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Based on record review, document review, interview, and policy review the facility failed to ensure (1) nursing staff reported the patients change of condition to the physician, (2) nursing care provided by nursing staff was adequately supervised, (3) nursing staff performed assessment and reassessments of the patients nursing care needs, and (4) revisions were made to the nursing plan of care based on changes in condition. The cumulative effects of these deficient practices places patients at risk of serious illness and/or death.

On 12/02/21 at 2:15 PM, the Chief Executive Officer (CEO) was notified that an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of patients in its care at risk for serious injury, serious harm, serious impairment, or death) was identified related to 42 CFR 482.23, requirements for the condition of participation of Nursing Services. The IJ was determined to first exist when it was identified that the facility failed to ensure nursing staff was supervised and able to identify a change in patient condition for P1. Nursing staff failed to assess, reassess and notify the physician of P1's change in condition. These failures resulted in the death of P1.

The facility provided an acceptable plan for removal of the IJ and on 12/06/21 at 3:20 PM, that included the following:

1. Educate all staff on Edmonson Fall Tool, Interventions, and Fall Policy. Completed December 5th, 2021.

2. Signs indicating moderate and high fall risks have been placed outside of patient door to alert staff. Staffing assignment sheet has been updated to reflect the fall level for immediate recognition along with the sign. Completed December 3rd, 2021.

3. Nursing board updated with small magnetic pins also for easy recognition of fall precaution level. Colors are assigned to moderate and high fall risks. The aides are included in the shift report where a review of the daily staffing assignment sheet with the color code that matches the sign outside of the individual patient door. Interventions for each level of fall risk are posted on the nursing board. The nurse will review the interventions for the patients with the nurse while reviewing the orders in the EHR. Completed December 5th, 2021.

4. Educated Aides on Fall Risks and Interventions, making sure patients are easily identified by wrist bands. Aides given the responsibility to replace missing wrist band daily and replacing any signs that may fall or be torn down by patients. Completed December 3rd, 2021.

5. Daily 24 hour falls review and tracking in QAPI with Nursing Leadership and CEO to review all falls and provide immediate remediation and updates to policies for staff. To Begin December 6, 2021, and review over 90 days until reached 85% reduction in falls.

6. Educate the nurses and aides beginning today December 6, 2021 on documented on Fall Care plans along with the interventions utilized for every patient. They will document whether the patient has met, not met or partially met the goal. If the patient has partially met or not met goal the nurses will discuss with Nursing leadership and the MDT team what other interventions need to be added (or removed) to prevent the patient from falling. This will be completed prior to the next shift for all staff working.

7. Educate all Professional Nurses on updated Physician Notification Policy attached and updated clinical parameters, these values were obtained from the Hospitalist prior to updating the policy (values from vital signs that need to be called to the physician to be approved through special session MEC December 6th, 2021) to be completed upon the next shift staff is assigned to work. Prior to their next scheduled shift. Completed December 6,2021.

8. Charge Nurses will be trained to be a point person for each shift, additional support provided by Nursing leadership during the day, and an on-call schedule will be posted in the nursing resource book for after hours and weekends. (Completed December 6th, 2021).

9. Educate Nurses on review lab results, note with reviewed by(nurse) date and initial, for all labs outside of normal limits call the physician and note in the narrative. To be completed by December 10,2021.

10. Education will be provided on change in patient condition (attached) of when to notify the physician and will be posted in nurse's station in resource book on neon paper for easy recognition. The hospital will also post on desktop and laptops for easy reference when charting. Staff will be educated prior to their next shift.

11. The CEO or Nurse designee will audit the charts daily for the following: Critical labs called to physician and noted in chart; Fall score and interventions match and signs posted; Notification of physician for VS outside of parameters with notes in narratives of the discussion; and RN assessment of patient in a 24-hour period and over the next 90 days until charts are 100% compliant with COP. This will begin 12/03/2021.

12. Each of the issues identified will be reported in the next MEC, QAPI and Governing Board Meetings. Each issue will be tracked in QAPI for compliance.

The hospital's plan of removal was validated by the surveyor on 12/06/21 at 3:45 PM, prior to survey exit.

In addition to implementing this plan of removal, the facility was instructed to report any falls, adverse events, transfers to ED or higher level of care through the Kansas Department of Health and Environment complaint hotline.


Findings Include:


1. The hospital failed to ensure nursing staff reported changes in a patient's condition to the physician for two patients (P1 and P3) transferred for emergency services of a total of 14 records reviewed; 2. failed to ensure nursing care provided to patients followed policies and procedures to assess, reassess, evaluate, and perform interventions for 11 patient (Patient (P)2, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) falls with five of those patients (P2, P11, P12, P13, and P14) that suffered bone fractures; and 3. failed to ensure the Director of Nursing (DON) supervised the provision of nursing care or oriented new nursing staff. The medical records failed to show evidence nursing staff assessed the patient as directed per policy following a change of condition, failed to notify the physician of changes in the patient's conditions, and failed to implement interventions to prevent falls. (Refer to A0385)

2. The hospital failed to develop a Multidisciplinary Treatment Plan (MTP)/Nursing Care Plan based on the individual's needs, problems identified, along with interventions and measurable goals for nine (Patients (P) 1, P2, P4, P5, P6, P7, P8, P9, P10) fourteen medical records reviewed. Failure to individualize the patients' MTPs leads to needs not being identified and addressed which can delay the patients' recovery and extend the length of hospitalization. (Refer to A0396)

3. The hospital failed to ensure nursing staff administered medications as order by the physician and failed to ensure nursing staff notified the physician that medications were not administered for one Patient (P3) of 14 records reviewed. (Refer to A0405)

Based on document review, record review, observation, interview, and policy review the hospital 1. failed to ensure nursing staff reported changes in a patient's condition to the physician for two patients (P1 and P3) transferred for emergency services of a total of 14 records reviewed; 2. failed to ensure nursing care provided to patients followed policies and procedures to assess, reassess, evaluate, and perform interventions for 11 patient (Patient (P)2, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) falls with five of those patients (P2, P11, P12, P13, and P14) that suffered bone fractures; and 3. failed to ensure the Director of Nursing (DON) supervised the provision of nursing care or oriented new nursing staff. Failure of the nursing staff to consistently oversee the care and safety of patients places all patients at risk of injury, harm, or death.

