HospitalInspections.org

A115
This CONDITION is not met as evidenced by:

Based on medical record review, policy review, document review, and interviews, it was determined that the facility failed to protect and promote the rights of all patients as evidenced by: Suicide precautions were not being implemented. Nursing staff were not following providers orders for 1:1 bedside (in-person) monitoring for patients at risk for suicide. Nursing staff were "downgrading" in-person, 1:1 sitter, bedside monitoring orders and implementing remote tele monitoring without a physician notification and/or order. Nursing and remote tele sitter staff are not conducting verification/confirmation of the tele monitoring camera/audio system use/functioning, were not providing patient/family education related to tele sitter monitoring and were not documenting the discontinuation of tele sitter monitoring. (A0144).

On 11/15/23 at 11:30 AM, an Immediate Jeopardy was identified for the CoP of Patient Rights related to the utilization of a remote tele sitter instead of an in-person, beside 1:1 sitter to monitor for Patient #1, who was identified as a high-risk suicide patient. This practice placed Patient #1 at risk for serious injury, serious harm, serious impairment, or death.

On 11/15/23 at 09:15 PM, the facility provided a corrective action plan to the onsite survey staff and immediately implemented the following actions: the policy "Screening, Assessment, and Care of the Patient at Risk for Suicide" was amended to require in-person, 1:1 bedside monitoring for all patients identified at moderate or high risk for suicide; the electronic medical record will no longer allow a remote tele sitter to be ordered for a moderate or high risk suicidal patient; the electronic medical record will generate an alert when a remote sitter is in place; management conducted a review of all patients at moderate and high-risk of suicide to ensure that an in-person 1:1 sitter was in place; and education was conducted for all staff members who provide care to suicidal patients related to the policy update and electronic medical record changes.

On 11/16/23 at 10:15 AM, the Immediate Jeopardy was removed based on observations, policy review, document review, and interviews, which verified that the corrective action plan was fully implemented.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting.

Based on policy review, observation, medical record review, document review, and interview, the facility did not ensure patients received care in a safe setting as evidenced by:
1.Nursing staff are not implementing suicide precautions. Specifically, staff did not keep Patient #1's door open to hear the remote tele sitter alarm while being monitored remotely for suicide risk. Staff do not complete room checks each shift to remove contraband and to secure medical equipment and other objects that have the potential for self -harm or use for harm to others.
2.Nursing staff are not following providers orders for in-person 1:1 bedside monitoring for patients at risk for suicide. Specifically, the provider was not notified that the registered nurse "downgraded" patients from high to moderate suicide risk and "ordered" a remote tele sitter instead of an in-person, bedside sitter without a physician order.
3.Nursing staff and remote tele sitter staff are not conducting verification/confirmation of the tele monitoring camera/audio system functioning, not providing patient/family education related to tele sitter monitoring, and not documenting the discontinuation of tele sitter monitoring.

Findings #1:

Review of the education document "Care of the Patient Placed on Suicide Watch-Nursing," (no date) revealed that as soon as the patient scores moderate or high on the Columbia Suicide Severity Rating Scale Screening, the registered nurse will ensure the treatment space is made as safe as possible. Environmental safety checks are completed and documented by the registered nurse during nursing hand off (shift change report) and documented in the electronic medical record not on the paper record. Safety interventions do not decrease based on the reassessment questions. Suicide precautions may not be removed until the patient's provider enters an order to discontinue suicide precautions.

Review of the education document "Care of the Patient Placed on Suicide Watch - Support Staff," (no date) revealed that a remote sitter technician may be utilized to monitor moderate risk suicide patients but never high-risk suicide patients. "The moderate risk of suicide patient should be okay to close the door to the bathroom as long as belongings are secured." When remote sitter monitoring is used, the nursing staff on the unit remains responsible for environmental checks. The nurses will re-check the room every shift.

