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The facility failed to ensure compliance with CFR 489.24 based on findings at A2401, A 2402, A2403, A2405, A2406, A 2407, A2408, and A2409.

Based on observations and interview, the facility failed to ensure signs were posted at the entrances of the facility that indicated the patient rights with respect to emergency services.

Findings include:

On 5/13/13 at 8:45 AM an initial tour of the facility was conducted with the Director of Nurses (DON). The DON indicated the facility had 3 entrances which were used by patients presenting to the facility. The main entrance was located at the front of the facility and was used as the entrance to the Psychiatric Assessment Services (PAS) during the hours of 7:00 AM through 5:00 PM.

The second entrance was located in the front of the facility near the PAS entrance. This entrance had been used for patients who were brought to the Psychiatric Observation Unit (POU) for admission, for patients who required medical screening, and for patients who arrived after 5:00 PM, or on weekends and holidays when the main entrance was locked. During the initial tour, the DON indicated this entrance was no longer used.

The third entrance was located toward the rear of the building, and was now used as the entrance for patients presenting to the POU.

During the tour, it was observed there was no signage posted at any of these three entrances regarding patient rights with respect to emergency medical conditions and women in labor, and whether the facility participated in the Medicaid program.

There was signage posted in the waiting areas of the PAS which addressed patient rights and indicated the facility participated in the Medicaid program.

During the survey, the DON indicated the second entrance, next to the PAS main entrance, was still being used for patients who presented after hours, on weekends, or who required medical screening.

Based on record review, document review, and interview, the facility failed to ensure medical records were accurately created and maintained including entering triage notes into the medical record for 11 of 31 patients (Patients #1, #11, #12, #13, #18, #19, #22, #23, #24, #27, and #29); failed to ensure COBRA (Consolidated Omnibus Reconciliation Act) transfer forms were contained in the medical record for 4 of 31 patients (Patients #5, #16, #17, and #8); failed to ensure Legal 2000 (Nevada Process of Civil Commitment) paperwork was completed correctly and maintained in the medical record for 3 of 31 patients (Patient #5, #8, #29); and failed to ensure discharge instructions and referrals were maintained in the medical record for 2 of 31 patients (Patients #6, #8).

Findings include:

Review of the patients' records revealed notes entered by the triage nurse were written on the triage form only. These triage notes were not included in the patient's medical record. The informal, hand written triage notes were attached to the psychiatric assessment services daily log.

The facility policy titled Psychiatric Evaluation Service (PES) - Evaluation, Assessment and Admitting Process last reviewed 2/18/10 documented "k. Referrals to Outside Agencies: 1. Included in the referral will be the name, address, and phone number of the agency, the contact person and the agency hours of operation... 4. The clinician will date, time and sign and have the consumer sign the referral form. 5. The consumer will be given a copy of the referral form. The original referral form will remain in the NNAMHS (Northern Nevada Adult Mental Health Services) medical record...."

The facility policy titled Consumer Transfers and Documentation (COBRA) last revised 1/19/12 documented:

- "V. Procedure; 1. This requirements apply to consumers being transferred from the NNAMHS campus, inpatient, or outpatient services....

- 3. MR-134 (Consumer Transport Form) is to be completed for consumers transferred or discharged from the NNAMHS inpatient facility or on campus to another facility including, but not limited to, acute care medical facility for medical clearance, medical evaluation, medical treatment, inpatient care, Emergency Department care, or a skilled nursing facility...

- 6. For each COBRA transfer, there must be a progress note explaining why the COBRA was done... b. This progress note must be completed even of the consumer was seen only in outpatient services, admissions, observation, or triage....d. Staff must document the mode of transportation in the progress notes, i.e. ambulance, state car, etc....

- 7. MR 134 must be completed and a copy sent to the facility to which the consumer is being transferred....

- 8. ... If the transport vehicle is ready for transfer the consumer, notify the receiving facility the COBRA forms will be faxed....Place the fax confirmation sheet in the medical record with the original COBRA forms...."

The facility's Legal 2000 R (revised) form included a section titled Discharge. The instructions for the revised form indicated "... 4) A discharge section has been added to the form. In a manner analagous to the certification section, the discharge section allows a physician to document the clinical justification for discharging an individual from Legal 2000 status."

Patient #5

Patient #5 was brought to the Psychiatric Assessment Services (PAS) by the police for medical clearance on 2/12/13 at 9:03 AM, with complaints of disorganized thoughts and speech, erratic behavior, irritable, and reported tactile hallucinations.

Patient #5 was evaluated by the psychiatrist at 10:59 AM. There was no documentation a physical assessment was completed including vital signs.

Documentation by the psychiatrist indicated the patient was referred to (facility name) for detoxification.

There was no documentation the patient agreed to the transfer, no documentation the receiving facility was notified of the transfer, and no documentation of how the patient was transported to the receiving facility.

The facility was asked for any additional documentation regarding Patient #5's care for this date. The medical records staff verbalized there were no additional notes for this patient for this date.

Patient #6

Patient #6 presented to the POU (Psychiatric Observation Unit) on 3/18/13 at 12:52, from the medical clinic with complaints of being very depressed and suicidal. The patient was admitted to the POU as a legal 2000 for observation for up to 72 hours.

Patient #6's medical record contained a copy of the Legal 2000 form. The form contained an area titled discharge, which was to be completed by a physician prior to the patient's discharge. The discharge area indicated the patient was observed and examined and was no longer a threat to self or others as a result of mental illness. This area was left blank.

On 5/14/13 at 3:15 PM, a Social Worker (Employee #31) was interviewed regarding the discharge process. The employee verbalized the physician does not usually complete the discharge section of the form. When the physician writes a discharge order, the patient was considered stable for discharge.

Patient #29

Patient #29 presented to the PAS on 3/18/13 at 12:32 PM, as per the PAS log and was triaged at 12:40 PM. Patient #29 documented on the triage form "in need of inpatient rehabilitation for drug abuse and/ suicidal thought." The nurse's triage note documented the patient was suicidal.

The psychologist's note dated 3/18/13 at 2:32 PM, documented - "Plan : Admit on legal 2000."

Documentation included a note by the Social Worker (Employee #31) dated 3/18/13 at 3:43 PM, to "initiate legal 2000."

Employee #31's note dated 3/18/13 at 3:52 PM, documented, "Patient released from legal 2000. He is denying that he is suicidal and states he is frustrated because he isn't in rehab (rehabilitation)....referred to rehab and shelter."

