HospitalInspections.org

Based on policy review, document review and interview, the Governing Body failed to assume responsibility and provide oversight, ensure all staff honored patient rights, and ensure appropriate nursing services were provided.
The failure of the Governing Body to assume responsibility and provide oversight to ensure patients were provided care in a safe setting placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY.

The findings included:

1. The Governing Body failed to ensure the Medical Staff bylaws were developed and approved in accordance with State practice acts.
Refer to A 047

2. The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A 057

2. The Governing Body failed to ensure all patients' right to receive safe care was promoted.
Refer to A 0115 A 0144

3. The Governing Body failed to ensure Nursing services were provided to meet the needs of all patients.
Refer to A 385 and A 397

Based on policy review, Medical Executive Committee (MEC) meeting minutes, bylaws and interview, the Governing Body failed to ensure the medical staff bylaws were developed in accordance with the facility policy and State law practice acts.
The failure of the Governing Body to ensure medical staff bylaws were appropriate to ensure safe patient care resulted in a SERIOUS AND IMMEDIATE THREAT and placed all patients in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the facility "EMTALA [Emergency Medical Treatment And labor Act] - Medical Screening Examination [MSE] and Stabilization" policy revealed, "...Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...A qualified licensed independent practitioner (LIP)...A qualified staff member who...is functioning within the scope of his or her license in compliance with State law and applicable practice acts (e.g., Medical or Nurse Practice Acts)..."

2. Review of the facility medical staff bylaws revealed, "...i. The following mental health professionals are deemed to be credentialed to perform medical screening examinations to determine whether an individual has an emergency medical condition and, therefore, are Qualified Mental Health Professionals (QMHP): (i) Licensed Physicians; (ii) Licensed Psychologists; (iii) Licensed Social Workers; (iv) Registered Nurses; and (v) Licensed Professional Counselors..."

Review of the Medical Executive Committee (MEC) meeting minutes dated March 23, 2017 revealed the bylaws were approved.

In an interview on 4/2/18 at 1:45 PM in the conference room the Director of Quality confirmed the MEC bylaws had been approved.

3. Review of the State Health Related Board Statutes for Licensed Psychologists, Licensed Social Workers, Registered Nurses and Licensed Professional Counselors revealed the scope of practices for these disciplines do not allow them to independently practice medicine, treat patients and prescribe medical treatment for patients. Therefore, cannot be considered a Qualified Medical Professional (QMP) or Licensed Independent Practitioner (LIP).

4. Medical record review revealed Patient #1 presented to Hospital #1's Intake Assessment Emergency Department on 2/14/17 seeking Inpatient Treatment, Treatment Recommendations, and Medication Management. A RN and Assessor (Masters of Art in Sociology) performed a medical screening examination on Patient #1. There was no documentation a Physician assessed or examined the patient. Patient #1 was discharged home from the Intake Assessment Emergency Department with no treatment interventions on 2/14/17. On 2/19/17 the police department discovered that Patient #1 had shot and killed his wife and then shot and killed himself.
Refer to A 144.

Based on medical record review and interview, the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital, ensure patient rights were protected, and ensure nursing meets the needs of all patients.

The findings included:

1. Review of the Intake Assessment dated 2/14/17 for Patient #1 revealed the patient presented to the facility requesting inpatient treatment, treatment recommendations and medication management. The patient and patient's wife had a verbal altercation and the patient's wife was afraid of the patient. The facility failed to investigate the altercation and the wife's fearfulness. The facility conducted an inaccurate assessment of Patient #1's alcohol abuse. The facility failed to provide treatment interventions for the patient's complaints and symptoms. The patient was discharged from the Intake Assessment area. The police report dated 2/19/17 revealed the patient shot and killed his wife and then shot and killed himself.
Refer to A144

2. Medical record review for Patient #3 revealed the patient was discharged from the facility on 6/20/17. Facility staff continued to document vital signs, weight, and meal intakes on 6/21/17 after the patient had been transferred to the Emergency Room on 6/20/17.
Refer to 397

3. Medical record review for Patient # 5 revealed on 1/4/18 the patient had elevated Blood Urea Nitrogen (BUN) and Creatinine lab levels. On 1/5/18 the physician ordered strict intake and output on the patient. The intake and output was not strictly documented and there no assessment to identify an adequate fluid intake for Patient #5. On 1/10/18 Patient #5 was transferred to the hospital with "...Acute Kidney Injury..."
Refer to A397

4. Medical record review for Patient #19 revealed RN #1 administered Haldol and Ativan intramuscular on 1/2/18 at 8:15 AM. There was no documentation of the time the order was prescribed.
Refer to A397

Based on policy review, medical record review, and interview, the facility failed to ensure patients' rights were protected to receive care in a safe setting and ensure prompt notification of family members when patients are hospitalized.
Failure of the hospital to ensure all patients' received care in a safe setting to protect their emotional health and safety placed Patient #1 and all all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY.

