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Based on review of Medical Staff Rules and Regulations, credentialing file, medical records, interviews with staff, physician and vendor, and job description review, the facility's leadership failed to ensure a contract agreement with defined responsibilities was in place for a contract vendor (Scribe #3) who was authenticating discharge summaries for 3 of 26 sampled records. (#10, #11, and #25).

The findings include:

Review on 02/11/2021 of the facility's "2019 Medical Staff Rules and Regulations" revealed "...5.8 Discharge Documentation: 5.8.1 Except in cases of administrative discharge, patients shall be discharged only on a written order of the attending Member....5.8.3 At the time of discharge, the attending Member shall complete the discharge according to the approved guidelines, state final diagnoses and sign the record. 5.8.4 The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient's condition on discharge...."

Review on 02/11/2021 of Scribe #3's credentialing file revealed no active Family Nurse Practitioner (FNP) license. Review revealed an FNP license for Scribe #3 lapsed in 2017. The facility did not provide a current or active Family Nurse Practitioner license for Scribe #3. Review of the file revealed no current appointment to the medical staff and no privileges granted.

Interview on 02/11/2021 at 1730 with the Director of Quality #9 revealed Scribe #3 was no longer an active medical staff member and had no privileges at the facility. Interview revealed Scribe #3 was not an employee of the facility. Interview further revealed that Scribe #3 worked with MD #4 reviewing the physician's discharge summaries. Interview revealed there was no active contract or agreement in place with Scribe #3 to perform these services at the facility. Interview revealed Scribe #3 had previously worked at the facility as a Nurse Practitioner and had let her license lapse. Interview revealed Scribe #3 had not been employed or had privileges at the facility since 2017.

1. Review on 02/11/2021 of Patient #10's discharge summary dated 02/01/2021 revealed "Psychiatric and Medical Diagnoses: 1. Schizoaffective disorder, bipolar type, nonpsychotic, severe. 2. Autistic spectrum disorder. 3. Gastroesophageal reflux disease. 4. Hypothyroidism. 5. Allergy: Penicillin, Pertussis vaccine, sulfa drugs." Review revealed the discharge summary contained an electronic signature by Scribe #3 with a title of FNP following the signature dated 02/01/2021 at 11:32:01 AM.

Interview on 02/11/2021 at 1415 with MD #4 revealed Scribe #3 had worked for MD #4 for a while. Interview revealed Scribe #3 transcribed the patient's discharge summaries.

Telephone interview on 02/11/2021 at 1740 with Scribe #3 revealed Scribe #3's job was to "read and review" the discharge summaries. Interview revealed Scribe #3 was the "Authenticator" of the discharge summaries.

2. Review on 02/11/2021 of Patient #11's discharge summary dated 10/09/2020 revealed "Psychiatric and Medical Diagnoses: 1. Schizophrenia, chronic, paranoid, severe. 2. Hypertension. 3. No known drug allergy...." Review revealed the discharge summary contained an electronic signature by Scribe #3 with a title of FNP dated 10/09/2020 at 08:02:46.

Interview on 02/11/2021 at 1415 with MD #4 revealed Scribe #3 had worked for MD #4 for a while. Interview revealed Scribe #3 transcribed the patient's discharge summaries.

Telephone interview on 02/11/2021 at 1740 with Scribe #3 revealed Scribe #3's job was to "read and review" the discharge summaries. Interview revealed Scribe #3 was the "Authenticator" of the discharge summaries.

3. Review on 02/11/2021 of Patient #25's discharge summary dated 10/04/2020 revealed "Psychiatric and Medical Diagnoses: 1. Schizoaffective disorder, bipolar type, manic, severe. 2. Allergy: No Known Drug allergy." Review revealed the discharge summary contained an electronic signature by Scribe #3 with a title of FNP following the signature dated 10/04/2020 at 2:22:27 PM.

Interview on 02/11/2021 at 1415 with MD #4 revealed Scribe #3 had worked for MD #4 for a while. Interview revealed Scribe #3 transcribed the patient's discharge summaries.