There was no documentation in the medical record of the legal 2000 form indicating the patient was safe for discharge, and no copies of the referrals made for the patient.

The facility was asked to provide additional information but was unable to do so.



26252

Patient #16

Review of the facility's Psychiatric Assessment Services Daily Log, dated Tuesday 3/26/13, indicted Patient #16 presented to the facility at 9:45 AM, and was triaged by a registered nurse at 9:55 AM. There was an "E" next to the patient's name, which indicated the situation was emergent. The log further indicated, the patient was new to the facility and was transferred out of the facility for medical clearance.

Review of Patient #16's triage record, which was referred to as "the half sheet," indicated the following: staff notations indicated the patient had "SI (suicidal ideation) thoughts sometimes, hears voices, was scared at times, had been confused for three weeks following a ruptured appendix which was treated in February 2013." The patient indicated the reason for seeking services was due to having had a "ruptured appendicitis and poison went to the brain and stayed confused all the time." There was no indication of what type of help was being seeked that day.

Following several requests to review Patient #16's transfer sheet, which was also referred to as the COBRA, the survey team was informed on the morning of 5/16/13, that a COBRA/Transfer form could not be found. The survey team was also informed, aside from the log and the triage record, which were in hard copy format, there was no record of Patient #16 in their automated system, which was referred to as AVATAR. The findings were confirmed by Employee #9 and Employee #2.

Due to the transfer form not being available, and there was no indication on the Psychiatric Assessment Services Daily Log or the triage record where the patient had been transferred to, the survey team was unable to determine whether or not the transfer was appropriate or carried out following regulatory requirements.

Resident #17

Review of the facility's Psychiatric Assessment Services Daily Log, dated Friday 4/5/13, indicated Patient #17 presented to the facility at 3:01 PM, and was triaged by a registered nurse at 3:11 PM. The log indicated, the patient was new to the facility and was transferred out of the facility for medical clearance.

Aside from geographic information, review of Patient #17's triage record, indicated the following: "legal 2000," the reason for seeking services was for "mental health," and the type of help being seeked that day was for counseling/therapy and medication. There was no information on the rest of the patient's status (i.e. vital signs, SI (suicidal ideation), HI (homicidal ideation), etc...), or any information for the reason why a "legal 2000" was implemented, or why the transfer for medical clearance was indicated.

Following several requests to review Patient #17's transfer sheet, the survey team was informed on the morning of 5/16/13, that a COBRA/Transfer form could not be found. The survey team was also informed, aside from the log and the triage record, which were in hard copy format, there was no record of Patient #17 in their automated system, which was referred to as AVATAR. The findings were confirmed by Employee #9 and Employee #2.

Due to the transfer form not being available, and there was no indication on the Psychiatric Assessment Services Daily Log or the triage record where the patient had been transferred to, the survey team was unable to determine whether or not the transfer was appropriate or carried out following regulatory requirements.

Cross reference Tag A2409.


22116


The facility confirmed patients being brought directly to the POU (psychiatric observation unit) under Legal 2000 actions were logged in on a Medical tracking sheet. This sheet identified arrival time, method of transfer/transport (police, ambulance, hospital) and whether the patient was accepted or declined for admission. The codes for declination were medically unstable (1), grossly intoxicated (2), physically violent (3) or under 18 years old (4). A column "notations" indicated if a patient was declined related to medical status or COBRA'd (transferred to another provider), a reason needed to be documented.

Patient #8

Review of the POU Medical tracking log for 12/13/12-12/24/12 revealed 14 patients had been logged in. This log indicated Patient #8 arrived to the facility on 12/19/12, by the local police department at 2:10 PM and time completed was 3:00 PM. A check mark was made in the accept/decline column and then a "D" written over the checkmark, indicating "declined". A notation under comments indicated Patient #8 "had insurance". No other documentation was entered.

The facility provided computer documentation demonstrating Patient #8 was seen on 12/19/13, by the psychologist following an episode of expressed suicidal thoughts. A LOCUS (Level of Care Utilization System) completed on 12/19/12, indicated Patient #8 had 23 out of 35 points which identified him as a Level 5, requiring medically monitored residential services. Patient #8 was placed on a Legal 2000, and informed of the admission process for the POU. The patient information (face sheet) indicated Patient #8 was admitted to the facility on 12/19/12 at 2:10 PM. There was no date or time of discharge.

Requests to the facility were submitted on 5/13/13, 5/14/13 and 5/15/13, for any additional computer or hard copy documentation for Patient#8. The facility was unable to provide this.

An interview with the medical records staff and the Director of Nursing on 5/15/13, revealed the chart could not be located.

An interview with the Director of Nursing in the afternoon of 5/15/13, revealed Patient #8 had insurance and Patient #8 chose to be admitted to another psychiatric hospital. Patient #8 was never admitted into the facility POU. The facility requested and received documentation of Patient #8's transfer from the receiving hospital on 5/15/13, to substantiate this information.

Cross reference A 2409

Based on document reviews, interviews, and record reviews, the facility failed to ensure a central log was maintained to allow tracking of each patient seeking assistance, whether the client or the facility refused treatment and the disposition of the patient; whether they were transferred, admitted and treated, stabilized and transferred or discharged for 6 of 6 months.

Findings include:

The facility provided individual log sheets for daily patient visits into the PAS (psychiatric assessment services) for the time period of October 2012 through May 2013. These logs were organized by month and included triage sheets for each patient that entered into the PAS. This data was stored in cardboard file boxes with each month's data rubber-banded together.

The PAS log had multiple documentation of patients who left with the paperwork, and indications they would return at a later date. There was no method that could be demonstrated to indicate when these patients did or did not return. There was no method of tracking that could be demonstrated to show patients were entered into any system which enabled accessible data for the facility to evaluate compliance.

An interview with one of the triage nurses (Employee #5) in the afternoon of 5/13/13, revealed the computer system did not allow entry of patients into the data base until the patients completed and submitted their paperwork, following triage.

During the survey, it was also determined the facility kept separate logs for patients who entered the PAS system on Legal 2000, came after hours into the POU (psychiatric observation unit) or patients who received a medical clearance evaluation.