Observation on 11/14/23 at 11:03 AM revealed Patient #1's room was located across the hall from the nursing station with the door closed. Through the door window it was noted that the interior safety garage door (used to secure medical equipment) was open. Behind the safety garage door was a computer, a television, a cardiac monitor, suction equipment, an oxygen flow meter, a locked sharps container, gloves, a sink, and upper/lower cupboards. Patient #1 was being monitored by a remote tele sitter. Interview with Staff (E), Emergency Department Director, verified that nursing staff determined that Patient #1 was at moderate risk for suicide. Staff (E) stated that the expectation is that the door remains open if the room is not directly next to the nursing station, so staff can hear the remote monitoring alarm. However, it is nursing judgement to close the door. Staff (E) contacted the remote tele sitter to trigger the remote monitoring alarm located in Patient #1's room with the door closed. The alarm was audible from the nursing station across from the room, but faint.

Review of the emergency department medical record for Patient #1 revealed on 11/12/23 at 09:53 PM, Patient #1 arrived at the facility with suicidal ideation. At 09:58 PM, the Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #1 was at high risk for suicide. At 10:09 PM, the physician ordered a bedside, 1:1 sitter for a high suicide risk and a crisis evaluation consult. On 11/13/23 at 04:49 PM, the Columbia Suicide Severity Rating Scale was completed by Staff (F), Crisis Worker, who determined Patient #1 was at high risk for suicide. At 07:37 PM, the registered nurse "ordered" to begin remote tele sitting monitoring according to the crisis worker. On 11/14/23 at 11:16 AM, the Columbia Suicide Severity Rating Scale was completed by Staff (F), Crisis Worker, who indicated Patient #1 was high risk for suicide. At 05:31 PM, Patient #1 was transferred to inpatient behavioral health unit at another facility.
(There is no evidence in the medical record that Patient #1's belongings were checked and secured. After 11/12/23 at 10:15 PM to 11/14/23 at 05:31 PM, there is no documentation to indicate nursing staff conducted an environmental check of Patient #1's room each shift).

Review of the emergency department medical record dated 01/28/23 at 12:56 AM revealed Patient #7 arrived at the facility with suicidal ideation. At 01:09 AM, a Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #7 was at high risk for suicide. At 01:24 AM, the provider note indicated that Patient #7 had suicidal and homicidal ideation. At 01:27 AM, the provider ordered an in-person bedside, 1:1 sitter for high suicide risk. At 03:07 AM, the registered nurse "ordered" staff to "begin remote sitting" (offsite telemonitoring) for a moderate risk of suicide.
(There is no evidence in the medical record after 01/28/23 at 01:14 AM to 01/30/23 at 05:11 PM to indicate that nursing staff conducted environmental checks of Patient #7's room each shift).

Review of the emergency department medical record dated 01/05/23 at 05:41 PM revealed Patient #12 arrived at the facility with suicidal ideation. At 06:11 PM, a Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #12 was at moderate risk for suicide. The registered nurse "ordered" staff to "begin remote sitting" (offsite telemonitoring) for moderate risk of suicide. At 07:45 PM, the provider ordered an in-person bedside, 1:1 sitter for high suicide risk. (There is no evidence in the medical record from 01/05/23 at 05:41 PM to 01/6/23 at 01:14 PM to indicate that that nursing staff conducted environmental checks of Patient #12's room each shift).

Review of the emergency department medical record dated 07/14/23 at 12:25 PM revealed Patient #13 arrived at the facility with suicidal ideation. At 12:46 PM a Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #13 was at moderate risk for suicide. At 01:09 PM, the provider ordered an in-person bedside, 1:1 sitter for high suicide risk. On 07/15/23 at 12:27 AM, The registered nurse "ordered" staff to "begin remote sitting" (offsite telemonitoring) for a moderate risk of suicide.
(There is no evidence in the medical record after 07/14/23 at 12:46 to 07/15/23 at 12:33 PM to indicate nursing staff conducted environmental checks of Patient #13's room each shift).

Interview on 11/14/23 at 03:20 PM with Staff (E), Director of Emergency Services, revealed that the interior garage door doesn't necessarily need to be pulled down if there is a 1:1 sitter in place or for a patient determined to be at moderate risk for suicide. The interior garage door would block the television.

Interview on 11/16/23 at 09:49 AM Staff (A), Director of Clinical Regulatory Compliance, stated that the interior safety garage door remains open, so staff have access to medical equipment.

Findings #2:

Review of the education document "The Columbia Suicide Severity Rating Scale Screening," (no date) revealed a suicide screening assessment tool that is completed by the registered nurse. A provider must be notified, and the name of the provider must be documented (in the medical record) when a patient screens at moderate or high risk for suicide.

