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Based on policy review, document review and interview, the Governing Body failed to assume responsibility and provide oversight to ensure qualified staff provided examinations.

The findings included:

The governing body failed to ensure licensed and credentialed professional practitioners conducted evaluations to determine if an emergency psychiatric condition existed.

Refer to A 045

Based on policy review, medical record review, personnel file review, and interview, the governing body failed to ensure licensed and credentialed professional practitioners conducted evaluations to determine if an emergency psychiatric condition existed for 2 of 3 (Patient #1 and 2) sampled patients.

The findings included:

1. Review of the facility medical staff rules and regulations "Exhibit A" revealed, " ...Qualified Medical Persons ...The following are recognized as Qualified Medical Persons: Physicians, Nurse Practitioners, Registered Nurses, and Physician Assistants."

2. Review of the facility "ADMISSION PROCEDURE (Intake)" policy revealed, " ...Any person who presents requesting a psychiatric service assessment will be assessed. The assessment will be completed by a Registered Nurse (RN) or Mental Health Professional identified as qualified medical professionals (QMP's)...Upon arrival, individuals to be assessed will be asked for a form of identification and insurance cards...MEDICAL SCREENING ...When a patient arrives at the facility and request an examination or treatment of a medical or psychiatric condition, a Medical Screening will be completed without delay to determine whether an emergency medical condition exist...If the nurse determines an emergency medical condition exists, staff will follow the EMTALA [Emergency Medical Treatment and Labor Act] compliance procedures ...If the patient has no emergent medical condition then the patient will continue with the QMP to complete the intake assessment ..."

3. Review of the facility "EMTALA" policy revealed, " ...Any person who presents to the Hospital will be evaluated to determine whether the person has an emergency medical condition ...Psychiatric Emergency ...'Danger to self'...'Danger to others'...Examples ...Depression with feelings of suicidal hopelessness ...History of recent suicide attempt or suicidal ideation ...Medical Screening Examinations ...[named facility] maintains an on-call list of physicians who are responsible to perform medical screening evaluations to determine whether an individual has an emergency medical condition ...In the absence of a physician, a registered nurse who has demonstrated competency may conduct medical screening examinations ..."

4. 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).

5. Medical record review revealed Patient #1 was a 42 year old who presented to the hospital's Intake Assessment Department on 3/21/18 at 2:06 PM with the precipitating crisis/chief complaint of " ...Pt [patient] present extremely tearful reporting feelings of hopelessness and helplessness. Pt denies SI [suicidal ideations] currently but recently expressed wishing she was dead. Pt is not able to contract for safety. Pt spouse is fearful of what pt may do to herself due to pt explosive anger and uncontrolled behavior ...Pt reports self-medicating with alcohol and sometimes 'bingeing' daily ..."

Review of the "Suicide Risk Assessment" (SRA) revealed Assessor #1 (Master of Science in Human Services) scored Patient #1 as a 3 (High) for Ideations, "pt reports wishing she was dead."

Assessor #1 failed to document if Patient #1's suicidal ideations were fleeting, periodic or constant and if her ideations were increasing in severity, urgency, or frequency.

Assessor #1 determined Patient #1's overall Suicidal Risk Assessment score to be 40 which was a medium risk level.

Assessor #1 documented that Patient #1 was currently seeing a Psychiatrist on an outpatient basis and had inpatient treatment at another hospital in 2003 for a suicide attempt.

Assessor #1 documented that Patient #1 was currently prescribed Cymbalta 60 mg (milligrams) daily and Xanax 1 mg four times per day. Assessor #1 documented that Patient #1 was compliant with taking her medications as ordered.

Review of the Alcohol Use Screening revealed Assessor #1 failed to document the following answers for Patient #1:
Does this patient sometimes drink beer, wine, or alcohol?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking?
How often during the last year have you had a feeling of guilt or remorse after drinking?

Assessor #1 failed to document a Total Score for the Alcohol Use Screening for Patient #1.

Assessor #1 documented that withdrawal symptoms were N/A (non-applicable).

Assessor #1 failed to document Patient #1's History of Tobacco Use/Exposure to Tobacco.

Assessor #1 failed to document Patient #1's Mental Status Examination including the following:
Appearance.
Hygiene.
Eye Contact.
Posture.
Motor Behavior.
Speech.
Affect.
Mood.
Cognition/Thought Content/Thought Process.

Review of the "Level of Care Recommendations" revealed Assessor #1 contacted Physician #1 on 3/21/18 at 2:47 PM. Assessor #1 documented Major Depressive Disorder Severe without Psychosis and Alcohol Dependence, Uncomplicated as Patient #1's diagnoses. Acute Inpatient treatment was recommended due to "Potential danger to self or others."

There was no documentation a physician assessed, examined, treated, or diagnosed Patient #1 in the Intake Department.

In an interview on 4/25/18 at 2:31 PM, in the meeting room, Assessor #1 verified after completing the Intake Assessment and making diagnoses based on the assessment, she called Physician #1 and gave him the information on Patient #1 and the physician recommended inpatient treatment. Assessor #1 verified that she failed to complete sections of the intake assessment under the SRA, Alcohol Use Screening, History of Tobacco Use/Exposure to Tobacco, and Patient #1's Mental Status Examination..