26252


Staff Interviews

On 5/15/13 at approximately 1:30 PM, in an interview with the Director of Nursing (DON-Employee #2), the DON indicated patients received at the emergency entrance/ Patient Observation Unit (POU) after hours and on the weekends would have a POU Tracking Data Sheet (also called a POU Tracking and Referral Daily Check List form), and an incident report completed by staff. The DON indicated a log was not kept for this activity or consolidated onto another log for tracking.

On the morning of 5/16/13, in an interview with the DON (Employee #2), the DON indicated he was aware of the Psychiatric Assessment Services Daily log and the Medical Clearance Tracking Sheet. The DON indicated there was an "After Hours Walk-ins" form, which was completed for patients who presented and were seen after hours. The DON indicated the completed "After Hour Walk-ins" form was sent to and retained in a file in his office. The DON confirmed the facility did not have a centralized log.

On the morning of 5/16/13, at approximately 8:00 AM, in an interview with the Psychiatric Assessment Services (PAS) Coordinator and House Supervisor (Employee #4), indicated there was not a log for those who presented after hours, on holidays and on weekends. The Coordinator indicated the patients admitted after hours, on the weekends, and on holidays to the Patient Observation Unit were listed on the facility's census sheet.

On the morning of 5/16/13, an interview to discuss the tracking of patients who presented to the facility after hours, on weekends and holidays, was conducted with the quality assurance (QA) nurse (Employee #13). The QA nurse indicated there was not a log used for the tracking of patients who presented to the facility after hours, on weekends and on holidays. The QA nurse clarified the "Medical Clearance Tracking Sheet" was used to track the completed medical clearances that were completed at the facility regardless of whether or not the patient went to the observation unit.

On the morning of 5/16/13 in an interview with the Clinical Director (Employee #1), the Director indicated she was aware of the tracking and manual logs for the Psychiatric Assessment Services Daily Log and relied on the incident reports for additional information for patients seeking assistance after hours.

Based on record review, document review and interview, the facility failed to ensure medical screening exams were completed by professional staff in a timely manner and in accordance with the facility's policy for 10 of 31 patients (Patients #5, #24, #27, #10. #11, #12, #13, #22, #23, #28).

Findings include:

The facility policy titled Psychiatric Evaluation Service (PES) - Evaluation, Assessment and Admitting Process last reviewed 2/18/10 documented "... 3. PAS...b. All consumers will have an initial assessment completed by a registered nurse and by a licensed clinician (i.e. AP (Advance Practice Nurse), Licensed Clinical Social Worker, and or Licensed Psychologist)."

The facility's policy titled Psychiatric Assessment Services last reviewed 8/16/12, documented
"III Procedure... b. A clinical professional will triage each individual within 15 minutes of arrival to ensure that the individual is seeking provided mental health services, is not a danger to self or others, is a Washoe County resident, does not have access to other mental health providers through insurance benefits, and is not carrying a weapon. In the case of an emergency, all individuals regardless of their residency or insurance status will be assessed for immediate services, and then referred to the appropriate providers for continued services."

The facility policy titled Physical Health Screening last reviewed 10/18/12, documented " IV Procedure: 1. All individuals presenting to the Psychiatric Assessment Services (PAS) subsequent to being triaged will participate in a nursing assessment that includes the following elements:
- a) Allergy Assessment
- b) General physical condition, including vital signs
- c) Medical history
- d) Medication history
- e) Systems Review
- f) Pain Assessment
- g) Consumer Family Education
- h) Physical marks/wounds/injuries"

Patient #5

Patient #5 was brought to the PAS (Psychiatric Assessment Services) by the police for medical clearance on 2/12/13 at 9:03 AM with complaints of disorganized thoughts and speech, erratic behavior, irritable and reported tactile hallucinations.

Patient #5 was evaluated by the psychiatrist at 10:59 AM. There was no documentation a physical assessment was completed including vital signs.

Documentation by the psychiatrist indicated the patient was referred to (facility name) for detoxification.

There was no documentation the patient agreed to the transfer, no documentation the receiving facility was notified of the transfer, and no documentation of how the patient was transported to the receiving facility.

The facility was asked for any additional documentation regarding Patient #5's care for this date. The medical records staff verbalized there were no additional notes for this Patient for this date.

Patient #24

Patient #24 presented to the PAS (Psychiatric Assessment Services) area on 3/6/13 at 9:00 AM as per the PAS daily log.

The triage form completed by the patient documented "Need to have myself put in the mental hospital before I hurt some one or myself for not being on my meds (medications). The type of help the patient was seeking indicated - Counseling therapy, Medication.

The initial triage was completed by Employee #6. The triage note documented SI (suicidal ideation) negative, HI (homicidal ideations) - negative, W (weapon) - negative. DM daily; Imlay. There was no additional notes documented by the triage nurse.

There was no further assessment by the Licensed Social Worker or the psychologist.

Review of the PAS log dated 3/6/13, indicated Patient #24 signed in at 8:43 AM and was triaged at 9:00 AM. The PAS log documented "Imlay" under the column for open, closed, new or return. The PAS log indicated Patient #24 was referred out to the rural clinic at 9:13 AM.

There was no further documentation or a medical record for the 3/6/13 encounter. This was confirmed by the medical records staff.

On 5/15/13 at 11:00 AM, the RN (Employee #6) was interviewed. The employee verbalized she did the initial triage on Patient #24 and confirmed the documented triage notes. The employee indicated Patient #24 was a resident of Imlay, which is Humboldt County. The employee added it was the policy of NNAMHS (Northern Nevada Adult Mental Health Services) to treat only patients who reside in Washoe County.

The employee confirmed Patient #24 was being seen by a rural clinic in Lovelock, and therefore was referred back to the rural clinic. She believed the patient was only looking for a warm place to stay.

The employee indicated she was not sure if the patient had any medications. When asked if she provided Patient #24 with any medication, the employee responded "No, we can't give medications to patients if they live outside of Washoe county." The employee verbalized - this practice was just changed last week.

Employee #6 then indicated since the patient did not have a place to stay at the present time, she referred him to a homeless shelter. She instructed the patient that if he stayed at the shelter for a couple of days, the shelter could then send a letter to NNAMHS indicating the patient now resided in Washoe County. Once the letter was received, the patient could then be treated at NNAMHS. Employee #6 then provided a copy of the letter dated 3/7/13 from a men's shelter in Reno, titled Resident Verification, to the inspectors.

