaluation and treatment to his wounds.

During the same interview, the CNO/Acting Administrator stated that at the time of the incident, she was the designated Acting Administrator. A request was made on 7/21/15 for the investigative report of the adverse event and the CNO/Acting Administrator was unable to provide it. The CNO/Acting Administrator confirmed that no documentation of an investigation existed and the adverse event was not included in the hospital's QAPI program for follow up.

The Vice President of Plant Operations and Compliance was interviewd on 7/21/15 at 10:12 AM. She stated she was in the building at the time Patient #2 broke a mirror in his room and injured himself with a piece of broken glass. A copy of the investigation of the incident was requested from the VP of Plant Operations and Compliance on 7/21/15 and she was unable to produce documentation of an investigation and steps taken to ensure patient and staff safety in the hospital. The VP of Plant Operations and Compliance confirmed that no documentation of an investigation existed.

The hospital did not have a clear process to analyze causes of adverse patient events, implement preventative actions, and provide feedback and learning throughout the hospital.