Findings Include:

1. Review of the policy titled, "Physician Notification of Change of Patient Condition," revised 10/2020, indicated " ...The patient's physician is notified by telephone immediately of any adverse changes in the patient's condition. Verbal communication is the only acceptable form of this type of crucial communication ...Licenses Nurse will immediately notify the patient's physician of any significant change in the patient's condition including, but not limited to: change in level of consciousness ...significant changes in vital signs ...excessive pain ...increased agitation and aggressive behavior." The policy did not contain instruction about notifying the physician when a patient falls.
Review of the facility policy titled, "Assessment and Reassessment," revised 10/2020, showed a Registered Nurse (RN) will complete an assessment once every 24 hours.

Review of the facility policy titled, "Blood Glucose Monitoring Parameters," revised 10/2020, showed for any significant hyper/hypoglycemic blood glucose levels, the physician will be notified, after interventions to control blood glucose levels per policy have been completed. When the blood sugar is at a level the physician has indicated to be notified at, licensed nurse will notify the physician appropriately and document all findings, assessment and actions taken.


Patient 1

Review of P1's "Psychiatric Evaluation" found under the history and physical (H&P)/Discharge (DC) tab dated 10/06/21, showed P1 was 71-year-old with a diagnosis (DX) of major depressive order with psychosis admitted on 10/04/21.

Review of P1's "Lab Results" found under the labs tab, specifically the complete blood count (CBC), dated 10/06/21 at 2:30 AM, showed P1's white blood count (WBC) was elevated at 13.5 (normal 4.8 -10.8 - a high WBC count usually indicates an increased production of white blood cells to fight an infection).
Review of the "Hospitalist Progress Note" found under the physician progress notes tab, dated 10/08/21 at 10:30 AM, showed the physician was aware and documented P1's WBC was 13.5. Continued review of the hospitalist progress notes and physician orders failed to show the physician ordered another CBC lab to recheck P1's WBC count. The physician orders and progress notes also failed to show evidence that a urinalysis (a test of the urine used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes) had been ordered or performed.

Review of the "Nursing Admission Assessment Behavioral Health" found under the nursing assessments tab dated 10/04/21 at 3:01 PM, showed P1 was ambulatory, independent with activities of daily living (ADL's) absent of pain, absent of bilateral lower extremity (BLE) edema, urine noted to be clear, skin absent of bruises and abrasions, and was oriented to person, place, and month.

Review of the "Edmonson Psychiatric Fall Risk Assessment" found under the nurse's notes tab, showed daily assessments of fall risk from 10/04/21 through 10/14/21 with a fall risk score of 91, indicating P1 was a moderate risk for falls. On 10/15/21 and 10/16/21 P1's fall risk score increased to 101, and on 10/17/21 and 10/18/21 P1's fall risk score increased to 111. A fall risk score 100 or greater indicated P1 was a high risk for falls.

Review of the "Behavior Mapping 12 Hour Shift" documentation found in the nurses notes tab from 10/04/21 through 10/18/21, failed to show rounds were performed every 10 minutes, as required for a moderate and high fall risk score.

Review of the "Nursing Shift Assessments" found under the nursing assessments tab dated 10/10/21, showed P1 had scattered bruises on the lower right back. On 10/11/21, P1 was noted to have additional bruises on the right upper arm and was now noted to be incontinent of urine. On 10/12/21 at 7:00 PM, P1 was noted to have bilateral lower extremity (BLE) 1+ pitting (grading system is often used to determine the severity of the edema on a scale from +1 to +4) pedal (feet or lower legs) edema (buildup of fluid), urine output was not assessed, and was noted to now have an additional abrasion to the left elbow and a bruise to the right flank area. On 10/13/21 at 5:00 PM, P1 was noted to now have BLE 2+ pitting edema and no skin abrasions or bruises were noted by the Registered Nurse (RN). P1 was noted to still be incontinent of urine. On 10/13/21 at 7:00 PM, the RN again noted BLE edema was present, the urine not assessed, and a right flank bruise noted to be the size of a half dollar, along with a left elbow abrasion that was scabbed over. On 10/14/21 at 9:00 AM, the RN noted P1's urine was dark, nonpitting BLE edema, and a large bruise on right lower back. On 10/14/21 at 7:45 PM the RN noted P1 was still incontinent, bruise on right lower back, and BLE edema present. On 10/15/21 at 8:00 AM the RN showed no assessment of edema was performed and the skin assessment failed to show bruises or abrasions were present. On 10/15/21 at 6:30 PM the RN noted there was 2+pitting edema to the BLE's, patient incontinent urine and the skin assessment failed to show the presence of bruises and abrasions. On 10/16/21 8:00 AM the RN assessment showed P1's heart rate (HR) was 109 (tachycardia is a heart rate over 100 beats per minute), BLE 2 + pitting edema, and healing bruise right lower back. The assessment showed P1 was now no longer ambulatory and in a wheelchair (WC). On 10/16/21 at 6:30 PM, the RN noted P1 was incontinent of urine, had two + BLE pitting edema with no skin assessment. On 10/17/21 at 8:00 AM, the RN assessment showed P1's HR was 113, BLE 3 + pitting edema, a healing bruise on back and was a total assist with all care that day. On 10/17/21 at 6:20 PM, the RN assessment showed continued tachycardia with a HR of 108. P1 was noted to be uncooperative with skin assessment, BLE 2 + plus pitting edema, incontinent of urine, with no assessment of urine color, and still in non-ambulatory in a WC. On 10/18/21 at 8:00 AM, the RN failed to assess P1's BLE edema, urine color, or skin. P1 was still incontinent of urine and in a WC. On 10/18/21 at 5:00 PM the RN failed to assess the BLE edema or P1's skin, P1 was still urine incontinent and non-ambulatory in a WC. On 10/18/21 at 6:30 PM, the RN noted P1's respiratory rate (RR) was 22 per minute (normal respiration rates for an adult range from 12 to 16 breaths per minute) and an oxygen saturation (Sat) 90% (normal level of oxygen is usually 95% or higher). P1 was noted to have lower abdominal pain 6 on 10 scale, diminished appetite, lethargy, BLE 2 + pitting edema, skin assessment was noted as normal and the patient was oliguric (absent of urine) and holding abdomen.