Patient #24 returned to the PAS on 3/29/13 at 9:20 AM as per the PAS log. The psychologist's assessment dated 3/29/13 documented "Presents to the PAS Clinic, requesting to be re-opened to outpatient services, upon relocating to Reno area from rural Nevada." The patient was then scheduled for follow up appointments.

Patient #24's medical record indicated the patient was seen on 5/3/13 for a scheduled follow up appointment with the psychiatrist. The psychiatrist's notes documented " Pt (patient) presents today upset with NNAMHS and not being seen sooner to get back on medications."

On 5/16/13 at 11:00 AM, the RN Manager of the PAS unit (Employee #4) was interviewed regarding services provided to residents who live out of the Washoe County area. Employee #4 verbalized, we do not provide outpatient services to patients who live outside of Washoe County. The only exception is in an emergency. The employee indicated - this policy had just been changed last week and now it no longer matters where the patient lives.

Patient #27

Patient #27 presented to the PAS on 11/13/13 at 10:35 AM, as per the PAS daily log. The patient was triaged at 10:42 AM, with documentation by the staff indicating the patient was not suicidal or homicidal. The patient documented the reason for seeking services was: Need help, can't focus, Drug Court. The triage form had the initials of the staff performing the triage.

The triage form also had initials of the financial staff who met with the patient.

The PAS log documented the patient left at 12:21 PM, with a notation indicating the patient will return tomorrow. There was no additional documentation regarding the reason the patient left. The patient did not receive a full assessment as needed.

The patient did return on 11/14/13 at 7:36 AM and was triaged at 7:56 AM. A complete assessment was done on this date.



22116


Patient # 10

Patient #10 was brought to the PAS clinic by his employer after making threats of harm to self and co-workers. Review of the PAS log revealed this was at 12:29 PM on 1/22/13. Patient #10 indicated the reason he was seeking services was because "Suicide: only way to cope with thoughts of hurting others". He was triaged at 12:34 PM and was marked U (for urgent) on the log. The clinical record revealed Patient #10 had completed his nursing and psychiatric assessments by 3:30 PM.

Review of the clinical record revealed conflicting data documented by Patient #10 as well as the nurse and psychiatric clincial staff:
1) Initial complaints documented by Patient #10 which appeared to indicated Patient #10 was exhibiting suicide or homicidal ideation. Patient #10 acknowledged he was not allowed to return to work until he got some help.
2) Nursing documentation revealed Patient #10 had anger issues and referred to counseling. Patient #10 was given a list of Community resources including the Crisis Call line and referred to counseling.
3) Psychiatric documentation revealed Patient #10 had no homicidal ideation, and denied attacking co-workers, although Patient #10 did threaten them.
4) There was no evidence the employer who brought Patient #10 to the PAS was interviewed.
5) There was no indication the facility addressed the employer's stipulation that Patient #10 could not return to work until he received help.

Patient #10 was referred for counseling, with an appointment made for 1/28/13 (six days later).

The facility could not provide any information to indicate whether Patient #10 complied with his outpatient clinic appointments

Patient #11

Patient #11 arrived at the PAS on 1/22/13 at 10:10 AM. The triage sheet indicated Patient #11's visit was "court ordered" and he was seeking counseling help but there was no further detail as to what "court ordered" might have meant. Patient #11 was triaged at 10:25 AM, and the PAS log indicated he was discharged at the same time. The PAS log indicated referrals were given to Patient #11. There was no indication what these referrals were. There was no evidence the triage nurse obtained any vital signs.

Patient #12

Patient #12 arrived at the PAS on 1/24/13 at 1:44 PM, and triaged at 1:50 PM. Patient #12 indicated on the triage sheet he needed to get medicines from the medication clinic as he had just moved back to Nevada from California. The triage note indicated vital signs were needed.

The facility could not provide any vital signs for this visit. Patient #10 was to be seen in the Medication clinic but there was no date as to when this would occur. A follow-up note written on 3/18/13, revealed the patient had not been seen and prescriptions could not be filled until he was seen.

Patient #13

Patient #13 arrived at the PAS at 2:50 PM on 1/31/13, and triaged at 2:55 PM, by one of the social service staff. Patient #13 indicated the reasons he was seeking services was to "stop the madness inside my head" and had been a patient in the past. The triage note indicated Patient #13 was homeless and had no insurance. The triage note indicated Patient #13 saw the finance department at 3:50 PM. The PAS log indicated that Patient #13 was only partially through his assessment and he left at 4:15 PM, to return tomorrow. There was no further documentation available. There was no evidence any vital signs were obtained.

Patient #22

Patient #22 was a 41 year old male who had a history of psychiatric observation care related to homicidal ideation in May of 2007.

Review of PAS daily log, triage sheets and clinical records revealed Patient #22 came to the PAS on 4/1/13, 4/2/13, 4/29/13, 4/30/13, 5/1/13 and 5/3/13.

4/1/13: Patient #22 signed in at 2:50 PM and was triaged at 2:57 PM. His reason for coming to PAS was depression and paranoia. Patient #22 expressed concerns he could not take care of his kids and commented "My heart is dying". There was no elaboration documented regarding this comment. There was no documentation of vital signs. The triage nurse indicated there were no suicidal, homicidal ideations or hallucinations. The PAS log indicated Patient #22 left at 3:10 PM and took the paperwork with him.

4/2/13: Patient #22 signed in at 3:23 PM and was triaged at 3:50 PM. The documented reason for coming to PAS was depression, post trauma and family history of schizophrenia. This triage indicated Patient #22 did have visual and auditory hallucinations and his father had committed suicide. The triage note indicated vital signs were needed. The PAS log indicated Patient #22 left at 4:00 PM and took the paperwork with him.

4/29/13: Patient #22 returned to the PAS at 1:06 PM and triaged at 1:10 PM. The PAS log indicated that once again Patient took the paperwork and left the PAS at 1:30 PM.
All three logs indicated that Patient #22 was a "closed" status, rather than a returning patient.

Further documentation revealed:
1) An entry by the financial department indicating on 4/30/13, the insurance data form was signed by the financial office at 2:30 PM, but no other information was available.
2) The clinical record and patient data information sheet indicated an admission date of 5/1/13 but no other documentation supported this.
3) Patient #22 returned to the PAS on 5/3/13, and documented the reason was "doctors orders". The clinical record revealed Patient #22 was assessed by the nurse and psychologist. Review of the vital signs sheet revealed no vital signs were obtained until 5/3/13. The LOCUS (Level of Care Utilization System) score was 22-Level 4 which indicated medically monitored non-residential services interventions and referred to several outpatient services.