The findings included:

1. The hospital failed to ensure all patients received care in a safe setting.
Refer to A 144

2. The hospital failed to notify family members when a patient transferred to the hospital.
Refer to A 133

Based on medical record review and interview, the hospital failed to promptly notify a family member of patient transfer to another hospital for 1 of 4 (Patient #5) sampled patients that were admitted as inpatients and then transferred to another hospital.

The findings included:

1. Medical record review revealed Patient #5 was admitted to Hospital #1 on 1/3/18 with the diagnoses of Bipolar Disorder, Diabetes, Hypertension and Urinary Tract Infections.

2. Review of the a nurse's note dated 1/10/18 at 8:47 AM revealed a physician's order was obtained to send the patient to Hospital #3. The nurse documented, "...[sign for No] family listed to contact."

3. In an interview on 3/29/18 at 3:00 PM in the conference room the Chief Nursing Officer was unable to provide information that a family contact was obtained and notified that the patient had been transferred to Hospital #3.

Based on policy review, document review, medical record review, and interview, the hospital failed to ensure vulnerable patients received appropriate care in a safe setting for 1 of 10 (Patient #1) sampled patients who were discharged from the Intake Assessment without admission.
Failure of the hospital to ensure all patients' received care in a safe setting to protect their emotional health and safety placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the "Emergency Plan of Services" policy revealed, "...[Name of Hospital #1] maintains a emergency services which are organized, directed and staffed according to the nature and extent of health care needs anticipated and the scope of services offered by the facility...1. Codes will be designated and known to all staff for use in communicating medical and psychiatric emergencies within the facility. The following codes are designated...Code Yellow - Psychiatric Emergency...Any employee discovering a medical or psychiatric crisis should remain with the patient and summon assistance by calling the appropriate code. The code should also be announced as appropriate using the overhead paging system...4. Assessment of Medical/Psychiatric Crisis...Emergency psychiatric and medical assessment and stabilization should be directed by the attending physician, Internal Medicine Physician or Medical Director or another available physician...The patient or other individual should immediately be assessed to determine whether an emergent condition exists...The registered nurse should report the medical/psychiatric emergency to the Director of Nursing and the CEO [Chief Executive Officer] or administrative designee...5. Psychiatric Emergencies...A psychiatric emergency is defined as severe mental debilitation due to psychiatric or chemical dependency disorders in which failure to stabilize could result in potential for injury to self or others..."

Review of the "Risk Reduction Guidelines" policy revealed, "...It is the policy of [Name of hospital #1] that patients who exhibit high risk behaviors (i.e. demonstrating ideations, impulses or behaviors indicating they are a danger to themselves or others) will be placed on appropriate precautions to minimize the threat of injury or harm...Patients are assessed upon admission and reassessed throughout hospitalization...for any behavior or behavioral history that demonstrates a need for high risk precautions...Early identifiers (definitions)...Suicide/Self Harm...threats to self or others, isolating behavior, active, viable plan to harm self, self-injurious behavior, attempts to harm others... Homicide/Assault/Aggression - history of acts of aggression towards others; current acts of aggression towards others or verbal threats of violence towards others...A comprehensive evaluation should be performed and documented on all individuals assessed by the Needs Assessment and Referral Center (NARC) Staff...An initial Evaluation of Risk Form should be completed on all assessments by NARC Staff identifying the following:
Who the informant is.
Suicide Risk Assessment.
Homicidal Risk Assessment.
History of violence/sexual aggression.
Weapons screening.
Accuracy of reports and history of risk.
Suicide and homicide/violence risk factors.
Internal/External Protective factors.
Summary Evaluation of Risk of suicide/homicide/assaultive behavior/vulnerability..."