Review of P1's "Nursing Notes" found under the nursing notes tab, dated 10/15/21 at 6:00 PM showed P1 was placing self on the floor from the WC. The RN noted reduced strength in lower limbs and was essentially non-weight bearing, confused and disoriented.

The medical record failed to show nursing notified the physician of P1's changes in condition and decline in function, first documented on 10/10/21. The medical record failed to show the physician was notified of P1's bruises, abrasions, decline of ambulatory function requiring a WC, incontinence, changes in VS's, specifically tachycardia and low O2 Sat, abdominal pain, decreased urine output with dark color, or of the BLE 3 + pitting edema.

Review of P1's "Nursing Notes" found under the nursing notes tab, dated 10/18/21 at 6:00 PM showed P1 was confused, with less urine output, appetite was decreased, total assist with all activities of daily living (ADL's), HR regular/irregular 120's, RR 22 and was clutching low abdomen often. On 10/19/21 at 12:30 AM the RN note showed P1 had a change in physical status with shivering, rapid respirations, and pursed lips. Lips and nails were pink with some delay in capillary refill, skin cool and dry to touch, continued to shiver. P1's HR was 119, RR 28-32, O2 Sat 80-82%. The note showed the RN made the physician aware and orders were received on 10/19/21 at 12:45 to call emergency medical services (EMS) for transportation to the hospital.

The medical record failed to show the physician was notified of the RN's assessment that showed a significant change in P1's condition on 10/18/21 at 6:00 PM, until 6 hours and 30 minutes after the findings.


During an interview on 11/30/21 at 8:25 AM with the Chief Executive Officer (CEO), stated that Hospital B had called the nurse to let her know P1 had expired due to urosepsis and that there was no documentation of this report in the medical record. The CEO confirmed that the medical record should have included the hospital report that the RN had received.

During this interview the CEO confirmed the medical record failed to show nursing notified the physician of P1's changes in condition and decline, confirmed the physician was not made aware of the RN's assessment on 10/18/21 at 6:00 PM that showed a significant change in P1's condition, until 6 hours and 30 minutes after the findings. The CEO also confirmed the physician was not aware of P1's bruises, abrasions, decline of ambulatory function requiring a WC, incontinence, changes in VS's, specifically tachycardia and low O2 Sat, abdominal pain, decreased urine output with dark color, or of the BLE 3 + pitting edema.


Patient 3

Review of P3's "Psychiatric Evaluation" found under the H&P tab dated 09/07/21 showed P3 was admitted with a past medical history (PMHX) of Parkinson's disease, Type 2 diabetes and a current DXs of paranoid (great fear) delusions (false beliefs), schizophrenia, and anxiety.

Review of the "Nursing Shift Assessments" found under the nursing assessments tab, showed P3's shift assessments were performed by a Licensed Practical Nurse (LPN) on 09/10/21 and 09/11/21. P3 medical record did not include a nursing shift assessment completed by a Registered Nurse (RN) on 09/10/21 or 09/11/21, in accordance with hospital policy that directs the RN to complete an assessment once every 24 hours, despite an RN supervisor working on both shifts.

Review of the "Nursing Notes" found under the nursing notes tab, dated 09/10/21 at 6:00 PM, showed P3 was noted to be sweating profusely. At 6:30 PM P3's blood sugar (BS) was noted to be 58 milligrams per deciliter (mg/dL) (According to the American Diabetes Association a normal blood glucose levels for adults are 70-99 mg/dL). P3 "was given several protein rich snacks and a Pepsi at the request of the patient." P3's BS was not rechecked again until 10:00 PM, 3.5 hours after the low blood sugar was first identified. On 09/11/21 at 12:00 AM, the nursing note showed P3 was sleeping in the commons area and at 12:15 AM documentation showed P3 became stuporous and non-responsive to painful stimuli, with drooling and limp extremities. P3's pupils were noted to be fully dilated. Staff documented making several attempts to wake the patient, but the patient remained nonverbal and unresponsive. P3's blood sugar was rechecked and documented to be 342 mg/dL. Documentation showed nursing failed to notify the physician of the initial hypoglycemic (low blood sugar) episode after interventions to control the blood glucose had been completed. Nursing staff notified the physician on 09/11/21 at 12:19 AM, 5 hours 11 minutes after the required notification time of P3's symptoms of low blood sugar. The physician ordered P3 to be transferred to the hospital by emergency medical services (EMS).