Patient #23

Patient #23 was a 36 year old who presented in the PAS on 4/2/13 at 4:18 PM. The PAS log indicated Patient #23 was a walk in patient and new to this service. Patient #23 was triaged by a triage nurse (Employee #5) at 4:22 PM. The log indicated that Patient #23 left at 4:30, approximately 12 minutes after she signed in.

Review of the triage sheet that was filled out by Patient #23 revealed she was requesting counseling services for "Needing psychiatric help for PTSD (post traumatic stress disorder) outbursts, and suicidal tendencies, thoughts, actions and plans". Patient #23 indicated she was a resident of Washoe County, and did not have insurance.

Review of the triage sheet revealed documentation of the word "SAFE" under the suicide/homicide/hallucination section of the triage sheet. There was no evidence any vital signs were obtained during the triage. There was no other paperwork included in the facility information regarding Patient #23, or evidence she ever returned..

An interview was conducted in the afternoon of 5/13/13, with Employee #5. Employee #5 confirmed she did recall Patient #23 and those were her initials on the triage sheet. Employee #5 was asked what she meant by the word "SAFE". Employee #5 related that she asked Patient #23 if she could "come back tomorrow" and Patient #23 acknowledged she could. Employee #5 stated "It was 4:15 PM and I leave at 4:30 PM." Employee #5 acknowledged that if patients say they can return, it means they aren't really suicidal.

An interview with Employee #10, a social worker in PAS, was conducted on 5/15/13 at 9:00 AM. Employee #10 acknowledged that she would conduct triage interviews if the triage nurses were busy. Employee #10 indicated she specifically asked patients if they were suicidal. Employee #10 acknowledged asking someone if they could come back another day was not an appropriate assessment of suicide intent.

An interview with Employee #6, another triage nurse was conducted on 5/16/13 at 9:00 AM. Employee #6 indicated she specifically asked patients if they were suicidal.

An interview with the Director of Nursing (Employee #2) in the morning of 5/14/13, revealed staff should be asking patients specific questions regarding how they are feeling, are they suicidal or homicidal to determine if there is concern, not whether the patient can return another day.

Patient #28

Patient #28 arrived at the PAS at 10:25 AM on 2/27/13, indicating his reasons for seeking services were "anxiety, depression and coming off opiates". Patient #28 checked the space between counseling and medications. Patient #28 indicated he resided in Washoe Co, but his mailing address was Carson City (Carson City County) and had no insurance. Patient #28 was triaged at 10:33 AM by a triage nurse.

Documentation by the triage nurse indicated Patient #28 had last taken opiates approximately five to six days ago. The nurse also indicated Patient #28 had no appetite, was anxious and depressed.

Review of the completed paperwork revealed Patient #28 had completed the paperwork at 4:45 PM on 1/27/13 but did not come back to the PAS until 2/27/13. There was no evidence any vital signs were obtained on either day.

The PAS log indicated Patient #28 was "missing" when his name was called to continue through the PAS system on 2/27/13. The facility could not demonstrate any further contact with this patient.

Interviews with the facility staff (administrative assistants, financial staff, registered nurses, social workers, the Director of Nursing and the Agency director) confirmed the procedure for walk-in patients in the PAS (Psychiatric Assessment Services). This process included the PAS doors being unlocked at 7:30 AM. Patients signed in and completed a triage information sheet. Patients were usually seen on a first come, first serve basis. The progress of the patient through the PAS process was documented on the PAS log and the triage sheet. The PAS staff would put up a sign at 4:30 PM indicating the clinic was closed and at 5:00 PM, the doors would be locked.

The triage sheet would accompany the patient through the PAS process. The triage sheet asked for general information such as name, address/phone, birth date, social security, insurance and whether the person was a Washoe County resident. None of the staff could confirm why patients were asked if they resided in Washoe County. (This was the county the facility was located in.) The triage sheet also had the various sequence of the PAS process: Triage, Finance, Health, Psych, COD only (co-occurring disorders). The staff confirmed the triage sheet would be initialed and time indicated as a patient completed each sequence. Staff confirmed the financial sequence always followed the triage. The patients could not be entered into the computer system until they completed the financial review.

The triage form also had a space marked "Reason for seeking services" and the type of help requested which the individual patient would fill out. Staff confirmed it was the process of the PAS system that all patients who signed in were triaged within 15 minutes of arrival. Staff confirmed that this triage was usually performed by the registered nurse (RN) but might be done by the social worker or other clinical staff if the RN was not available.

It was observed that a vital sign sheet was available to document vital signs. An interview with with the triage nurse (Employee #5), in the afternoon of 5/13/13, indicated vital signs were not part of the triage process. Employee #5 described that vital signs were documented on a separate sheet (a gold vital sign sheet), instead of on the triage sheet. Vital signs were done as part of the nursing assessment because there would be too many vital sign sheets to keep track of if vitals were done in triage. An interview with the social worker (Employee #10) indicated that vital signs were to be done during the triage stage.

Employee #5 revealed triage staff would inform patients in the waiting room around 3:30 PM, that they might not be able to be seen that day and they could come back another day. These patients who chose to return would be identified on the PAS log as "R" for return, so that staff would be able to process them first.

The facility was asked for policies or procedures to describe the process of triage, but was unable to provide any policies.

Cross reference A 2407
Cross reference A 2408

Based on record review and interview, the facility failed to ensure medical treatment was provided within the capabilities of the staff and the needs of the individual patient for 2 of 31 patients (Patients #23, #24).

Findings include:

Patient #23

Patient #23 was a 36 year old who presented in the PAS on 4/2/13 at 4:18 PM. The PAS log indicated Patient #23 was a walk in patient and new to this service. Patient #23 was triaged by a triage nurse (Employee #5) at 4:22 PM. The log indicated that Patient #23 left at 4:30, approximately 12 minutes after she signed in.

Review of the triage sheet that was filled out by Patient #23 revealed she was requesting counseling services for "Needing psychiatric help for PTSD (post traumatic stress disorder) outbursts, and suicidal tendencies, thoughts, actions and plans". Patient #23 indicated she was a resident of Washoe County, and did not have insurance.

Review of the triage sheet revealed documentation of the word "SAFE" under the suicide/homicide/hallucination section of the triage sheet. There was no evidence any vital signs were obtained during the triage. There was no other paperwork included in the facility information regarding Patient #23, or evidence she ever returned..