Telephone interview on 02/11/2021 at 1740 with scribe #3 revealed Scribe #3's job was to "read and review" the discharge summaries. Interview revealed Scribe #3 was the "Authenticator" of the discharge summaries.

Interview on 02/11/2021 at 1830 with the Chief Executive Officer (CEO) revealed Scribe #3 worked with MD #4 reviewing and authenticating discharge summaries. Interview revealed the scribe was not an employee of the facility and was not a member of the medical staff. Interview revealed no contract or agreement was in place until just prior to the conversation on 02/11/2021 with the surveyor when a verbal agreement was obtained with Scribe #3.

Review of the verbal agreement obtained via telephone on 02/11/2021 with Scribe #3 revealed, a Job Description Form with a revision date of 02/21, that documented "Contract Employee Name (Scribe #3), Position Title: Scribe, and Reports to Psychiatrist. Position Summary: To assist the clinical business and administrative functions related to the medical practice both in the hospital and office of the Psychiatrist employing the Scribe."

In summary, Scribe #3 was actively reviewing and signing discharge summaries as completing the discharge summary and the scribe had no active membership to the medical staff, no privileges, and was not employed by the facility. Review revealed no description of the scribe's duties, responsibilities or qualifications was in place when Scribe #3 was reviewing and signing discharge summaries at the facility.

Based on facility policy and procedure review, observation, medical record review, and staff interviews, the facility staff failed to ensure that translator services were provided for a Spanish speaking patient in 1 of 1 Spanish speaking patients observed (Patient #17).

The findings include:

Review on 02/11/2021 of the hospital policy titled, "Language, Speech and Hearing Impaired Services" revised on 01/15/2021 revealed, "Foreign language speaking or hearing impaired patient and their companions will have equal access to all prescribed treatment services during hospitalization at (Hospital Name) ... Procedure ... 2. Interpreter services will be requested within 60 minutes of the arrival of patients who speak a foreign language or are hearing impaired ..."

Observation during unit tour on 02/10/2021 at 1500 revealed a male patient (Patient #17) sitting in a wheelchair beside the nurse's station. Observation revealed Patient #17 was speaking in Spanish. Observation revealed the Registered Nurse (RN) was in the room behind the nurse's station and Mental Health Technician (MHT) #15 was sitting at the nurse's station with a clipboard.

Review on 02/11/2021 of the open medical record for Patient #17 revealed a 51-year-old male that presented to the facility as an IVC (involuntarily commitment) on 02/10/2021 at 1128 for "Schizophrenia with psychosis (mental illness where the person cannot tell what is real and what is not)." Review revealed Patient #17 was admitted to the inpatient unit on 02/10/2021 at 1430. Review of the Nurse's note dated 02/10/2021 at 1500 revealed " ... Patient refuses to speak English, he speaks Spanish + (and) answers in Spanish ..." Medical record review revealed Patient #17 was placed in a physical hold on 02/10/2021 at 1842 and released at 1940 (58 minutes in the physical hold). Review of the "Post Intervention Face to Face Evaluation" dated 02/10/2021 at 1842 revealed "Per RN (Name) translates - Pt (patient) delusional." Review revealed the physical hold was for Patient #17 "trying to attack staff and going behind nurses station". Review of Physician orders dated 02/10/2021 at 1940 revealed an order for "Seclusion/Restraint Order ADULT Initial Order Physicial Restraints (sic) (Holds) Danger to Self/Self Injurious Behavior ... Comments: PT (Patient) IS Spanish SPEAKING. PT SHOWING AGGRESSION WHEN STAFF APPROACHES HIM TO CHECK ON HIM. PT IS IN PSYCHOSIS-YELLING OUT SPEAKING Spanish ..." Review of the "RN Seclusion & (and) Restraint Note" dated 02/10/2021 at 2358 revealed "Patient psychotic (not in touch with reality) ... Spanish speaking (sic) unable to communicate pain or discomfort"

Interview on 02/10/2021 at 1545 with MHT #15 revealed Patient #17 arrived on the unit at 1430 sitting in a wheelchair. Interview revealed Patient #17 was "Spanish speaking." Interview revealed MHT #15 was there to assist the RN with the patient search and skin assessment. Interview revealed Patient #17 could not go into his assigned patient room until the patient search and skin assessment was performed. Interview revealed MHT #15 did not request a Spanish interpreter during the 75 minutes Patient #17 had been on the unit.