Review of the policy "Screening, Assessment, and Care of the Patient at Risk for Suicide" last revised 06/21/22, indicated that the Columbia-Suicide Severity Rating Scale will be used to screen patients for suicide risk and is performed by a registered nurse, mental health specialist, or provider. If a patient is at moderate risk for suicide, the attending provider is contacted immediately, and a sitter is assigned (may use a remote sitter) to the patient until cleared by the attending provider or behavioral health staff. If a patient is at high risk for suicide, the attending provider is contacted immediately and a 1:1 suicide watch is initiated and maintained until cleared by the attending provider or behavioral health staff. In emergency situations, the RN is permitted to place the patient on suicide precautions and will obtain an order as soon as possible.

Review of the education document "Care of the Patient Placed on Suicide Watch-Nursing," (no date) revealed that suicide precautions may not be removed until the patient's provider enters an order to discontinue the suicide precautions. If a behavioral health crisis worker evaluates the patient and recommends that precautions be stopped, the provider still must enter the order.

Review of the education document "Care of the Patient Placed on Suicide Watch-Remote Sitter Techs," (no date) revealed that high risk suicide patients are never to be monitored by camera.

Interview on 11/14/23 at 10:36 AM Staff (G), Charge Registered Nurse, while touring the emergency department, revealed that it is nursing protocol to order and implement remote tele sitting monitoring during triage based on the Columbia Suicide Severity Rating Scale assessment of a patient at moderate risk for suicide. Remote tele sitters can never be used for patients at high risk for suicide. A provider should sign off the "nursing order." Staff (G) stated that Patient #1 was currently on remote tele sitter monitoring for moderate suicide risk and suicidal ideation. Patient #1 initially scored high on the Columbia Suicide Severity Rating Scale but was downgraded to moderate risk with use of remote tele monitoring, after a crisis worker evaluation.

Interview on 11/14/23 at 11:03 AM with Staff (E), Emergency Department Director, verified that Patient #1 was on suicide precautions. A high-risk suicide 1:1 sitter can only be discontinued by a provider and only a provider can "downgrade" to a moderate suicide remote tele sitter. An order is needed for both discontinuing and/or "downgrading" to a remote tele sitter.

Review of the emergency department medical record dated 11/12/23 at 09:53 PM revealed Patient #1 arrived at the facility with suicidal ideation. At 09:58 PM, the Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #1 was at high risk for suicide. At 10:09 PM, the physician ordered a bedside, 1:1 sitter for high suicide risk and a crisis evaluation consult. On 11/13/23 at 04:49 PM, the Columbia Suicide Severity Rating Scale was completed by Staff (F), Crisis Worker, who determined Patient #1 was at high risk for suicide. At 07:37 PM, the registered nurse "ordered" staff to "begin remote sitting" (offsite telemonitoring). At 07:38 PM, the registered nurse note indicated Patient #1 could be placed on remote tele sitter monitoring according to the crisis worker. On 11/14/23 at 11:16 AM, a Columbia Suicide Severity Rating Scale was completed by Staff (F), Crisis Worker, who indicated Patient #1 was at high risk for suicide. At 05:31 PM, Patient #1 was transferred to inpatient behavioral health facility. (There is no evidence in the medical record to indicate a physician wrote an order to change/discontinue the in-person, bedside 1:1 sitter and/or that the physician was notified that the registered nurse "downgraded" Patient #1 from an in-person, bedside 1:1 sitter to a remote tele sitter).

Review of the emergency department medical record dated 01/28/23 at 12:56 AM revealed Patient #7 arrived in custody of the police at the facility for a mental health evaluation due to suicidal ideation. At 01:09 AM, the Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #7 was at high risk for suicide. At 01:24 AM, the provider note indicated that Patient #7 had suicidal and homicidal ideation. At 01:27 AM, the provider ordered an in-person, bedside 1:1 sitter for a high suicide risk. At 03:07 AM, the registered nurse "ordered" staff to "begin remote sitting" (offsite tele sitter monitoring) for a moderate risk of suicide. (There is no evidence in the medical record to indicate a physician wrote an order to change/discontinue the in-person, bedside 1:1 sitter and/or that the physician was notified that the registered nurse "downgraded" Patient #7 from an in-person, bedside 1:1 sitter to a remote tele sitter).