An interview was conducted in the afternoon of 5/13/13, with Employee #5. Employee #5 confirmed she did recall Patient #23 and those were her initials on the triage sheet. Employee #5 was asked what she meant by the word "SAFE". Employee #5 related that she asked Patient #23 if she could "come back tomorrow" and Patient #23 acknowledged she could. Employee #5 stated "It was 4:15 PM and I leave at 4:30 PM." Employee #5 acknowledged that if patients say they can return, it means they aren't really suicidal.

An interview with Employee #10, a social worker in PAS, was conducted on 5/15/13 at 9:00 AM. Employee #10 acknowledged that she would conduct triage interviews if the triage nurses were busy. Employee #10 indicated she specifically asked patients if they were suicidal. Employee #10 acknowledged asking someone if they could come back another day was not an appropriate assessment of suicide intent.

An interview with Employee #6, another triage nurse was conducted on 5/16/13 at 9:00 AM. Employee #6 indicated she specifically asked patients if they were suicidal.

An interview with the Director of Nursing (Employee #2) in the morning of 5/14/13, revealed staff should be asking patients specific questions regarding how they are feeling, are they suicidal or homicidal to determine if there is concern, not whether the patient can return another day.

Cross reference A 2406
Cross reference A 2408



26907


Patient #24

Patient #24 presented to the PAS (Psychiatric Assessment Services) area on 3/6/13 at 9:00 AM as per the PAS daily log.

The triage form completed by the patient documented "Need to have myself put in the mental hospital before I hurt some one or myself for not being on my meds (medications). The type of help the patient was seeking indicated - Counseling therapy, Medication.

The initial triage was completed by Employee #6. The triage note documented SI (suicidal ideation) negative, HI (homicidal ideations) - negative, W (weapon) - negative. DM daily; Imlay. There was no additional notes documented by the triage nurse.

There was no further assessment by the Licensed Social Worker or the psychologist.

Review of the PAS log dated 3/6/13, indicated Patient #24 signed in at 8:43 AM and was triaged at 9:00 AM. The PAS log documented "Imlay" under the column for open, closed, new or return. The PAS log indicated Patient #24 was referred out to the rural clinic at 9:13 AM.

There was no further documentation or a medical record for the 3/6/13 encounter. This was confirmed by the medical records staff.

On 5/15/13 at 11:00 AM, the RN (Employee #6) was interviewed. The employee verbalized she did the initial triage on Patient #24. and confirmed the documented triage notes. The employee indicated Patient #24 was a resident of Imlay, which is Humboldt County. The employee added it was the policy of NNAMHS (Northern Nevada Adult Mental Health Services) to treat only patients who reside in Washoe County.

The employee confirmed Patient #24 was being seen by a rural clinic in Lovelock, and therefore was referred back to the rural clinic. She believed the patient was only looking for a warm place to stay.

The employee indicated she was not sure if the patient had any medications. When asked if she provided Patient #24 with any medication, the employee responded "No, we can't give medications to patients if they live outside of Washoe county." The employee verbalized - this practice was just changed last week.

Employee #6 then indicated since the patient did not have a place to stay at the present time, she referred him to a homeless shelter. She instructed the patient that if he stayed at the shelter for a couple of days, the shelter could then send a letter to NNAMHS indicating the patient now resided in Washoe County. Once the letter was received, the patient could then be treated at NNAMHS. Employee #6 then provided a copy of the letter dated 3/7/13 from a men's shelter in Reno, titled Resident Verification, to the inspectors.

Patient #24 returned to the PAS on 3/29/13 at 9:20 AM as per the PAS log. The psychologist's assessment dated 3/29/13 documented "Presents to the PAS Clinic, requesting to be re-opened to outpatient services, upon relocating to Reno area from rural Nevada." The patient was then scheduled for follow up appointments.

Patient #24's medical record indicated the patient was seen on 5/3/13 for a scheduled follow up appointment with the psychiatrist. The psychiatrist's notes documented " Pt (patient) presents today upset with NNAMHS and not being seen sooner to get back on medications."

On 5/16/13 at 11:00 AM, the RN Manager of the PAS unit (Employee #4) was interviewed regarding services provided to residents who live out of the Washoe County area. Employee #4 verbalized, we do not provide outpatient services to patients who live outside of Washoe County. The only exception is in an emergency. The employee indicated - this policy had just been changed last week and now it no longer matters where the patient lives.

Cross reference A 2406
Cross reference A 2408

Based on record review, document review, and interview, the facility failed to ensure appropriate medical screenings were not delayed for patients who arrived at the end of the day and/or had no insurance for 1 of 31 patients (Patient #23); medical screening was not delayed for determining residency for 1 of 31 patients (Patient #24); and medical screening was not delayed due to the length of time required for the registration process for all patients presenting to the Psychiatic Assessment Services (PAS) during the 6 of 6 months PAS log review.

Findings include:

Patient #23

Patient #23 was a 36 year old who presented in the PAS on 4/2/13 at 4:18 PM. The PAS log indicated Patient #23 was a walk in patient and new to this service. Patient #23 was triaged by a triage nurse (Employee #5) at 4:22 PM. The log indicated that Patient #23 left at 4:30, approximately 12 minutes after she signed in.

Review of the triage sheet that was filled out by Patient #23 revealed she was requesting counseling services for "Needing psychiatric help for PTSD (post traumatic stress disorder) outbursts, and suicidal tendencies, thoughts, actions and plans". Patient #23 indicated she was a resident of Washoe County, and did not have insurance.

Review of the triage sheet revealed documentation of the word "SAFE" under the suicide/homicide/hallucination section of the triage sheet. There was no evidence any vital signs were obtained during the triage. There was no other paperwork included in the facility information regarding Patient #23, or evidence she ever returned..

An interview was conducted in the afternoon of 5/13/13, with Employee #5. Employee #5 confirmed she did recall Patient #23 and those were her initials on the triage sheet. Employee #5 was asked what she meant by the word "SAFE". Employee #5 related that she asked Patient #23 if she could "come back tomorrow" and Patient #23 acknowledged she could. Employee #5 stated "It was 4:15 PM and I leave at 4:30 PM." Employee #5 acknowledged that if patients say they can return, it means they aren't really suicidal.