Review of the "Assessment" policy revealed, "...All patients awaiting assessment will receive a thorough assessment and evaluation and will be assessed and reassessed throughout their assessment waiting period. Procedure: 1. Upon arrival of the individual to our facility for the evaluation...the receptionist will ask the individual/family to complete the Registration paperwork that includes the Triage Form, Communicable Disease Form, HIPPA notification and demographics...5. Upon completion of the assessment...If appropriate, the individual will be given three referrals, unless driven by a Managed Care Company or referral request, with all necessary demographic information to obtain an appointment...6. The recommendations for services will always be based entirely upon clinical necessity of the individual..."

2. Medical record review from Hospital #2 revealed Patient #1 was admitted on 2/6/17 with diagnoses of Acute Traumatic Minimally Displaced Fractures of the Ribs, Pulmonary Contusion, Alcohol Abuse, and Right Clavicular Fracture.

Review of a blood alcohol test collected on 2/6/17 at 8:21 PM revealed Patient #1 had a level of 173 mg/dl (milligrams/deciliter). The normal reference range was 0-10 mg/dl and results greater than 50 mg/dl indicated toxic level.

Review of a physician's progress note dated 2/7/17 at 10:54 AM revealed, " ...History of heavy alcohol use..."

Review of a Physical Therapy (PT) Evaluation dated 2/9/17 revealed, "...pt [patient] states wife is years older than him and will not be available to assist pt at home in this condition...very fearful of pain and noted to be very anxious ..." Further review of the PT evaluation revealed Patient #1's anticipated discharge disposition was to an inpatient rehabilitation facility.

Review of a Social Worker note dated 2/9/17 at 10:06 AM revealed the SW had spoke to Patient #1's wife and she cannot care for him at home.

Review of a SW note dated 2/10/17 at 3:14 PM revealed that Patient #1's insurance denied his request for inpatient skilled rehabilitation after discharge from the hospital.

Patient #1 was discharged home from Hospital #2 on 2/10/17.

3. Review of Patient #1's "Inquiry Call Data Collection" Referral form revealed Physician #2's nurse called Hospital #1 on 2/14/17 at 11:24 AM and indicated that Patient #1 was "...on his way for detox from alcohol ..."

Review of the "Registration/Information Worksheet" revealed that Patient #1, a 57 year old male, arrived at Hospital #1 on 2/14/17 at 12:15 PM. Patient #1 signed a consent for the staff at Hospital #1 to perform an assessment and to verify insurance benefits. Review of the Primary Insurance revealed a named insurance carrier and the Secondary Insurance was "self-pay."

Review of the "Triage Form - Needs Assessment" completed by Patient #1 revealed he was seeking Inpatient Treatment, Treatment Recommendations, and Medication Management. Patient #1 also documented the following concerns:
Appetite/Sleep Disturbance.
Martial or Relationship Stressor.
Problems at Work.
Feelings of Anger.
Excessive Worry or Unwanted Thoughts.
Difficulty Concentrating.
Depression/Sadness/Crying Spells.
Loss of Interest/Enjoyment in Sexual Activity.
Alcohol or Drug Use.
Easily Annoyed/Irritated/Tense/Nervous.
Temper Outburst/Destructive to Property, and
Impulsiveness/Acting without Thinking.
Patient #1 identified a feeling of wanting to harm self, and a strong/moderate desire to die right now. Patient #1 revealed that his alcohol and marijuana use brought him to Hospital #1 requesting help.

Review of the "MEDICAL SCREENING FORM" dated 2/14/17 at 1:40 PM completed by Registered Nurse (RN) #1 documented hypertension, gastrointestinal dysfunction, and current broken bones/fractures as Patient #1's other current medical conditions. The Breathalyzer section was blank.

In an interview on 3/28/18 at 10:20 AM in the conference room, RN (Registered Nurse) #1 verified that a Code Yellow was announced related to a verbal altercation between Patient #1 and his wife and the wife was fearful of Patient #1. RN #1 also stated the patient was concerned because his insurance did not cover inpatient treatment. There was no documentation that RN #1 identified or provided interventions related to the Code Yellow in Patient #1's assessment.

a. Review of the "COMPREHENSIVE / PSYCHOSOCIAL ASSESSMENT TOOL - Part 1 (Initial Screening)" dated 2/14/17 beginning at 1:52 PM and completed by Assessor #1 (who had a Master of Arts in Sociology) revealed the following:

Chief Complaint: Assessor #1 documented that Patient #1 stated, "Depression, alcohol" and Patient #1's wife stated, "Severe alcoholism. He's been through DT's [delirium tremens] 4 times in past 4 months." Assessor #1 documented the patient's wife reported the patient drank half a pint of vodka yesterday. Assessor #1 documented, "Pt. reported that life is useless, 'what the F... what does it matter'..."