Interview on 02/11/2021 at 1119 with RN #13 revealed she had received admission information on Patient #17 prior to his arrival. Interview revealed RN #13 was working in the admission area when Patient #17 arrived. Interview revealed RN #13 was told in report that Patient #17 spoke English fluently. Interview revealed RN #13 had not seen or talked to Patient #17.

Interview on 02/11/2021 at 1150 with RN #14 revealed she was the RN assigned to the admission unit when Patient #17 was brought in. Interview revealed Patient #17 "would not speak or do anything" while in the admission unit. Interview revealed RN #14 did not hear Patient #17 speak. Interview revealed RN #14 revealed she normally would have called a Spanish speaking interpreter.

Interview on 02/11/2021 at 1642 with Admission Director #8 revealed the staff should have called a Spanish interpreter for Patient #17. Interview revealed Patient #17 responded to questions with the word "No".

In summary, Patient #17 arrived to the facility on 02/10/2021 at 1128 and was admitted to the unit on 02/10/2021 at 1430. The first documentation of a unit nurse translating was on 02/10/2021 at 1842 during a restraint hold. This was 7 hours and 14 minutes after arrival to the facility. The first documentation of the facility translator translating for the patient was on 02/11/2021 at 0730 (20 hours and 2 minutes after arrival to facility).

Based on review of policy, medical records, incident report log, and interviews with staff, the facility failed to ensure tracking of patient safety events by failing to document, investigate and complete an incident report for 1 of 1 record with a discharge in error (#11) and 1 of 2 records with a medication error (#4).

The findings include:

Review of policy titled "Occurrence Reporting" with revision date of 01/20, revealed "Policy: The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers or has direct knowledge of an occurrence. Occurrences are defined as any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability. Purpose: The Healthcare Peer Review Report is a risk management tool that notifies the hospital of potential areas of loss. It enables the hospital to take corrective action, reducing the losses and improving the quality of healthcare provided in the hospital....3. An HPR Report should be filed for any occurrence including, but not limited to: ...c. An undesirable event occurs which appears inconsistent with normal patient care. d. A significant potential violation of established policy and procedure occurs. e. An unusual event occurs which does or may result in personal and/or bodily injury. f. An event occurs which, by standards, appears unexpected and/or unintended (i.e., medication error, medical emergency) ....r. Any other significant issue which is not consistent with expected patient care operations...."

1. Review of Patient #11's Discharge summary dated 10/12/2020 at 0818 revealed Patient #11 was admitted on 05/20/2020 for "Schizophrenia, chronic, paranoid, severe". Review revealed Patient #11 was discharged on 09/16/2020. Review revealed Patient #11 was readmitted on 09/16/2020 then discharged on 09/29/2020. Review of the discharge summary (in Patient #11's medical record,) written by MD #5 dated 10/03/2020 at 2013 revealed "This is a 50-year-old white male with several medical conditions and schizophrenia, came back very quickly after the discharge."

Interview on 02/11/2021 at 1100 with CCO (Chief Clinical Officer) revealed Patient #11 left the facility at 1320 on 09/16/2020 via cab to arrive at a Group Home approximately 3 hours away. Interview revealed Patient #11 arrived at the Group Home with the owner realizing Patient #11 was not the resident whom the Group Home owner had received papers and had agreed to accept prior to Patient #11's arrival. Interview revealed Patient #11 was transported back to the facility and arrived at approximately 2345 on 09/16/2020 (10 hours and 23 minutes after the patient departed). Interview revealed Patient #11 had not been discharged by the physician and was transported to the Group Home in error.

