HospitalInspections.org

Based on random review of medical records and confirmed in interview, the facility failed to ensure the patient medical record included all the results of a physician's assessment in one of eight ( Patient #A) records reviewed.

Findings included:

Review of records revealed Patient #A is a 45 year old female who came to the facility emergency room on 09/24/2024 on an emergency detention order (EDO) for suicidal ideation.

Review of Patient #A's certificate of examination submitted to the county court along with her OPC (order of protective custody) revealed it was signed by Staff # 6. It included an assessment from 09/25/2024 and quote from Patient #A who stated "I am going to kill myself either today when I get out of the hospital or some time soon."

Review of Patient #A's medical record revealed no documentation of an assessment performed by Staff #6 and/or the assessment that included the medical examination for the OPC.

In an interview with Staff #2 on 05/08/2025 at 2:10 PM, she acknowledged that Staff #6 was on the schedule for that day and that he should have entered his assessment in Patient #A's chart.