A review of P3's "Medication Administration Record" (MAR), found under the medications tab, from admission on 09/07/21 through 09/11/21 showed nursing failed to administer the following physician ordered medications:

09/08/21 - Norvasc (used to treat high blood pressure) 10 milligrams (mg), Cogentin (used to treat Parkinson's disease) .15 mg, Clozaril (used as a sedative) 200 mg, Haloperidol (antipsychotic) 10 mg, Lantus (used to treat high blood sugar) 10 units, Flomax (used to improve urination) 0.4 mg, Cozaar (used to treat high blood pressure) 50 mg, Novolog (used to treat high blood sugar) 8 units at 2:00 PM and Novolog 8 units at 8:00 PM, Trileptal (used to treat seizures) 600 mg at 8:00 AM.

09/09/21 - Norvasc 10 mg, Clozaril 200 mg, Cozaar 50 mg, Flomax 0.4 mg, Novolog 8 units at 2:00 PM and Novolog 8 units at 8:00 PM, Trileptal 600 mg at 8:00 PM.

09/10/21 - Synthroid (thyroid supplement) 175 mcg, Cozaar 50 mg, Glucophage (used to treat high blood sugar) 1000 mg, Metoprolol ER (used to treat high blood pressure) 25 mg, Trileptal 600 mg at 8:00 AM.

There was no documented evidence to show nursing notified the physician of medications that were not administered; the initial hypoglycemic (low blood sugar) episode after interventions to control the blood glucose had been completed and did not notify the physician until 09/11/21 at 12:19 AM, 5 hours 11 minutes after P3's symptoms of low blood sugar when the physician ordered P3 to be transferred to the hospital by emergency medical services (EMS).

Review of "Hospital B's H&P" found under the other documentation tab dated 09/11/21 at 8:02 AM, showed "a 70 year old male who was brought to the emergency room (ER) from his facility for altered mental status (AMS), ...in the ER he was hypertensive (high blood pressure) and tachycardic (fast heart rate), ...and acute toxic metabolic encephalopathy (an acute mental status alteration) suspected primarily due to medication induced with underlying psychiatric component, ...accelerated hypertension likely due to agitation and missed medications."

During an interview with the CEO on 12/01/21 at 12:51 PM, the CEO confirmed the LPN and RN failed to notify the physician P3's change in condition, low blood sugar, or medications that were not administered on 09/08/21, 09/09/21 and 09/10/21. The CEO also stated the regulations require an RN to assess the patient once every 24 hours. The CEO confirmed P3 did not receive a nursing shift assessment by an RN on 09/10/21 and 09/11/21.


2. Review of the policy titled, "Fall Prevention Protocol," revised 08/2020, indicated all hospital patients will be assessed to minimize their risk of falling ...1. All inpatients will be assessed for fall risk using the ...Edmonson Psychiatric Fall Risk Assessment ...upon admission ...every shift ...2. Edmonson Psychiatric Fall Risk Assessment ...a. Scoring i. Low Risk: 0-74 ii. Moderate Risk: 75-100 iii. High Risk: 101 and above ...Low Fall Risk Interventions ...15-minute rounding, yellow arm band/yellow socks ...Moderate Fall Risk Intervention in addition to the Low Fall Risk Interventions listed above include the following ...Identify Fall Risk on Care Plan ...Limit use of PRN medications ...High Fall Risk Interventions, in addition to the Low/Moderate Fall Risk Interventions listed above, the following are also included; 1:1 observation (by physician order), round every 10 minutes ...Post Fall Follow Up ...Review fall risk precautions and add additional precautions if indicated. Care plan updated as indicated ...Reporting patient fall must be reported through the standard incident reporting process and submitted to the Director of Nursing."

Review of the facility Falls Risk Interventions Protocol showed patients with a fall score of 0-74 are consider low fall risk, patients with a fall risk score of 75-99 are considered a moderate fall risk, and patients with a fall risk score of 100 or greater are considered a high fall risk. Patients ...with a moderate and high fall risk score, showed the following interventions: apply falls risk arm band, place red metallic marker on nurse board in nursing station, a falls risk sticker on the medical record and round every 10 minutes.

During an interview with the Chief Executive Officer (CEO) on 11/29/21 at 8:45 AM, the CEO provided the surveyor with a list of 16 patients that had been transferred to the hospital from 03/16/21 through 10/04/21. The CEO stated he/she knew that five (P2, P11, P12, P13, and P14) of the 16 patients on the list had suffered a fall with FX. The CEO stated that the facility had 15 additional falls in the month of November but was unable to provide the outcomes of 14 of the falls when requested by the surveyor.

During an interview on 11/29/21 at 4:35 PM, the Risk Manager (RM), after reviewing the 17 incident reports that were found in a stack on the floor in the Director of Nursing (DON's) office, discovered that 15 of 17 incident reports in the month of November 2021 were falls. The RM was unable to provide the outcomes related to the falls.

During an interview on 11/30/21 at 4:30 PM, the RM stated a falls log had been created that included the 15 patient falls. Five (P2, P11, P12, P13, P14) of the 15 patient falls occurred prior to November 2021 and resulted in those patients suffering bone FX's. Three of the patient falls occurred in April 2021, one in May 2021, and one in June 2021. The RM stated the five medical records failed to show 10-minute rounding had been performed per policy and failed to identify if fall interventions were in place which would have included a yellow falls risk arm band, yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record.


Patient 2

Review of P2's "Psychiatric Evaluation" found under the history and physical H&P / DC tab dated 06/10/21 showed a 71-year-old admitted with a DX of schizophrenia (a mental health condition) versus schizoaffective disorder bipolar type (a mental health condition), and dementia (memory loss) with behavioral disturbances.

Review of P2's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 76 on 06/25/21 and 98 on 06/26/21. P2 was a moderate fall risk.

Review of the "Behavior Mapping 12 Hour Shift" documentation showed that no 10-minute rounding performed as required for a moderate and high fall risk score.