Review of the emergency department medical record dated 01/05/23 at 05:41 PM revealed Patient #12 arrived at the facility for a psychiatric evaluation due to suicidal ideation. At 06:11 PM, the Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #12 was at moderate risk for suicide. The registered nurse "ordered" staff to "begin remote sitting" (offsite tele sitter monitoring) for a moderate risk of suicide. At 07:45 PM, the provider ordered an in-person, bedside 1:1 sitter for a high suicide risk. (There is no evidence in the medical record to indicate a physician wrote an order to change/discontinue the in-person, bedside 1:1 sitter and/or that the physician was notified that the registered nurse "downgraded" Patient #12 from an in-person, bedside 1:1 sitter to a remote tele sitter).

Review of the emergency department medical record dated 07/14/23 at 12:25 PM revealed Patient #13 arrived at the facility for a psychiatric evaluation due to suicidal ideation. At 12:46 PM, the Columbia Suicide Severity Rating Scale assessment was completed by a registered nurse that indicated Patient #13 was at moderate risk for suicide. At 01:09 PM, the provider ordered an in-person bedside, 1:1 sitter for high suicide risk. On 07/15/23 at 12:27 AM, The registered nurse "ordered" staff to "begin remote sitting" (offsite telemonitoring) for a moderate risk of suicide. (There is no evidence in the medical record to indicate nursing staff implemented the in-person, beside 1:1 sitter physician order, that the physician changed/discontinued the 1:1 in-person sitter order, and/or that the physician was notified that the registered nurse "downgraded" Patient #12 from an in-person, bedside sitter to remote telemonitoring).

Interview on 11/15/23 at 03:00 PM with Staff (BB), Director of Inpatient Services, revealed nursing staff would notify the provider when "downgrading" a physician order for a 1:1 sitter for a high suicide risk patient to a virtual tele sitter.

Findings #3:

Review of policy "Tele sitter (Remote): Continuous Visual Patient Monitoring" last revised 10/19/23 included that upon the initiation of remote tele sitter services, the registered nurse provides patient/family education and documents the education in the medical record. The registered nurse documents assessments and discontinuation of remote tele sitter monitoring when indicated. The remote tele sitter is required to document the initiation of tele sitting services, including the verification that the camera was working with no visual obstructions to monitor the patient; confirmation that the patient can hear verbal instructions given by the remote tele sitter; and the discontinuation of tele sitting services.

Review of the emergency department medical record from 11/12/23 to 11/14/23 for Patient #1 revealed on 11/13/23 at 07:38 PM, the registered nurse "downgraded" Patient #1 from a high suicide risk to a moderate suicide risk and implemented a remote tele sitter for patient monitoring. (There is no documentation of the following: the initiation of remote tele sitter services; verification of camera function (audio and visual); confirmation that Patient #1 could hear verbal instructions from the remote tele sitter; patient and/or family education regarding remote sitter use and assessment; and discontinuation of the remote sitter monitoring by the registered nurse).

Review of the emergency department medical record from 01/28/23 to 01/30/23 for Patient #7 revealed on 01/28/23 at 03:07 AM, the registered nurse "downgraded" Patient #7 from a high suicide risk to a moderate suicide risk and implemented a remote tele sitter for patient monitoring. (There is no documentation of the following: the initiation of remote tele sitter services; verification of camera function (audio and visual); confirmation that Patient #7 could hear verbal instructions from the remote tele sitter; patient and/or family education regarding remote sitter use and assessment; and discontinuation of the remote sitter monitoring by the registered nurse).

Review of the emergency department medical record from 01/05/23 to 01/06/23 for Patient #12 revealed on 01/05/23 at 05:41 PM, the registered nurse determined Patient #12 was a moderate suicide risk and implemented a remote tele sitter for patient monitoring. (There is no documentation of the initiation of remote tele sitter services, verification with nursing staff that camera was working with no visual obstructions to monitor the patient, and confirmation that Patient #12 could hear verbal instructions from the remote tele sitter. There is no documentation of patient and family education regarding remote sitter use and assessment and discontinuation of the remote sitter monitoring by the registered nurse.