Review of the incident report log revealed no incident report for Patient #11 regarding an error in discharge on 09/16/2020.

Interview on 02/11/2021 at 1310 with Director of Quality revealed an incident report was not completed. Interview revealed the staff was instructed to complete the incident report, but an incident report was never completed. Interview revealed the policy was not followed. Interview revealed an incident report should have been completed. Interview revealed the purpose of the incident report is to identify and track opportunities for improvement. The interview added without the incident report, there is no ability to track the incidents.

2. Review of Patient #4's discharge summary dated 09/22/2020 revealed Patient #4 was admitted on 09/06/2020 at 0344 for Major depressive disorder, Post traumatic stress disorder, and Diabetes. Review of handwritten admission orders dated 09/06/2020 at 0400 revealed "Levemir (long acting insulin) 5 (units) HS (bedtime), 1st dose now, 5 units Novolog AC (rapid acting insulin before meals) with meals, Type 1 sliding scale AC and HS (Order set for insulin dependent diabetics). Review revealed the admission telephone orders were written by RN #12 and received from MD #11. Review of the MAR (medication administration record) dated 09/06/2020 through 09/07/2020 revealed Patient #4 received insulin using the incorrect order set on 09/06/2020 at 1120, 1723, and 2306. Review revealed Patient #4 received insulin using the incorrect order set on 09/07/2020 at 0824 and 1315.

Interview on 02/10/2021 at 1245 with MD #11 revealed Patient #4 should have been on Type 1 Diabetic Insulin order set. Interview revealed Patient #4's orders were written for the routine insulin orders instead of Type 1 Diabetic insulin orders. Interview revealed the medication transcription error caused Patient #4 to receive less insulin than she should have received, which could have been the cause of her uncontrolled glucose results.

Interview on 02/11/2021 at 1400 with RN #12 revealed Patient #4's insulin order set was incorrectly clicked on the computer on admission. Interview revealed no incident report was completed after the incident was discovered by the physician.

Interview on 02/11/2021 at 1310 with Director of Quality #1 revealed an email was sent to the director of Admissions to complete an incident report. Interview revealed an incident report was not done. Interview revealed the director of Admissions is no longer employed. Interview revealed an incident report should have been written. Interview revealed the purpose of the incident report is to identify and track opportunities for improvement. Adding without the incident report, there is no ability to track the incidents.

Based on review of policy, medical records, and interviews with staff, the facility failed to follow physician's orders in 1 of 1 diabetics patients receiving insulin. (Patient #4).

The findings include:

Review of the policy titled "Medication Administration" with a revision date of 07/2020, revealed "PROCEDURE: All verbal/telephone orders require verbal read-back to the physician. 1. Telephone orders are documented in the medical record via HCS (electronic medical records) using the following format: Example: Date/Time: Acetaminophen 650 mg po (by mouth) q (every) 6 hrs (hours) PRN (as needed) for Headache *TORB (telephone order read back)/physician name/RN or LPN signature and title. *Make certain that the nurse types the order into HCS before reading it back. 2. Orders to be e-signed in the medical record via HCS by the physician. The order will be e-signed within 48 hours...."