A review of the facility patient hospital transfer log, created and provided to the surveyor on 11/30/21, showed P2 was transferred to the hospital on 06/26/21. The reason for the transfer was not listed on the log.

A review of Hospital B's diagnostic radiology report found under the others tab dated 06/26/21 at 3:10 PM, showed P2 suffered a fracture (FX) of the right ankle.

A review of the facility incident tracking log, created and provided to the surveyor on 11/30/21, failed to show there were any fall intervention in place prior to P2's fall. The log confirmed P2 suffered a right ankle fracture (FX).

During an interview on 11/29/21 at 3:50 PM with the CEO, the CEO confirmed the findings on the transfer log, incident tracking log, and in the medical record of P2. The CEO confirmed P2 suffered a right ankle FX. The CEO confirmed the nurses failed to put into place fall risk prevention interventions required for the fall score of (98). Fall risk interventions that should have been in place included a yellow falls risk arm band / yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record.


Patient 5

Review of P5's "Psychiatric Evaluation" found under the H&P/DC tab, dated 11/25/21 at 9:00 AM, showed P5 was admitted on 11/23/21 with a medical history (HX) of dementia and a current DX of generalized anxiety disorder, major depressive disorder with psychotic features, and a delusional disorder.

Review of P5's "Edmonson Psychiatric Fall Risk Assessment" found under the nurse's notes tab, showed a fall risk score of 87 on 11/29/21 and 95 on 11/30/21 which indicated P5 had a moderate fall risk score.

Observation of P5 in the patient commons area, during a tour on 11/30/21 at 2:15 PM, revealed P5 failed to have the required fall interventions in place that included a yellow falls risk arm band/yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record. These observations were confirmed by the RM at the time of the tour.


Patient 6

Review of P6's "Psychiatric Evaluation" found under the H&P/DC tab dated 11/24/21 at 1:00 PM failed to show a completed psychiatric evaluation had been performed.

Review of the "Medical Consultation Note" found under the consultations tab dated 11/23/21 at 1:01 PM, showed P6 was admitted on 11/23/21 with auditory and visual hallucinations causing paranoia and delusions.

Review of P6's "Edmonson Psychiatric Fall Risk Assessment" found under the nurse's notes tab, showed a fall risk score of 82 on 11/29/21 and 86 on 11/30/21 which indicated P6 had a moderate fall risk score.

Review of the "Behavior Mapping 12 Hour Shift" documentation showed that no 10-minute rounding performed as required for a moderate and high fall risk score.

Observation of P6 in the patient commons area during a tour on 11/30/21 at 2:15 PM revealed P6 failed to have the required fall interventions in place that included a yellow falls risk arm band/yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record. These observations were confirmed by the RM at the time of the tour.


Patient 7

Review of P7's "Psychiatric Evaluation" found under the H&P / DC tab dated 10/31/21, no time documented, showed P7 was admitted on 10/29/21 with DX of delusional disorder and major depressive disorder with verbal and physical aggression.

Review of the facility November 2021 fall log showed P7 fell on 11/23/21 and 11/26/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

Review of P7's "Edmonson Psychiatric Fall Risk Assessment" found under the nurse's notes tab, showed a fall risk score of 109 on 11/23/21 and 108 on 11/26/21 and 118 on 11/30/21 which indicated P7 had a high fall risk score.

Review of the "Behavior Mapping 12 Hour Shift" documentation showed that no 10-minute rounding performed as required for a moderate and high fall risk score.

Observation of P7 in the patient commons area made during a tour on 11/30/21 at 2:15 PM revealed P7 failed to have the required fall interventions in place after two prior falls that had occurred on 11/23/21 and 11/26/21. P7 was observed not to have a yellow falls risk arm band / yellow socks, 10-minute rounding, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record. The RM confirmed these observations at the time of the tour.

During an interview with the unit Mental Health Aide (MHA) on 12/02/21 at 10:00 AM, stated that the only patient that was a fall risk was P7. The MHA confirmed P7 did not have an armband, fall risk sticker or metallic marker on nurse board for being a fall risk. The MHA stated the only way she knows if patients are a fall risk is by asking the nurse each day.


Patient 8

Review of P8's "Psychiatric Evaluation" found under the H&P/DC tab dated 10/07/21, no time, showed P8 was admitted on 10/05/21 with a PMHX of Alzheimer's, and a current DX of depression and anxiety.

Review of P8's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 95 on 11/08/21 and 101 on 11/13/21 which indicated P8 had a high fall risk score.

Review of the facility November 2021 fall log showed P8 fell on 11/08/21 and 11/13/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

During an interview on 12/02/21 at 11:50 AM, P8's medical records findings were confirmed with the RM. The RM confirmed there was no documentation in the medical record that showed fall precautions were in place.


Patient 9

Review of P9's "Psychiatric Evaluation" found under the H&P / DC tab dated 11/18/21 at 10:27 AM showed P9 was admitted on 10/16/21 with a DX of depression and anxiety.

Review of P9's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 109 on 11/25/21, 121 on 11/26/21, and 114 on 11/30/21 which indicated P8 had a high fall risk score.

Review of the facility November 2021 fall log showed P9 fell on 11/25/21 and 11/26/21 The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

Observation of P9 on 11/30/21 at 2:15 PM while touring the patient commons area, showed P9 failed to have any of the required fall interventions in place per the fall risk intervention protocol, which included a yellow falls risk arm band/yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record. These findings were confirmed by the RM at the time of tour.


Patient 10

Review of P10's "Psychiatric evaluation" found under the H&P/DC tab dated 11/05/21 at 8:00 AM showed a PMHX of dementia. The psychiatric evaluation failed to show a complete exam had been performed and failed to show the final DX's.