6. Medical record review revealed Patient #2 was a 25 year old who presented to the hospital's Intake Assessment Department on 4/24/18 at 4:55 AM with the precipitating crisis/chief complaint of " ...Pt sleeping, eating, racing thoughts, paranoid behaviors ...been depressed ...Using crystal meth, Xanax, and alcohol, heroin to cope ...feeling hopeless and not living at times ...blacking out, experiencing psychosis drug induced, Paranoid ..."

Assessor #2 (Master of Social Work) determined Patient #2's overall Suicidal Risk Assessment score to be 52 which was a high risk level.

There was no documentation Assessor #2 notified the Nurse Supervisor or the Practitioner of Patient #2's SRA high risk level.

Review of the "Level of Care Recommendations" revealed Assessor #2 contacted Physician #2 on 4/24/18 at 5:35 AM. Assessor #2 documented Opioid Abuse with Opioid Induced Psychotic Disorder as Patient #2's diagnoses.

There are no treatment recommendations or outpatient referrals identified by Assessor #2.

There was no documentation a physician assessed, examined, treated, or diagnosed Patient #1 in the Intake Department.

Review of a physician order dated 4/24/18 at 8:00 AM revealed Patient #2 was admitted to Inpatient treatment with a diagnosis of Opioid Abuse with Opioid Induced Psychotic Disorder.

7. In an interview on 4/25/18 beginning at 10:30 AM, the Director of Intake verified after the Assessor's complete the Intake Assessment, they call the physician and review the case with them. The Director revealed the physician may ask more questions and then will make recommendations for treatment.

When asked about the SRA, the Director of Intake revealed the Assessor must notify the Charge Nurse or House Supervisor and the Physician when a patient had a medium, high, or severe level score.

Based on policy review, record review, and interview, the hospital failed to ensure patients received care in a safe setting to protect their emotional health for 1 of 3 (Patient #1) sampled patients.

The findings included:

Review of "Patient Rights" revealed, "Patients have the right to be treated with consideration, respect and full recognition of their dignity and individuality ..."

Medical record review revealed Patient #1 was a 42 year old who presented to the hospital's Intake Assessment Department on 3/21/18 at 2:06 PM and was admitted for Inpatient treatment. There was no documentation of personal items such as clothing in Patient #1's medical record.

In a telephone interview on 4/25/18 at 1:07 PM, Patient #1 stated, " ...I went in there with 3 bottles of medications and I only came out with 2 ...my husband is my witness ...I wasn't given my clothing and hygiene items until the next afternoon after I was admitted ...I had to sleep in my clothes and didn't have a toothbrush ...when I got my things some of my clothes were missing ..."

In an interview on 4/30/18 at 3:35 PM, in the meeting room, the Risk Manager verified that Patient #1 did not have a personal item log in her record.

Based on medical record review and interview, the facility failed to ensure medical record entries were complete for 1 of 3 (Patient #1) sampled patients.

The findings included:

Medical record review revealed Patient #1 was a 42 year old who presented to the hospital's Intake Assessment Department on 3/21/18 at 2:06 PM with the precipitating crisis/chief complaint of " ...Pt [patient] present extremely tearful reporting feelings of hopelessness and helplessness. Patient #1 was admitted for Inpatient treatment.

Review of the "Suicide Risk Assessment" (SRA) revealed Assessor #1 documented, "pt reports wishing she was dead."

Assessor #1 failed to document if Patient #1's suicidal ideations were fleeting, periodic or constant and if her ideations were increasing in severity, urgency, or frequency.

Review of the Alcohol Use Screening revealed Assessor #1 failed to document the following answers for Patient #1:
Does this patient sometimes drink beer, wine, or alcohol?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking?
How often during the last year have you had a feeling of guilt or remorse after drinking?

Assessor #1 failed to document a Total Score for the Alcohol Use Screening for Patient #1.

Assessor #1 failed to document Patient #1's History of Tobacco Use/Exposure to Tobacco.

Assessor #1 failed to document Patient #1's Mental Status Examination including the following:
Appearance.
Hygiene.
Eye Contact.
Posture.
Motor Behavior.
Speech.
Affect.
Mood.
Cognition/Thought Content/Thought Process.

In an interview on 4/25/18 at 2:31 PM, in the meeting room, Assessor #1 verified she failed to complete sections of the intake assessment under the SRA, Alcohol Use Screening, History of Tobacco Use/Exposure to Tobacco, and Patient #1's Mental Status Examination.

Review of a "DISCHARGE AGAINST MEDICAL ADVICE" form signed by Patient #1 on 3/24/18 at 7:45 AM revealed the form was not signed by a nurse..

Review of a "PRACTITIONER ORDER SHEET" revealed "Date Order Written: 1/24/18 ...ORDER Call for 2nd opinion for AMA [Against Medical Advice] discharge ..." The order was dated 1/24/18 by RN #1 and Physician #1.

In an interview on 4/30/18 at 3:30 PM, in the meeting room, RN #1 was asked if Patient #1 gave her the AMA form dated 3/24/18 at 7:45 AM. RN #1 stated, "Yes. It was my oversight I didn't sign it." RN #1 verified that the physician's order for the 2nd opinion for AMA discharge should have been dated 3/24/18.