The "Problems with performing activities of daily living (feeding, bathing, hygiene, dressing)" section revealed Assessor #1 documented that wife reported that Patient #1 needed help with getting dressed, showering, and getting out of bed.

The "Alcohol / Drug Use" section revealed Assessor #1 documented that Patient #1 drank 1 pint of vodka daily with the last use on 2/13/17 at 1:00 PM. Assessor #1 documented that Patient #1 had a history of withdrawals and DT's with the most recent complaint last week.

The "Withdrawal Symptoms/Behaviors from Alcohol/Drug Use" section revealed Assessor #1 documented the patient's symptoms of "shakes...diarrhea...sleeplessness..."
The patient and or wife reported when he has the "shakes...when I don't drink...I usually drink and then it quits" with the most recent being last week.
The patient and or wife reported the "diarrhea" frequency was "a lot" with the duration of a "couple of days" with the most recent being yesterday, 2/13/17.

The "Abuse, Neglect, or Trauma Assessment" section revealed Assessor #1 documented that Patient #1 had a history of physical and mental abuse by his father during his childhood.

Review of the "INITIAL EVALUATION OF RISK TO SELF/OTHERS" completed by Assessor #1 on 2/14/17 at 2:39 PM, revealed the following:
Suicide Risk Assessment: Patient #1 denied suicidal ideations or plans. Assessor #1 documented the patient stated, "I don't want to be here but I don't have thoughts of killing myself. I just wish something would take me." In answer to "Previous Hx [history] of Ideation (Specify if within the past 6 months" the pt reported, "...this year..." There was no documentation Assessor #1 further assessed the suicidal ideation the patient had reported as being "this year [less than 2 months into the year]."

The "Weapons Screening" section revealed Assessor #1 documented Patient #1 admitted he had access to weapons, owned a gun, and had guns in the home.
There was no documentation the facility provided safe interventions related to the weapons screening.

The "Accuracy of Reports and History of Risk: Is there any evidence or concern that the patient or others may be concealing or denying current or past Suicide / homicide / assaultive ideation/behaviors?" section revealed Assessor #1 documented "No."
There was no documentation Assessor #1 further assessed the suicidal ideation the patient had reported as being "this year [less than 2 months into the year]." There was no documentation the assessor assessed the wife's fear of the patient.

Suicide and Homicide / Violence Risk Factors: Assessor #1 documented that Patient #1 had the following Risk Factors:
45 years and older.
had possession of weapons.
severe problems with significant others.
history of bipolar disorder.
alcohol or drug use.
hopelessness.
blunted / flat affect.
rapid mood shifts.
severe worry / rumination, and
severe anxiety / panic.
There was no documentation the facility provided treatment or interventions for these risk factors.

Assessor #1 documented, "Pt is 57, diagnosed with bipolar, very depressed and anxious, abusing alcohol, having marital problems."

The "Internal / External Protective Factors" section revealed Assessor #1 failed to identify if Patient #1 felt safe going home or if Patient #1's wife felt she could keep Patient #1 safe.

The "Summary Evaluation of Risk of Suicide / Homicide /Assaultive Behavior / Vulnerability" section revealed Assessor #1 documented that Patient #1 was a "Low to No Risk" for Suicide and Homicide.

Assessor #1 documented that the evaluation was reviewed via telephone call with Physician #1 (the on call Psychiatrist at Hospital #1) on 2/14/17 at 2:59 PM.

The patient initially documented he had a moderate-strong desire to "die right now" and feeling of self-harm. Later in the assessment process, Assessor #1 documented Patient #1 had no suicidal or homicidal ideations. There was no documentation Assessor #1 addressed these changes in the patients status.
There was no documentation the assessor identified or provided interventions related to the verbal altercation between Patient #1 and his wife or the wife's fearfulness of the patient.

b. Review of the "Comprehensive/Psychological Assessment Tool - Part 2 (Inpatient/PHP/IOP Admissions)" form revealed Assessor #1 documented the following:

The "Major Life Areas" section revealed Patient #1 admitted "Problems at Work or School...has missed some work and hasn't been performing well...Deterioration in Hygiene and/or Grooming...Per wife pt doesn't take care of his grooming as well when drinks...Loss of Energy or Interest in Activities...for past 3 months...Social Withdrawal...has lost interest in everything...Isolating from everyone for past 3 months..."