Review of the emergency department medical record from 07/14/23 to 07/15/23 for Patient #13 revealed on 07/15/23 at 12:27 AM, the registered nurse "downgraded" Patient #13 from a high suicide risk to a moderate suicide risk and implemented a remote tele sitter for patient monitoring. (There is no documentation of the following: the initiation of remote tele sitter services; verification of camera function (audio and visual); confirmation that Patient #13 could hear verbal instructions from the remote tele sitter; patient and/or family education regarding remote sitter use and assessment; and discontinuation of the remote sitter monitoring by the registered nurse).

A1100
This CONDITION is not met as evidenced by:

Based on policy review, document review, medical record review, and interview, it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice as evidence by: The facility allows non-licensed, unqualified behavioral health assessment specialists/crisis workers to conduct psychiatric evaluations and make recommendations. The facility failed to ensure that the on-call consultant psychiatrists conducted an examination, reviewed the medical record, and provided a written opinion for patients they have been requested to provide a consultation for (TAG-A1112).

Cross Reference:
482.55(b)(2) Qualified Emergency Services Personnel

Based on document review, policy review, medical record review, and interview the facility failed to ensure there is adequate personnel, qualified in emergency care, to meet the written emergency procedures and needs anticipated by the facility as evidenced by:
1.Behavioral health assessment specialists/crisis workers, who are not licensed in New York State, performed psychiatric assessments and psychosocial evaluations for five of 15 emergency department patients (Patient #3, #4, #6, #7 and #9).
2.The facility failed to ensure that on-call consultant psychiatrists conducted an examination, reviewed the medical record, and provided a written opinion for five of 15 patients (Patient #3, #4, #6, #7 and #9).

Findings #1:

Review of the document "New York State Department of Health Dear Chief Executive Officer letter 08-01," dated 04/25/08 indicated that if a psychiatric assessment is an appropriate part of a medical screening examination and a psychiatrist/physician with the appropriate skills and training is not immediately available to assess the patient, such assessment may be conducted by other appropriately credentialed licensed staff such as a registered professional nurse, nurse practitioner, physician assistant, psychologist, clinical social worker, and/or a master degree social workers. When the assessment is not carried out by a psychiatrist or other appropriately qualified physician, the licensed staff assessing the patient for a psychiatric emergency must directly consult with a psychiatrist or other appropriately credentialed physician (credentialed on the staff of the hospital) regarding disposition of the patient. The conversation with the psychiatrist or appropriately credentialed physician must be documented on the patient record including the name of the psychiatrist/physician and the time of the consultation.

Review of policy "Referrals, Psychiatric," last revised 03/08/22 indicated that a social worker, registered nurse, or trained crisis worker may assist physicians and registered nurses with completing assessments, coordinating services, and care. Patients presenting with suicidal ideation, or an attempt will have a suicide risk scale completed by the registered nurse, crisis staff, or licensed master's degree social worker, and placed in the medical record.

Review on 09/29/23 of the "Behavioral Health Assessment Specialist (or crisis worker) Job Description," (no date), indicated the required education was an associate degree, but a bachelor's degree in psychology or a related field is preferred. The required experience was one year working in a psychiatric setting, human service, or related field. The essential function of the behavioral health assessment specialist was to provide evaluations, assessments, crisis intervention, and referrals for all populations served by the department in the emergency room. The behavioral health assessment specialist recognizes and identifies actual or potential situations which places the organization at risk for corporate compliance violations. (This job description does not require staff to be licensed in a New York State in a healthcare field).

Review on 09/29/23 of personnel files of current behavioral health assessment specialist/crisis workers revealed that Staff (F) hired in 02/2022, Staff (Q) hired in 03/2019, and Staff (R) hired in 08/2022, do not have a healthcare license in New York State.

Medical record review revealed psychiatric assessments were completed by Staff (F), Behavioral Health Assessment Specialist/Crisis Worker for Patient #4 on 01/26/23; Patient #6 on 01/27/23; Patient #7 on 01/29/23; Patient #9 on 09/05/23 and 09/08/23. Staff (Q) Behavioral Health Assessment Specialist/Crisis Worker completed psychiatric assessment for Patient #3 on 01/22/23. (There is no evidence to indicate the registered nurse or provider signed off on the evaluations).

