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Based on interview, record review, and facility policy review, it was determined the facility failed to ensure psychiatric evaluations were conducted by a physician for 3 (Patients 2, 3, and 4) of 5 medical records reviewed. In addition, the facility failed to ensure the physician co-signed the mental health portion of the psychiatric evaluation conducted by the Advanced Practice Registered Nurse (APRN).

Findings Include:

Review of the facility policy titled, "Patient Bill of Rights," last revised 02/2018, indicated, the governing body shall ensure: each patient had the right to respectful care provided by competent personnel.

1. Review of Patient 2 ' s medical record showed an admission date of 07/12/22 at 11:55 AM with diagnoses that included major depression, psychosis and generalized anxiety. Further review of the medical record showed Staff U, APRN conducted the psychiatric evaluation for Patient 2 on 07/13/22 at 5:00 PM. There was no evidence the physician reviewed, conducted, and/or signed the psychosocial evaluation.

2. Review of Patient 3 ' s medical record showed an admission date of 07/13/22 at 7:36 PM with diagnoses that included bipolar disorder, attention deficit hyperactive disorder, and depression. Further review of the medical record showed Staff T, APRN conducted the psychiatric evaluation for Patient 3 on 07/14/22 at 11:00 AM. There was no evidence the physician reviewed, conducted, and/or signed the psychiatric evaluation.

3. Review of Patient 4 ' s medical record showed an admission date of 07/13/22 at 11:19 PM with diagnoses that included schizophrenia and psychosis. Further review of the medical record showed the Staff T, APRN conducted the psychiatric evaluation for Patient 4 on 07/14/22 at 11:00 AM. There was no evidence the physician reviewed, conducted, and/or signed the psychiatric evaluation.


During an interview on 07/21/22 at 1:30 PM, the Risk Manager indicated the facility ' s APRNs conducted most of the psychiatric evaluations on weekends. According to the Risk Manager, the facility used APRNs to conduct psychiatric evaluations and was not aware the physician needed to conduct the psychiatric evaluations and counter sign the mental status portion of the evaluation if completed by the APRNs.