The "Behavior Changes" section revealed Patient #1 admitted "Irritability Poor Impulse Control...per wife- impulsive-drives his motorcycle under the influence. buys scratch offs [lottery tickets] daily...increase in irritability for more than 3 months..."

The "Sleep" section revealed Patient #1 admitted "Not sleeping...'I've gone days'...Difficulty Going to Sleep (Initial Insomnia)...mind races...has to get up at 3 am for work..."

The "Eating" section revealed Patient #1 admitted "...Compulsive Overeating...daily...loss of appetite for past 3 months..." Assessor #1 documented the patient had lost 50 pounds in the past 3 months.

The "Anxiety" section revealed Patient #1 admitted "Panic Attacks...'All the time' up to 10 times a day at work...Obsessive/Compulsive Thoughts...could be anything..." the "Anxiety scale", with "1 meaning no anxiety and 10" is the worst, rate your anxiety." The patient's anxiety level scale was documented to be a "10...when having anxiety attacks...5-in general." There was no documentation the facility treated or addressed the patient's identified anxiety levels.

The "Family Assessment" section documented the patient lived "with wife but they don't stay in the same room. Wife reports that she is his care taker and is codependent..." In answer to "What effect does the patient's condition have on the family" Assessor #1 documented the wife reported, "It's deteriorated it, both extended and in house." In answer to "What effect does the family have on the patient's condition" Assessor #1 documented, "Pt reported that it was determined 3 months [ago] by wife that they would be married on paper only."

c. The "Chemical Dependency Assessment [CDA]" of the "Comprehensive/Psychological Assessment Tool - Part 2 (Inpatient/PHP/IOP Admissions)" revealed Assessor #1 documented:

Question #1- "No" the patient did not have a current substance abuse diagnosis. The section for the "Physician who diagnosed the patient" was left blank.
There was no documentation the facility obtained the information from Hospital #2 or the patient's primary psychiatrist that would have revealed the patient did have a current substance abuse diagnosis.

Question #2- "Yes" the patient was willing to come off of all addictive substances. In answer to "What is the patient's motivation to seek treatment today?" the patient reported, "Just want peace, I want peace again."

Question #3- "Yes" in answer to "According to the patient, is substance abuse a major part of the problem?"

Question #4- "Yes" in answer to "Is the patient free of psychosis or cognitive deficits and thus appropriate for a high functioning unit such as West [inpatient unit] or TRP [Total Recovery Program]?"

Question #5 a. - "How often do you have a drink containing alcohol?" with an answer of "4 or more times a week" scoring 4 points.

Question 5 b. - "How many drinks containing alcohol do you have on a typical day when you are drinking?" with an answer of "10 or more" scoring 4 points.
Question #5 c. - "How often do you have six or more drinks on one occasion?" with an answer of "Daily or almost daily" scoring 4 points. A "Total Score" of 12 was obtained based on Question #5.

The CDA section contained questions requiring a "Total Score" and revealed, "The score is based on a scale of 0-12...In men, a score of 4 or more is considered positive for identifying hazardous drinking or active alcohol use...IF ALL ANSWERS TO QUESTIONS 1, 2, 3, AND 4 ARE YES, PATIENT SHOULD BE ADMITTED TO THE TOTAL RECOVERY PROGRAM."

d. Assessor #1 documented, "...Pt denies SI [suicidal ideation], HI [homicidal ideation], psychosis and withdrawal. Pt has bipolar and is very depressed and anxious..." The assessor documented the patient's symptoms, "do not meet criteria for emergent medical condition" and reviewed with the physician via telephone on 2/14/17 at 2:59 PM.

Assessor #1 documented the "Provisional Diagnosis" of Bipolar/Depressed-Severe and Alcohol use Disorder-Severe.

Review of the "RECOMMENDATIONS FOR SERVICES/REFUSALS OF TREATMENT" form dated 2/14/17 revealed Patient #1 was referred back to his previous Psychiatrist (Physician #4, his primary outpatient psychiatrist) and to AA meetings.
There was no documentation the patient was informed of an urgency level at which to see his psychiatrist.
There was no documentation the intake assessment information was referred to his Psychiatrist.
There was no documentation the patient's concern that his insurance did not cover inpatient treatment and no documentation the staff addressed that concern.
There was no documentation a physician examined or assessed the patient.
The patient was discharged home with his wife on 2/14/17 at 2:39 PM without any treatment.