Interview on 09/27/23 at 02:33 PM with Staff (G), Emergency Department Charge Nurse, stated that the behavioral health assessment specialist/crisis worker completes a crisis evaluation once a patient is medically cleared to be seen. The behavioral health assessment specialist/crisis worker is the liaison between the patient and the psychiatrist. The behavioral health assessment specialist/crisis worker will seek the knowledge and opinion of the nursing staff to help get a clear picture of the patient.

Interview on 09/27/23 at 02:58 PM with Staff (H), Chief of the Emergency Department, stated the behavioral health assessment specialist/crisis worker can perform their evaluations either in person or virtually through an iPad. Virtual evaluations are conducted when there is not a behavioral health assessment specialist/crisis worker on site. The behavioral health assessment specialist/crisis worker reviews each case with the attending provider and then speaks with the on-call psychiatrist by phone. A secure chat feature in the electronic medical record allows a group message between the attending provider, behavioral health assessment specialist/crisis worker, psychiatrist, and nursing to discuss a plan.

Interview on 9/28/23 at 04:30 PM with Staff (A), Director of Clinical Regulatory Compliance, and on 11/15/23 at 03:00 PM with Staff (BB), Director of Inpatient Services verified these findings.

Interview on 09/29/23 at 09:24 AM with Staff (N), Chief Medical Officer, stated the behavioral health assessment specialist/crisis consult is to specifically consult the behavioral health assessment specialist/crisis worker, not a specific psychiatrist. The behavioral health assessment specialist/crisis worker conducts the intake (psychosocial) evaluation and discusses it with the psychiatrist on call.

Findings #2:

Review of the Corning Hospital "Medical Staff Rules and Regulations," last updated 12/4/17 revealed it is the duty of the medical staff, through its department chairs, chiefs of service, and executive committee, to see that members of the staff do not fail in the matter of calling consultants as needed in accordance with generally accepted standards of patient care. The attending practitioner is responsible for requesting consultations when indicated, which shall include an examination of the patient, review of patient's records, and a written opinion signed by the consultant in the patients record.

Review of the Corning Hospital Medical Staff Bylaws revised 01/4/21 revealed consulting staff shall consist of physicians, podiatrists, and dentists who have recognized professional ability but are not members of the staff, who come to the hospital on call or on a regularly scheduled basis, but do not have admitting privileges. The consulting staff member shall provide medical consultation upon request of the attending practitioner.

Review of policy "Medical Screening Examinations, Stabilizing Treatment & Appropriate Transfers (EMTALA)" last revised 08/01/22 indicated that a qualified medical professional may consult with on-call physicians by telephone when appropriate.

Medical record review revealed a psychiatric consultation was requested by the emergency department provider for Patient #3 on 01/22/23, Patient #4 on 01/26/23, Patient #6 on 01/26/23, Patient #7 on 01/28/23, Patient #8 on 09/03/23, Patient #9 on 09/05/23, and Patient #12 on 01/05/23. (There is no evidence to indicate that an on-call psychiatric consultant conducted an examination of the patient, review of patient's records and/or a written opinion signed by the consultant in the patients record as required by the Medical Staff Rules and Regulations).

Interview on 09/27/23 at 01:15 PM, Staff (A), Director of Clinical Regulatory Compliance stated that the psychiatrist is not required to enter a note or sign attestation in a patient's medical record when the behavioral health assessment specialists/crisis workers review the crisis evaluation over the phone.

Interview on 09/28/23 at 04:30 PM, Staff (A) Director of Clinical Regulatory Compliance, and on 11/15/23 at 03:00 PM with Staff (BB), Director of Inpatient Services, verified these findings.

Interview on 09/29/23 at 09:24 AM with Staff (N), Chief Medical Officer, stated "Psychiatry" is educated to review the patient's chart and to write notes of their recommendations. Psychiatry are educated on Medical Staff Rules and Regulations and can go into the chart (electronic medical record) and leave a note if they credentialed and/or licensed in New York State. If they are out of state it is left to the Emergency Department Physician to document because they are ultimately responsible.