Review of Patient #4's discharge summary dated 09/22/2020 revealed Patient #4 was admitted on 09/06/2020 at 0344 for Major depressive disorder, Post traumatic stress disorder, and Diabetes. Review of the handwritten admission orders dated 09/06/2020 at 0400 revealed "Levemir (long acting insulin) 5 (units) HS (bedtime), 1st dose now, 5 units Novolog AC (rapid acting insulin before meals) with meals, Type 1 sliding scale AC and HS (Order set for insulin dependent diabetics). Review revealed the admission telephone orders were written by RN #12 and received from MD #11. Review of insulin admission orders in the computer system dated 09/06/2020 at 0322 revealed "Notes: Low Dose sliding Scale: for Blood Glucose. < 70--initiate hypoglycemia Protocol, call MD. 70-130 Give 0 units. 131-180 Give 2 units. 181-240 Give 4 units. 241-300 Give 6 units. 301-350 Give 8 units. 351-400 Give 10 units, Call MD. > 400 Give 12 units, call MD. **Notify MD if BS (blood sugar) > 350. **Call MD if BS 70-180 for 48 hours possibly to discontinue sliding scale. **Call MD if BS >180 for 24 hours possibly to change diabetic management." Review of MD #11's orders dated 09/07/2020 at 1133 revealed MD #11 discontinued previous insulin orders. Review revealed MD #11 ordered the correct "Type 1 DM Sliding Scale orders" on 09/07/2020 at 1132 and were written as follows: "Type 1 DM sliding Scale: For Blood Glucose. <70 Initiate hypoglycemia protocol. 70-120: 0 units. 121-125: 1 units. 126-150: 2 units. 151-175: 3 units. 176-200: 4 units. 201-225: 5 units. 226-250: 6 units. 251-275: 7 units. 276-300: 8 units. 301-325: 9 units, call MD. 326-350: 10 units, call MD. 351-375: 11 units, call MD. 376-400: 12 units, call MD. 401-425: 13 units, call MD ** Notify MD if BS >250 and cover q 2 hours until BS <250."

Review of the MAR (Medication Administration Record) dated 09/06/2020 revealed Patient #4 received 10 units of Novolog insulin for the 364 blood sugar at 1120; 6 units at 1723 for blood sugar of 267; and 8 units of insulin for blood sugar of 301 at 2306. Review of the MAR dated 09/06/2020 through 09/07/2020 revealed Patient #4 received insulin using the incorrect order set on 09/06/2020 at 1120, 1723, and 2306. Review revealed Patient #4 received insulin using the incorrect order set on 09/07/2020 at 0824 and 1315. Review of MAR revealed the correct Type 1 Diabetic orders were written on 09/07/2020 at 1132, 31 hours and 32 minutes after the incorrect orders were written.

Interview on 02/11/2021 at 1400 with RN #12 revealed Patient #4's insulin order set was incorrectly clicked on the computer on admission. Interview revealed the correct order set was not placed in the computer for Patient #4 on admission. Interview revealed the order set entered on 09/06/2020 at 0400 required less insulin than the Type 1 Diabetic insulin orders.

Interview on 02/10/2021 at 1245 with MD #11 revealed Patient #4 should have been on Type 1 Diabetic Insulin order set. Interview revealed Patient #4's orders were written for the routine insulin orders instead of Type 1 Diabetic insulin orders. Interview revealed the error caused Patient #4 to receive less insulin than she should have received, causing her glucoses to go up and she was not as controlled. Interview revealed the correct order set requires the nurse to call the physician for elevated blood sugars adding that the RN did not notify the physician using the incorrect order set. Interview revealed Patient #4 was not on the correct order set.

Based on review of policy, Medical Staff Rules and Regulations, medical record, and interviews with staff, the facility failed to have a complete and accurate medical record by failing to document a discharge note for 1 of 1 patient discharged in error. (Patient #11).

The findings include:

Review of policy titled "Documentation Requirements in the Medical Record" with revision date of 12/18, revealed "Policy: All (named facility) staff shall adhere to established standards for documentation in the medical record. Purpose: To ensure continuity of care, optimal communication among clinical providers, and accuracy of the documentation of assessment and treatment of each patient. Procedure: The attending physician is responsible for a complete and legible medical record for each patient. Its content shall be pertinent and current, contain adequate documentation of medical events and conform to established standards of the Medical Record ..."

Interview on 02/11/2021 at 1100 with CCO (Chief Clinical Officer) revealed Patient #11 departed the facility at 1320 on 09/16/2020 via cab to arrive at a Group Home approximately 3 hours away. Interview revealed Patient #11 arrived at the Group Home with the owner realizing Patient #11 was not the resident whom the Group Home owner had received papers and had agreed to accept prior to Patient #11's arrival. Interview revealed Patient #11 was transported back to the facility and arrived at approximately 2345 on 09/16/2020 (10 hours and 25 minutes after departure).