4. Review of the Police Report dated 2/19/17 at 3:55 AM revealed police were on the scene at the home of Patient #1. The report revealed that the patient and his wife were deceased.

In an interview on 3/29/18 at 10:15 AM in the Homicide Police conference room, the Homicide Sergeant verified Patient #1 and his wife were found deceased on 2/19/17. The Sergeant stated Patient #1 shot his wife several times, killing her and then turned the gun on himself, killing himself.

5. In an interview on 3/28/18 at 10:20 AM in the conference room, RN #1 verified she performed the nursing part of the intake assessment for Patient #1. RN #1 stated the patient had come from his Orthopedic follow up appointment and was having problems with alcohol abuse. RN #1 stated it was her understanding that Patient #1 had detoxed at Hospital #2 (2/6/17 - 2/10/17), but had been drinking again, and was asking for pain medications. RN #1 stated that Patient #1 went to the Administration building upon arrival to Hospital #1's grounds, instead of the Assessment building. The patient and his wife got into a verbal altercation and the facility van came to take the patient to the Assessment building. There were tense emotions between the patient and his wife. RN #1 stated Patient #1 was rambling and angry. RN #1 stated the patient was angry that his insurance didn't provide better insurance and would not cover inpatient treatment. The patient's wife made statements that she was angry towards the patient about his behavior at home and that his drinking was ruining their home life. RN #1 stated nobody said why he wasn't admitted, but assumed it was because he didn't want a big bill, that's what he said.

In an interview on 3/28/18 at 11:04 AM in the conference room Assessor #1 (Master of Arts in Sociology) verified she performed the intake assessment for Patient #1. Assessor #1 stated the wife said she felt co-dependent. Assessor #1 stated after she completed her assessment, she called Physician #1 via phone and informed him that Patient #1 had detoxed in Hospital #2. Assessor #1 stated she was not told until after the patient left, that a Code Yellow had been called for Patient #1 and that his wife was afraid of him. Assessor #1 was asked, If she had been aware of the verbal altercation at the Administration building and that the wife was afraid of him, would she have assessed the patient differently. Assessor #1 stated, "I would have specifically asked the wife more questions if I had been made aware of the code situation and the wife voicing she was afraid of him."

In a telephone interview on 3/28/18 at 2:32 PM Physician #2 (Patient #1's Primary Care Physician) stated he was notified by Physician #3 (Patient #1's Orthopedist) that Patient #1 had been to Physician #3's office that morning and needed a behavioral hospital referral to Hospital #1 for alcohol treatment. The physician stated a referral was called in to Hospital #1 by his nurse.

In a telephone interview on 3/28/18 at 6:15 PM Physician #3 (Patient #1's Orthopedist) verified that he had seen Patient #1 in his office on 2/14/17. Physician #3 stated the patient was withdrawing from alcohol, was having marital problems with his wife and sleeping in separate areas of their home. Physician #3 stated after looking at the patient's situation, he notified Physician #2 (Patient #1's Primary Care Physician) of his concerns and the need for a referral to a behavioral hospital facility.

An interview was conducted with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Manager on 3/29/18 at 12:20 PM regarding the Code Yellow called for Patient #1 on 2/14/17. The CEO stated there was no documentation of the Code Yellow and could not recall who was present for the code. The CNO stated Patient #1's "wife came in asking for directions [to the assessment area], she [wife] was visibly upset. [Name of Patient #1] was getting loud...She [Patient #1's wife] didn't want to get in the car with him [Patient #1]...We called a Code yellow..."

In a telephone interview on 3/29/18 4:35 PM Physician #1 (The on call psychiatrist at Hospital #1) verified that he was notified via telephone by Assessor #1 of the 2/14/17 assessment information of Patient #1. Physician #1 stated he was informed that Patient #1 had detoxed from alcohol at Hospital #2, had no Suicidal or Homicidal Ideations and did not want to be hospitalized. Physician #1 stated the patient did not meet involuntary admission criteria. Physician #1 was asked if he had been informed about his behavior when the Code Yellow was called or that his wife was afraid of him. Physician #1 stated, "I was not told."