An interview with Employee #10, a social worker in PAS, was conducted on 5/15/13 at 9:00 AM. Employee #10 acknowledged that she would conduct triage interviews if the triage nurses were busy. Employee #10 indicated she specifically asked patients if they were suicidal. Employee #10 acknowledged asking someone if they could come back another day was not an appropriate assessment of suicide intent.

An interview with Employee #6, another triage nurse was conducted on 5/16/13 at 9:00 AM. Employee #6 indicated she specifically asked patients if they were suicidal.

An interview with the Director of Nursing (Employee #2) in the morning of 5/14/13, revealed staff should be asking patients specific questions regarding how they are feeling, are they suicidal or homicidal to determine if there is concern, not whether the patient can return another day.

Review of the facility quality assurance meetings for the past year revealed the following concerns were addressed. On 6/21/12, a request was made by one of the physicians to have a policy developed regarding the triage process. There was no further information regarding this request.

Interviews with the facility staff (administrative assistants, financial, registered nurses, social workers, Director of Nursing and Agency Director) confirmed the procedure for walk-in patients in the PAS (Psychiatric Assessment Services). This process included the PAS doors being unlocked at 7:30 AM. Patients signed in and completed a triage information sheet. Patients were usually seen as a first come, first serve. The progress of the patient through the PAS process was documented on the PAS log and the triage sheet. The PAS staff would put up a sign at 4:30 PM indicating the clinic was closed and at 5:00 PM, the doors would be locked.

Employee #5 was interviewed in the afternoon of 5/13/13. Employee #5 described the procedure for late afternoon patients. At approximately 3:30 PM, patients currently in the waiting room were informed they might not be able to be seen by the end of the day and would be given a choice whether they wanted to return at a later date, and be able to be seen more promptly.

The triage sheet asked patients whether they were residents of Washoe County and if they had insurance.

An interview revealed that after a patient was seen by a triage staff, they were then required to complete paperwork. After this paperwork was submitted, patients were then sent to the financial office before being seen by any clinical staff for assessments. Employee #16 confirmed in an interview at 8:30 AM on 5/15/13, patients were not entered into the computer system until they were screened by financial department. This was to determine if and what benefits they might have, if the facility was in network, what sliding scale range might be appropriate, and other financial status.

Random PAS log reviews:
1/22/13: (Tuesday) 26 patients logged in with 13 patients leaving the facility with paperwork, and 9 patients only completed partial assessments.

1/24/13: (Thursday) 11 patients logged in with two patients leaving the facility with paperwork. The other nine completed their assessments.

1/31/13: (Thursday) 15 patients logged in with three patients leaving the facility with paperwork, 10 completed their assessments, two patients only completed partial assessments.

2/27/13: (Wednesday) 22 patients logged in with seven patients leaving the facility with paperwork, and seven patients only completed partial assessments.

4/1/13 (Monday) 14 patients logged in with 5 patients leaving the facility with paperwork, and 1 patient only completed partial assessments.

4/2/13 (Tuesday) 18 patients logged in with 10 patients leaving the facility with paperwork, and two patients only completed partial assessments. (This included Patient #23.)

4/29/13: (Monday) 14 patients logged in with four patients leaving the facility with paperwork and four patients only completed partial assessments.

Cross reference A 2406
Cross reference A 2407



26907


Patient #24

Patient #24 presented to the PAS (Psychiatric Assessment Services) area on 3/6/13 at 9:00 AM as per the PAS daily log.

The triage form completed by the patient documented "Need to have myself put in the mental hospital before I hurt some one or myself for not being on my meds (medications). The type of help the patient was seeking indicated - Counseling therapy, Medication.

The initial triage was completed by Employee #6. The triage note documented IS (suicidal ideation) negative (neg); HI (homicidal ideations) - neg; Weapon - neg; DM daily; Imlay. There was no additional notes documented by the triage nurse.

There was no further assessment by the Licensed Social Worker or the psychologist.

Review of the PAS log dated 3/6/13, indicated Patient #24 signed in at 8:43 AM and was triaged at 9:00 AM. The PAS log documented "Imlay" under the column for open, closed, new or return. The PAS log indicated Patient #24 was referred out to the rural clinic at 9:13 AM.

There was no further documentation or a medical record for the 3/6/13 encounter. This was confirmed by the medical records staff.

On 5/15/13 at 11:00 AM, the RN (Employee #6) was interviewed. The employee verbalized she did the initial triage on Patient #24 and confirmed these were the only notes documented by her. The employee indicated she did not believe the patient was suicidal. The employee added Patient #24 was a resident of Imlay, which is in Humboldt County. The employee verbalized it was the policy of NNAMHS to treat only patients who reside in Washoe County.

The employee confirmed Patient #24 was being seen by a rural clinic in Lovelock, and therefore was referred back to the rural clinic. She believed the patient was only looking for a warm place to stay.

The employee indicated she was not sure if the patient had any medications. When asked if she provided Patient #24 with any medication, the employee responded "No, we can't give medications to patients if they live outside of Washoe county." The employee verbalized - this practice was just changed last week.

The employee then indicated since the patient did not have a place to stay at the present time, she referred him to a homeless shelter. She instructed the patient that if he stayed at the shelter for a couple of days, the shelter could then send a letter to NNANHS indicating the patient now resided in Washoe County. Once the letter was received, the patient could then be treated at NNAMHS. Employee #6 then provided a copy of the letter dated 3/7/13, to the inspectors. which indicated the patient was staying at their facility.

Patient #24 returned to the PAS on 3/29/13 at 9:20 AM as per the PAS log. The psychologist's assessment dated 3/29/13 documented "Presents to the PAS Clinic, requesting to be re-opened to outpatient services, upon relocating to Reno area from rural Nevada." The patient was then scheduled for follow up appointments.

Patient #24's medical record indicated the patient was seen on 5/3/13 for a scheduled follow up appointment with the psychiatrist. The psychiatrist's notes documented " Pt (patient) presents today upset with NNAMHS and not being seen sooner to get back on medications."

On 5/16/13 at 11:00 AM, the RN Manager of the PAS unit (Employee #4) was interviewed regarding services provided to residents who live out of the Washoe County area. Employee #4 verbalized the facility does not provide outpatient services to patients who live outside of Washoe County. The only exception was in an emergency. The employee indicated - this policy had just been changed last week and now it no longer matters where the patient lives.