Review of P10's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab showed a fall risk score of 75 on 11/08/21, 89 on 11/11/21, and 97 on 11/30/21 which indicated P10 had moderate fall risk score.

Review of the facility November 2021 fall log showed P10 fell on 11/08/21 and 11/13/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

Observation on 11/30/21 at 2:15 PM, during a tour of the patient commons area, P10 failed to have any of the required fall interventions in place per the fall risk intervention protocol, which included a yellow falls risk arm band/yellow socks, red metallic marker on nurse board in nursing station, and a falls risk sticker on the medical record. These findings were confirmed by the RM at the time of tour.


Patient 11

Review of P11's "Psychiatric H&P" found under the H&P/DC tab dated 05/04/21 at 6:08 PM showed P11 had a PMHX of dementia, gait imbalance, and repeated falls. The H&P showed the patient was transferred to the hospital from another facility for calling other residents names, physical violence, and attempting to leave the facility.

Review of P11's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 103 on 05/13/21 and 111 on 05/14/21. P11 had a high fall risk score.

Review of the facility November 2021 fall log showed P11 fell on 05/14/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

During an interview on 11/30/21 at 4:30 PM, the RM confirmed P11 had fallen on 05/14/21 and was transferred to the hospital and subsequently diagnosed with bone FX that was directly related to the fall that had occurred at the facility. The RM confirmed there was no documentation in the medical record that showed fall precautions were in place.


Patient 12

Review of P12's "Psychiatric H&P" found under the H&P/DC Summary tab dated 03/08/21 at 12:13 PM showed P12 had a PMHX of dementia. P12 was transferred to the hospital from home due to increasingly aggressive behavior, agitation, threatening gestures and hitting the caregiver. The physical exam showed the patient had contractures of the upper extremities, arthritic changes of the fingers, a slow gait and general appearance of frailness. The patient was noted to be oriented to self only. The assessment showed P12 had dementia with behavioral disturbances.

Review of P12's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 91 on 04/17/21 and 91 on 04/18/21 which indicated P12 had a moderate fall risk score.

Review of the facility November 2021 fall log showed P12 fell on 04/18/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

During an interview on 11/30/21 at 4:30 PM, the RM confirmed P12 had fallen on 04/18/21 and was transferred to the hospital and subsequently diagnosed with bone FX that was directly related to the fall that had occurred at the facility. The RM confirmed there was no documentation in the medical record that showed fall precautions were in place.


Patient 13

Review of P13's "Psychiatric H&P" found under the H&P / DC tab dated 04/14/21, no time, showed P13 had a PMHX of dementia and current DX of dementia with behaviors.

Review of P13's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 120 on 04/15/21 and 120 on 04/16/21 which indicated P12 had a high fall risk score.

Review of the facility November 2021 fall log showed P13 fell on 04/18/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

During an interview on 11/30/21 at 4:30 PM, the RM confirmed P13 had fallen on 04/18/21 and was transferred to the hospital and subsequently diagnosed with bone FX that was directly related to the fall that had occurred at the facility. The RM confirmed there was no documentation in the medical record that showed fall precautions were in place.


Patient 14

Review of P14's "Psychiatric H&P" found under the H&P/DC summary tab dated 03/16/21, no time, showed P14 had a PMHX of dementia with behavioral disturbances and current DX of dementia with behavioral disturbances and depression.

Review of P14's "Edmonson Psychiatric Fall Risk Assessment" found under the nurses notes tab, showed a fall risk score of 119 on 04/05/21 and 119 on 04/06/21 which indicated P14 had a high fall risk score.

Review of the facility November 2021 fall log showed P14 fell on 04/06/21. The log indicated it was unknown if any fall interventions had been in place and showed required 10-minute rounding had not been performed.

During an interview with the RM on 11/30/21 at 4:30 PM the RM confirmed P14 had fallen on 04/06/21 and was transferred to the hospital and subsequently diagnosed with bone FX that was directly related to the fall that had occurred at the facility. The RM confirmed there was no documentation in the medical record that showed fall precautions were in place.



3. Review of Director of Nursing (DON) job description effective date 02/15/17 showed, "ensure all nursing related staff is effectively trained ...properly hired and oriented ...organizes programs, policies, and procedures that are developed to assess, evaluation and meet the needs to the patients ...ensure all patient are assessed in an effective and timely manner ...collaborate with hospital leaders in developing, implementing, reviewing, revising, and monitoring hospital wide performance improvement activities ...ensure the hospital is sufficiently staffed to provide quality excellence ...implement effective policies and procedures to ensure patient's safety, quality care, and well-being ...the DON is required to effectively, manage, direct, and administer the nursing department in accordance with company policies and procedures, standard nursing practices, and governmental regulations so as to maintain quality of care for all patients." The DON job description under education and experience showed a BSN/RN, Master's degree was preferred. The DON job description was dated 09/20/21 but failed to show the signature of the DON indicating receipt and acknowledgement of the job requirements.

Review of four (RN1, RN2, LPN, MHA) personnel files failed to show an orientation provided by the DON that included physician notification parameters and fall prevention interventions.

Review of the facility orientation document provided to all nursing staff failed to show the DON provided nursing staff orie

Based on record review, policy review, and interview, the hospital failed to develop a Multidisciplinary Treatment Plan (MTP)/Nursing Care Plan based on the individual patient assessment that included interventions and measurable goals for nine of the 14 patients (Patients (P) 1, P2, P4, P5, P6, P7, P8, P9, P10) medical records reviewed. Failure to individualize the patients' MTP has the potential for care needs to not be identified or implemented which can delay the patients' recovery and extend the length of hospitalization for all patients in the facility.

