HospitalInspections.org

Based on record review and interview, the facility failed to ensure the medical record for 1 (P-1) of 4 psychiatric patients reviewed for clinical certification for mental health care, contained documentation of the examination conducted by the signer of the clinical certification, resulting in an incomplete medication record. Findings include:

A clinical certification form was filled out and signed by Staff GG on 9/23/25 at 1919. No corresponding documentation was found in the record regarding the details of Staff GG's examination of P-1.

On 10/21/25, at 1430 a phone interview with Staff GG revealed that he completed the certification on 9/23/25, and that he was not the initial provider to see P-1. Staff GG stated he received a handoff from the prior shift and worked the next day. Staff GG stated the typical process in the ED for a psychiatric evaluation includes medical clearance first, followed by a social work evaluation and petition, if criteria met, the physician certification is done. He did not remember if he made a medical record entry for P-1 regarding his psychiatric exam and completing the certification.

On 10/22/25 at 1117, an interview with Staff X revealed that it was his expectation that a medical record note be entered after a clinical certification is completed.

On 10/22/25, review of the policy titled, "Treatment and Services, Formal Voluntary and Involuntary Admission Process" dated 8/18/25 revealed, "Clinical Certificate ...the written conclusion of a physician ...that an individual is a person requiring treatment, together with the information and opinions, in reasonable detail, that underlie the conclusion ...A petition must be completed by a person who has personally observed and/or seen evidence of behaviors or action(s) documenting the patients need for further psychiatric evaluation and treatment ...Any individual 18 years of age or over may file a petition ...Two clinical certificates are required. They must be completed by a ...physician ...".