Review of Patient #11's closed medical record revealed a 50 year-old male who was admitted on 05/20/2020 with chronic Schizophrenia and severe paranoia. Review of a discharge summary written by MD #2 dated 10/03/2020 written at 2013 (09/16/2020 readmission) revealed "This is a 50-year-old white male with several medical conditions and schizophrenia, came back very quickly after the discharge." Review revealed Patient #11 had two admissions with the first admission on 05/20/2020 and discharge on 09/16/2020. Patient #11 was readmitted on 09/16/2020 then discharged on 09/29/2020. Review of the discharge summaries revealed no documentation of Patient #11 leaving the facility by error and arriving at the Group Home by mistake. Review revealed no documentation of a reason Patient #11 returned to facility on 09/16/2020, same day of discharge. Review of the complete, legal medical record revealed no documentation that Patient #11 was transported out of the facility in error.

Interview on 02/11/2021 at 1415 with MD #1 revealed Patient #11 had been on his service prior to his discharge on 09/16/2020. Interview revealed MD #1 was not made aware of the discharge error on 09/16/2020 for Patient #11 until 02/11/2021. Interview revealed there was no documentation in the medical record of the discharge error for Patient #11 on 09/16/2020.

Interview on 02/11/2021 at 1310 with the Director of Quality revealed there was no documentation in the discharge summaries of the discharge error for Patient #11 on 09/16/2020. Interview revealed Patient #11 returned under the service of another physician and MD #1 should have been made aware of the error with discharging Patient #11. Interview revealed the patient was transported from the facility in error and was away from the facility for about 10 hours and 25 minutes. Interview revealed the physicians should have written a note describing the incident and reason for the return admission. Interview revealed the medical chart was not complete and accurate.

Based on facility policy and procedure review, facility document review, and staff interview the facility staff failed to ensure staff and visitors entering the facility received a complete COVID-19 screening on 17 of 50 sampled log entries.

The findings include:

Review on 02/09/2021 of facility policy "COVID-19 Management" last reviewed on 11/24/2020 revealed "Policy: It is the policy of (named hospital) to provide a safe environment for both patients and staff related to COVID-19..." Procedure: 1. Everyone entering the facility will receive a COVID-19 screening which will include a questionnaire and body temperature check..."

Review on 02/11/2021 of the "COVID Screening - Daily Employee and Visitor Sign in Log" dated 02/10/2021 for the screening location "Admissions" revealed a total of 50 (fifty) staff/ visitors names and signatures. Review of the log revealed 2 (two) of the entries did not have temperatures and questionnaires completed, 4 (four) entries did not have the temperatures completed and 11(eleven) entries did not have the questionnaires completed. Review revealed total incomplete entries for the COVID-19 screening process was 17 (seventeen) for the 50 (fifty) people who presented at the admissions screening location on 02/10/2021.

Interview on 02/09/2021 at 1445 with Admission Director #8 revealed the current process has been in place since February 2, 2021. Interview revealed prior to February 2, 2021 all persons would complete a screening form with all components of the screening process (temperature and screening questions). Interview revealed the process changed to the log form to help speed up the screening process for employees and visitors. Interview revealed the form is currently competed for patients and the log for visitors and employees.

Interview on 02/11/2021 at 0950 with Screener #1 revealed she screens all persons prior to entering the facilty. Interview revealed the screening includes taking a temperature and having persons read the screening questions. Interview revealed upon completion of the screening, the persons screened "checks off" the appropriate places on the log. Interview revealed she is responsible for ensuring the log is complete.

Interview on 02/11/2021 at 1015 with Screener #2 revealed she is responsible for ensuring the log is complete.

Interview on 02/11/2021 at 1430 with IC Nurse #7 (Infection Control Nurse) revealed there is more education that needs to be done regarding completing the log.

NC00172268; NC00172229; NC00172765; NC00172662; NC00173538; NC00168890; NC00172388; NC00168295; NC00172076; NC00168354; NC00170775; NC00170873; NC00170236