Findings Include:

Review of the facility policy titled, "Multidisciplinary Treatment Plan," revised 10/2020 showed, "1. The Multidisciplinary Treatment Plan (MTP) is derived from the Psychiatric Evaluation and the assessments/diagnostic data collected within 72 hours of admission by the total Multidisciplinary Team. 2. Every patient will have an individualized MTP. This plan will include adequate documentation to justify the diagnosis, treatment and rehab activities ...6. The Initial Treatment Plan will be started upon admission which is the Nursing Care Plan (which is a part of the Master MTP). 7. The MTP includes: a ...Goals must be written as observable, measurable patient behaviors to be achieved ...8. Progress toward care goals will be updated daily by Nursing staff. Other team members will update progress toward care goals at least twice per week. 9. The Multi-disciplinary team will meet at least weekly (or more frequent according to patient need) to evaluate the treatment plan, and status of each goal for the patient. 10. If the goal and its objective(s) must be deferred, the reason for the deferment is documented in the patient's medical record. Deferment of care, treatment of services must be approved by the patient attending licensed independent practitioner, with the rationale for deferment documented ...13 ...c. Objectives are: 2. Expressed in behavioral terms that specify measurable indices in progress."


Patient 1

Review of P1's "Psychiatric Evaluation" found under the history and physical (H&P)/Discharge (DC) tab dated 10/06/21, showed a 71-year-old with a diagnosis (DX) of major depressive order with psychosis.

Review of the Psychiatric H&P found under the H&P/DC tab dated 10/05/21, showed a DX's and assessment plan of "1. Major Depressive Disorder with Psychosis 2. Anxiety 3. Delusions (false beliefs) Disorder."

Review P1's "Multidisciplinary Plan of Care" (POC) found under the multidisciplinary team tab dated 10/04/21 showed a problem list that included infection risk with a target date of 10/18/21 for interventions and modalities. The plan failed to show goals that were written as observable, measurable patient behaviors to be achieved, progress toward care goals, updated daily by nursing staff, or other team member updates toward progress care goals at least twice per week. The Multidisciplinary POC showed the status as deferred on 10/19/21 but failed to show the reason the objective(s) were deferred, or evidence the deferment of care was approved by the patients attending licensed independent practitioner, with the rationale for deferment documented.

Review of the Multidisciplinary Plan of Care (POC) dated 10/08/21 showed a problem list that included anxiety with target date of 10/10/21 for interventions and modalities. The Multidisciplinary POC failed to show goals that were written as observable, measurable patient behaviors to be achieved, progress toward care goals, updated daily by nursing staff, or other team members updates toward progress care goals at least twice per week. The Multidisciplinary POC showed the status as deferred on 10/19/21 but failed to show the reason the objective(s) were deferred, or evidence the deferment of care was approved by the patients attending licensed independent practitioner, with the rationale for deferment documented.

During an interview on 11/30/21 at 8:25 AM, the Chief Executive Officer (CEO) confirmed P1 was emergently transferred to the hospital on 10/18/21 and expired due to urosepsis (sepsis caused by an infection of the urinary tract). The CEO also confirmed P1's Multidisciplinary POC's opened on 10/04/21 and 10/08/21 failed to show goals that were written as observable, measurable patient behaviors to be achieved, progress toward care goals, updated daily by nursing staff, or other team member updates toward progress care goals at least twice per week.


Patient 2

Review of P2's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 08/22/21 showed a DX of paranoid (great fear) delusions and anxiety.

Review of P2's multidisciplinary POC found under the multidisciplinary team tab dated 08/20/21 showed an active problem list of aggression, fall risk moderate, infection risk, chronic pain, and mania. P2's multidisciplinary POC failed to show goals that were written as observable, measurable patient behaviors to be achieved, progress toward care goals, updated daily by nursing staff, or other team members documenting progress toward care goals at least twice per week. The multidisciplinary POC showed the status as deferred on 09/13/21 but failed to show the reason the objective(s) were deferred, or evidence the deferment of care was approved by the patients attending licensed independent practitioner, with the rationale for deferment documented.

During an interview with the Healthcare Information Manager (HIM) on 11/29/21 at 3:10 PM the above medical record findings were confirmed.


Patient 4

Review of P4's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 11/27/21 at 5:35 PM showed a DX of delusional disorder and major depressive disorder with severe psychotic features.

Review of P4's medical record showed P4 did not have a POC.

During an interview on 12/01/21 at 11:45 PM the RM confirmed P4 did not have a multidisciplinary POC.


Patient 5

Review of P5's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 11/25/21 at 9:00 AM showed a DX of generalized anxiety disorder, major depressive disorder with psychotic features, and delusional disorder.

Review of the P5's medical record showed P5 did not have a POC.

During an interview on 12/01/21 at 3:10 PM, the RM confirmed P5 did not have a multidisciplinary POC.


Patient 6

Review of P6's "Medical Consultation Note" found under the consults tab dated 11/24/21 at 1:01 PM showed P6 was admitted for auditory and visual hallucination causing paranoia and delusions, poor interaction, and possible Lewy body dementia.

Review of P6's medical record showed P6 did not have a POC.

During an interview on 12/01/21 at 3:30 PM, the RM confirmed P6 did not have a multidisciplinary POC.


Patient 7

Review of P7's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 10/31/21 showed a DX of delusional disorder, anxiety, major depressive disorder with psychosis.

Review of P7's medical record showed P7 did not have a POC.

During an interview on 12/02/21 at 10:45 AM, the RM confirmed P7 did not have a multidisciplinary POC.


Patient 8

Review of P8's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 10/07/21 showed a DX of depression and anxiety.

Review of P8's medical record showed P8 did not have a POC.

During an interview on 12/02/21 at 11:50 AM, the RM confirmed P8 did not have a multidisciplinary POC.


