HospitalInspections.org

Based on a review of clinical records and facility documentation, the facility failed to appoint a chief executive offier who is responsible for managing the hospital.

Findings were:

During a review of 4 clinical records, 1 of the 4 patients (patient #1) requested to be discharged from the facility 10:00 pm on 7-31-15. He was not evaluated by a physician until 1:00 pm on 8-3-15.

Facility policy PC-09 titled "Discharge; Unfavorable" stated the following:
"Registered Nurse
1. If patient signs a 4 hour notice of intent to leave treatment;
...
c. At expiration of 4 hours, if patient has not revoked notice, physician either voices desire to examine the patient for potential commitment of (sic) writes discharge order to discharge patient AMA. If the physician does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, a facility shall discharge the patient within the four-hour time frame. If the physician has reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician shall examine the patient as soon as possible with 24 hours after the request for discharge is made known to the facility and a staff member is designated to return the patient's belongings and valuables to the patient and escort patient out of the facility."

The above was confirmed in an interview with the facility Administrator, Health Information Management Director and Director of Nursing on the evening of 11-3-15.

Based on a review of documentation, the facility failed to ensure that a psychiatric evaluation was completed within 60 hours of admission.

Findings were:

During a review of clinical records for 4 patients, 1 of 4 patients (patient #1) did not receive a psychiatric evaluation within 60 hours. The patient was admitted at 6:00 pm on 7-31-15 and did not receive a psychiatric evaluation until 1:00 pm on 8-3-15, 71 hours after his admission.

The above was confirmed in an interview with the facility Administrator, Health Information Management Director and Director of Nursing on the evening of 11-3-15.