The facility's policy titled Psychiatric Assessment Services last reviewed 8/16/12, documented
"III Procedure... b. A clinical professional will triage each individual within 15 minutes of arrival to ensure that the individual is seeking provided mental health services, is not a danger to self or others, is a Washoe County resident, does not have access to other mental health providers through insurance benefits, and is not carrying a weapon. In the case of an emergency, all individuals regardless of their residency or insurance status will be assessed for immediate services, and then referred to the appropriate providers for continued services."

Random PAS log review:

11/2/12: (Friday) 14 patients logged in with four patients leaving the facility prior to any assessment. The patients who left had signed in from 1:15 PM to 2:25 PM.

3/18/13 (Monday) - 16 patients signed in with six patients leaving prior to being seen. The patients who left signed in from 12:59 PM to 2:35 PM. The comments on the PAS log included - 1 patient - Back at 4 PM, no documentation of the patient's return; 1 patient - missing; 1 patient- took paper work; 3 patients - Will return tomorrow.

3/29/13 (Friday) - 21 patients signed in with 8 patients leaving prior to being seen. The patients signed in from 10:35 AM through 2:55 PM. The notations indicated will return.

Based on record review and staff interview the facility failed to ensure transfers were screened and carried out following regulatory requirements as required for 4 of 31 patients (Patients #16, #17, #8, #5).

Findings include:

Patient #16

Review of the facility's Psychiatric Assessment Services Daily Log, dated Tuesday 3/26/13, indicted Patient #16 presented to the facility at 9:45 AM, and was triaged by a registered nurse at 9:55 AM. There was an "E" next to the patient's name, which indicated the situation was emergent. The log further indicated, the patient was new to the facility and was transferred out of the facility for medical clearance.

Review of Patient #16's triage record, which was referred to as "the half sheet," indicated the following: staff notations indicated the patient had "SI (suicidal ideation) thoughts sometimes, hears voices, was scared at times, had been confused for three weeks following a ruptured appendix which was treated in February 2013." The patient indicated the reason for seeking services was due to having had a "ruptured appendicitis and poison went to the brain and stayed confused all the time." There was no indication of what type of help was being seeked that day.

Following several requests to review Patient #16's transfer sheet, which was also referred to as the COBRA, the survey team was informed on the morning of 5/16/13, that a COBRA/Transfer form could not be found. The survey team was also informed, aside from the log and the triage record, which were in hard copy format, there was no record of Patient #16 in their automated system, which was referred to as AVATAR. The findings were confirmed by Employee #9 and Employee #2.

Due to the transfer form not being available, and there was no indication on the Psychiatric Assessment Services Daily Log or the triage record where the patient had been transferred to, the survey team was unable to determine whether or not the transfer was appropriate or carried out following regulatory requirements.

Resident #17

Review of the facility's Psychiatric Assessment Services Daily Log, dated Friday 4/5/13, indicated Patient #17 presented to the facility at 3:01 PM, and was triaged by a registered nurse at 3:11 PM. The log indicated, the patient was new to the facility and was transferred out of the facility for medical clearance.

Aside from geographic information, review of Patient #17's triage record, indicated the following: "legal 2000," the reason for seeking services was for "mental health," and the type of help being seeked that day was for counseling/therapy and medication. There was no information on the rest of the patient's status (i.e. vital signs, SI (suicidal ideation), HI (homicidal ideation), etc...), or any information for the reason why a "legal 2000" was implemented, or why the transfer for medical clearance was indicated.

Following several requests to review Patient #17's transfer sheet, the survey team was informed on the morning of 5/16/13, that a COBRA/Transfer form could not be found. The survey team was also informed, aside from the log and the triage record, which were in hard copy format, there was no record of Patient #17 in their automated system, which was referred to as AVATAR. The findings were confirmed by Employee #9 and Employee #2.

Due to the transfer form not being available, and there was no indication on the Psychiatric Assessment Services Daily Log or the triage record where the patient had been transferred to, the survey team was unable to determine whether or not the transfer was appropriate or carried out following regulatory requirements.


Cross reference Tag A2403.



22116

Patient #8

Patient #8 was admitted into the PAS (psychiatric assessment services) on 12/19/12, following a Legal 2000 intervention (Nevada Process of Legal Commitment).

It was determined Patient #8 was transferred to another psychiatric hospital related to insurance coverage.

The facility could not provide any medical records; either computer or hard copy information to demonstrate this was a safe and appropriate transfer. It could not be determined that Patient #8 had been stabilized. There was no evidence of a discharge summary, discharge note, in depth psychological evaluation although a LOCUS (Level of Care Utilization System) assessment was completed indicating a need for medically monitored residential services.

Cross reference A 2403



26907


Patient #5

Patient #5 was brought to the PAS (Psychiatric Assessment Services) by the police for medical clearance on 2/12/13 at 9:03 AM with complaints of disorganized thoughts and speech, erratic behavior, irritable and reported tactile hallucinations.

Patient #5 was evaluated by the psychiatrist at 10:59 AM. There was no documentation a physical assessment was completed including vital signs.

Documentation by the psychiatrist indicated the patient was referred to (facility name) for detoxification.

There was no documentation the patient agreed to the transfer, no documentation the receiving facility was notified of the transfer, and no documentation of how the patient was transported to the receiving facility.

The facility was asked for any additional documentation regarding Patient #5's care for this date. The medical records staff verbalized there were no additional notes for this Patient for this date.

The facility policy titled Consumer Transfers and Documentation (COBRA) last revised 1/19/12 documented:

- "V. Procedure; 1. This requirements apply to consumers being transferred from the NNAMHS campus, inpatient, or outpatient services....

- 3. MR-134 (Consumer Transport Form) is to be completed for consumers transferred or discharged from the NNAMHS inpatient facility or on campus to another facility including, but not limited to, acute care medical facility for medical clearance, medical evaluation, medical treatment, inpatient care, Emergency Department care, or a skilled nursing facility...

- 6. For each COBRA transfer, there must be a progress note explaining why the COBRA was done... b. This progress note must be completed even if the consumer was seen only in outpatient services, admissions, observation, or triage....d. Staff must document the mode of transportation in the progress notes, i.e. ambulance, state car, etc....

- 7. MR 134 must be completed and a copy sent to the facility to which the consumer is being transferred....

- 8. ... If the transport vehicle is ready for transfer the consumer, notify the receiving facility the COBRA forms will be faxed....Place the fax confirmation sheet in the medical record with the original COBRA forms...."