HospitalInspections.org

Based on hospital policy and procedure, medical record request and employee interview, it was determined that the hospital failed to ensure a patient medical record was maintained with all required documentation for at least 5 years. This deficient practice can result in a patient not getting appropriate psychiatric and medical care if they need further treatment.

Findings Include:

Hospital policy #12197131, titled "...Intake Sheet-Accepting Referrals," last approved 08/2022, revealed "...POLICY: ...The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...PROCEDURE: ...A copy, fax, or email of completed Triage Assessment Form for patients being admitted to the hospital shall be sent to the nursing station and admitting staff as well as uploaded into the Wellsky document storage. Nursing staff shall review information on the Intake Sheets and incorporate it into the nursing assessment of the patient...."

Hospital policy titled "NEUROPSYCHIATRIC HOSPITALS Medical Staff Bylaws PMHP,' last amended 11/2024, revealed "...BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP...5. Prepare and complete in a timely fashion medical and other records for the patients the Medical Staff member admits, or to whom the member provides care in the hospital...."

EMTALA Log dated 12/4/2025 showed Patient #4 arrival at 1610 with note stating " ...sent out for medical clearance ...."

A request was made for hospital medical records, including "Medical Screening Exam," for Patient #4. None were provided.

Employees #1, #3 and #4 confirmed during a joint interview conducted on May 14, 2025, that no hospital medical records for Patient #4 were available for review at the time of the survey.

Based on review of hospital policy and procedure, facility documents, medical records and employee interview, it was determined the hospital failed to ensure intake screening and admission documentation was completed pursuant to facility policy. This deficient practice poses the potential risk that a patient will not receive needed emergency medical care, resulting in patient harm or death.

Findings include:

Policy titled "EMTALA," Policy #12508324, Last Approved: October 2022, revealed "...Evaluation shall be performed...for an individual with an EMC (Emergency Medical Condition) which has not been stabilized..."

Policy titled "Intake Sheet-Accepting Referrals," Policy #12197131, Last Approved: October 2022, revealed "...Policy: The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...Original completed Triage Assessment Form shall be retained by the Intake Department...."

Policy titled "Criteria for Admission," Last Approved: March 2024, revealed "...Purpose: To implement appropriate admission of patients to the hospital by identifying inclusionary and exclusionary criteria for admission...."

Policy titled "Behavioral Health Admission Assessment-Nursing," Policy #12195052, Last Approved: October 2022, revealed "...Policy: Each patient's needs shall be assessed by an RN at the time of admission and documentation completed within twelve (12) hours upon admission by the RN...."

Facility document titled "EMTALA Log" revealed the following:

Patient #15 arrived at the hospital on May 10, 2025, at 9:48 AM, " ...Arrival Mode ...(Ambulance) ...Disposition ...Sent out for medical clearance ..."

Medical Screening Examination requested for Patient #15. None was provided.

Employee #3 confirmed during interviews conducted on May 15, 2025 and May 16, 2025, that no Medical Screening Examination documentation for Patient #15, from the May 10, 2025, at 9:48 AM arrival, was available for review at the time of the survey.

Based on Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital delayed examination and/or treatment for a patient who presented to the Hospital seeking emergency treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient is denied necessary medical treatment.

Findings include:

Hospital policy titled "EMTALA," Policy #12508324, Last Approved: 10/2022, revealed " ...After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC (emergency medical condition) who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. Evaluation and treatment shall be performed ...as quickly as possible ..."

A total of 20 patient medical records were randomly selected for review from the Hospital's EMTALA Log. Hospital documents revealed the following:

Patient # 20

Hospital document titled "EMTALA Log" revealed Patient #20 arrived at the hospital on May 7, 2025, at 2:15 PM as a "walk-in," with an Intake Start Time of 3:03 PM, and the Disposition was " ...admitted ..."

Hospital document titled "Nursing Admission Assessment" revealed " ...Date: 5/7/25 ...Time: 1550 ..."

Hospital document titled "Admission Orders" revealed " ...Date of Order: 5/7/25 ...Time of Order: 1530 ..."

Hospital document containing patient demographic information revealed " ...Admit Date & Time ...5/07/2025 16:30 ..."

Employee #3 acknowledged during interviews on May 15, 2025, and May 16, 2025, that documentation for Patient #20 revealed a delay between patient arrival and medical screening examination and/or treatment.

Based on hospital policy review, medical record review, and employee interview, it was determined that the administrator failed to implement and enforce hospital policy for transferring of patients to another facility. This deficient practice poses a potential risk of harm to patients by not receiving needed care in a safe and timely manner.

Findings Include:

Hospital Policy titled, "Transfer of Patient," Policy #10623375, Last Reviewed June 2023, revealed "...Patient transfers will be carried out per physician order in a safe and timely manner, keeping quality patient care a focus, with consideration for patient status. Appropriate patient information will accompany the patient during transfer ...PROCEDURE:...A. Routine/Non-Emergent Transfer:...1. The hospital will ensure a report regarding the patient's condition is called to the facility the patient is transferring to...Social Services or designee to arrange appropriate transfer and notify/contact the patient's receiving facility...Arrange transportation for the transfer as ordered by provider...All decisions regarding the type of transportation require approval from patient/Power of Attorney/Guardians prior to arrangement and the approval will be documented...Types of transportation must be decided based on the patient's condition...The nurse shall conduct a Nurse to Nurse phone report with the accepting facility and document the report in the nurse's notes...."

Medical record of Patient #20, revealed a document titled "Daily Nursing Assessment," dated May 14, 2025, that revealed " ...around 2150 BHA was going to take patient to bed ...patient was non responsive ...RN assessed unresponsiveness and called code blue ...patient had week [sic] pulse ...EMS arrived patient taken to Banner University Medical Center (BUMC) ...."

Medical record of Patient #5 revealed an untitled document timed at 1704 that showed " ...Talked to his primary nurse ...patient would be returning due to his altered mental status ...she was informed that patient would have to be returned ...."

Medical record of Patient #5 failed to show "...a physician order,... report regarding the patient's condition ... transfer as ordered by provider ...document the report in the nurse's notes ...."

Medical record of Patient #8, revealed document titled "Phoenix Medical Psychiatric Hospital medical screening exam" that revealed "reason for transfer" "patient needed medical clearance".

Medical record of Patient #8 failed to show "...a physician order,... report regarding the patient's condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse's notes ...."

Medical record of Patient #14 revealed "Physician/NP/PA Progress Note," timed 1808, revealed " ...patient sent to ER for medical clearance ...."

Medical record of Patient #14 failed to show "...a physician order,... report regarding the patient's condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse's notes ...."

Medical record of Patient # 20 failed to show "...a physician order,... report regarding the patient's condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse's notes ...."

Employees #3 and #4 confirmed during an interview conducted on May 14, 2025, that the medical record for Patients #5, #8, #14 and #20 failed to show "...a physician order,... report regarding the patient's condition ... transfer as ordered by provider ... Nurse to Nurse phone report with the accepting facility ... document the report in the nurse's notes ...."