In a telephone interview on 4/2/18 at 10:06 AM Physician #4 (Patient #1's outpatient Psychiatrist) stated the last time she had seen Patient #1 was 1/26/17. The physician stated the patient had a substance abuse problem with alcohol and needed a detox program.

In an interview of 4/2/18 at 12:45 PM in the conference room the Director of Admissions stated the nurse and assessor conduct the intake assessment and then it is called via phone to the physician for the physician's approval.

In an interview on 4/2/18 at 2:18 PM in the conference room the CEO stated the discharge papers that were sent home with Patient #1 would be the "Recommendations for Service/Refusal of Treatment" form. The CEO stated the top "Recommendations" section of the form is completed when "we don't think the patient meets inpatient qualifications and send this recommendation with the patient." The CEO stated the bottom section titled "Inpatient Treatment Refusal" is completed "If they refuse" inpatient treatment. The CEO stated refusal of inpatient treatment was not applicable for Patient #1, since he was not recommended for inpatient admission.

Based on medical record review and interview, the facility failed to ensure all patients' needs were met and all patient assessments were accurate.

The findings included:

1. Nursing services failed to ensure accurate patient assessments were documented.
Refer to A397

2. Nursing services failed to ensure all orders for drugs were timed and dated.
Refer to A397

Based on policy review, medical record review and interview, the Registered Nurse (RN) failed to ensure all patients' needs were met and assessments were accurate for 3 of 20 (Patient #3, 5 and 19) sampled patients.

The findings included:

1. Review of the facility's "Intake and Output" policy revealed, "An accurate account of fluid balance will be obtained and recorded when indicated to maintain homeostasis for the patient...All fluids given to the patient are recorded by time, type and amount of fluid ingested...Total both intake and output at the end of each shift...The intake and output for a 24-hour shift will be totaled and documented..."

2. Medical record review revealed Patient #3 was admitted to the hospital on 6/6/17 with diagnoses of Dementia with Delusions, Behavior Disturbance, and Hypertension. Patient #3 was sent to the Emergency Room on 6/20/17 at 8:08 PM and did not return to the hospital.

Review of the vital sign flow record and meal intake sheet for 6/21/17 revealed facility staff documented that Patient #3 ate 100% of breakfast and lunch. The patient's temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation are documented at 8:00 AM and 12:00 PM on 6/21/17. His weight was recorded at 8:00 AM.

In an interview on 3/28/18 at 9:40 AM, in the conference room, the Chief Nursing Officer verified that Patient #3 was not a patient in the hospital on 6/21/17 when the information was documented.

3. Medical record review revealed Patient #5 was admitted to Hospital #1 on 1/3/18 with the diagnoses of Bipolar Disorder, Diabetes, Hypertension and Urinary Tract Infections. The patient's admission weight was 165 pounds.

Review of the 1/4/18 laboratory (lab) results revealed the patient had an elevated Blood Urea Nitrogen (BUN) level of 32 milligrams per deciliter (mg/dl) (normal level 8-23) and an elevated Creatinine level of 1.53 mg/dl (normal level 0.6-1.3), placing the patient at risk for Dehydration and Acute Kidney Injury

Review of the physician's orders dated 1/5/18 revealed an order for strict intake and output related to the elevated BUN and Creatinine levels.

There was no documentation an assessment was performed to identify an adequate fluid intake for Patient #5 to potentially prevent the elevated labs, Dehydration and Acute Kidney Injury.

Review of the 24 hour Intake/Output Forms revealed the following:
1/6/18- The intake was documented to be 720 cc (cubic centimeters) (3 cups of liquid). There was no output documented.
1/7/18- There was no documentation of the patient's intake/output.
1/8/18- The intake was documented to be 1200 cc.
1/9/18- The intake was documented to be 1200 cc. There was no output documented.

Review of the 1/10/18 nursing noted revealed the patient had been transferred to Hospital #3 and admitted with "...Acute Kidney Injury."

4. Medical record review revealed Patient #19 arrived to the facility's Intake Assessment area via Sheriff's Department on 1/2/18 at 7:27 AM.

Review of the Medical Screening Form dated 1/2/18 at 8:15 AM revealed RN #1 administered Haldol 5 milligrams (mg) and Ativan 2 mg IM (intramuscular) to Patient #19.

Record review of the inpatient medical record revealed an order dated 1/2/18 for Haldol 5 mg and Ativan 2 mg. There was no documentation of a time the medication order was received.