Patient 9

Review of P9's "Psychiatric Evaluation" found under the H&P/DC Summary tab dated 11/18/21 showed a DX of depression and anxiety.

Review of P9's medical record showed P9 did not have a POC.

During an interview on 12/02/21 at 12:25 PM, the RM confirmed P9 did not have a multidisciplinary POC.


Patient 10

Review of P10's "Psychiatric Evaluation" under the H&P/DC Summary tab dated 11/05/21 at 8:00 AM showed a chief complaint of depression with a history of present illness that included attempted hanging and alcohol issues, and nonsensical speech. The psychiatric evaluation was incomplete and failed to show P10's DX's.

Review of 10's medical record showed P10 did not have a POC.

During an interview on 12/02/21 at 1:05 PM, the RM confirmed P10 did not have a completed multidisciplinary POC.


During an interview on 12/01/21 at 11:45 PM the RM confirmed the above patient medical records did not have a multidisciplinary POC based on the individual's needs, problems identified, along with interventions and measurable goals since the facility switched from paper medical records to electronic medical records (EMR) on November 1, 2021. CEO.

Base on record review, policy review and interview the hospital failed to ensure nursing staff administered medications as order by the physician and failed to ensure nursing staff notified the physician that medications were not administered for one Patient (P3) of 14 records reviewed. Failure to administer medications as ordered has the potential to place patients at risk for uncontrolled blood pressure, blood sugar and deterioration of health conditions.


Findings Include:


Review of a policy titled, "Medication Administration" revised 10/2018, showed, Medications will be administered only upon the order of a physician or authorized mid-level practitioner. Administration will be by clinicians licensed and authorized to do so ... ...Errors in administration of medication will be reported immediately to the attending physician ...


Patient 3

Review of P3's "Psychiatric Evaluation" found under the H&P tab dated 09/07/21 showed P3 was admitted with a past medical history (PMHX) of Parkinson's disease, Type 2 diabetes and a current DXs of paranoid (great fear) delusions (false beliefs), schizophrenia, and anxiety.

A review of P3's "Medication Administration Record" (MAR), found under the medications tab, from admission on 09/07/21 through 09/11/21 showed nursing failed to administer the following physician ordered medications:

09/08/21 - Norvasc (used to treat high blood pressure) 10 milligrams (mg), Cogentin (used to treat Parkinson's disease) .15 mg, Clozaril (used as a sedative) 200 mg, Haloperidol (antipsychotic) 10 mg, Lantus (used to treat high blood sugar) 10 units, Flomax (used to improve urination) 0.4 mg, Cozaar (used to treat high blood pressure) 50 mg, Novolog (used to treat high blood sugar) 8 units at 2:00 PM and Novolog 8 units at 8:00 PM, Trileptal (used to treat seizures) 600 mg at 8:00 AM.

09/09/21 - Norvasc 10 mg, Clozaril 200 mg, Cozaar 50 mg, Flomax 0.4 mg, Novolog 8 units at 2:00 PM and Novolog 8 units at 8:00 PM, Trileptal 600 mg at 8:00 PM.

09/10/21 - Synthroid (thyroid supplement) 175 mcg, Cozaar 50 mg, Glucophage (used to treat high blood sugar) 1000 mg, Metoprolol ER (used to treat high blood pressure) 25 mg, Trileptal 600 mg at 8:00 AM.

Review of the "Nursing Notes" found under the nursing notes tab, dated 09/10/21 at 6:00 PM, showed P3 was noted to be sweating profusely. At 6:30 PM P3's blood sugar (BS) was noted to be 58 milligrams per deciliter (mg/dL) (According to the American Diabetes Association a normal blood glucose levels for adults are 70-99 mg/dL). P3 "was given several protein rich snacks and a Pepsi at the request of the patient." P3's BS was not rechecked again until 10:00 PM, 3.5 hours after the low blood sugar was first identified. On 09/11/21 at 12:00 AM, the nursing note showed P3 was sleeping in the commons area and at 12:15 AM documentation showed P3 became stuporous and non-responsive to painful stimuli, with drooling and limp extremities. P3's pupils were noted to be fully dilated. Staff documented making several attempts to wake the patient, but the patient remained nonverbal and unresponsive. P3's blood sugar was rechecked and documented to be 342 mg/dL.

There was no documented evidence to show nursing notified the physician of medications that were not administered; the initial hypoglycemic (low blood sugar) episode after interventions to control the blood glucose had been completed and did not notify the physician until 09/11/21 at 12:19 AM, 5 hours 11 minutes after P3's symptoms of low blood sugar when the physician ordered P3 to be transferred to the hospital by emergency medical services (EMS).

Review of "Hospital B's H&P" found under the other documentation tab dated 09/11/21 at 8:02 AM, showed, P3, "a 70 year old male who was brought to the emergency room (ER) from his facility for altered mental status (AMS), ...in the ER he was hypertensive (high blood pressure) and tachycardic (fast heart rate), ...and acute toxic metabolic encephalopathy (an acute mental status alteration) suspected primarily due to medication induced with underlying psychiatric component, ...accelerated hypertension likely due to agitation and missed medications."



During an interview with the CEO on 12/01/21 at 12:51 PM, the CEO confirmed the LPN and RN failed to notify the physician P3's change in condition, low blood sugar, or medications that were not administered on 09/08/21, 09/09/21 and 09/10/21. The CEO also stated the regulations require an RN to assess the patient once every 24 hours. The CEO confirmed P3 did not receive a nursing shift assessment by an RN on 09/10/21 and 09/11/21.

Based on record review and interview the hospital failed to ensure a psychiatric evaluation was completed within 60 hours of admission for two of 14 patients (Patient (P) 6, P10) medical records reviewed. This failure had the potential to affect the assessment and psychiatric intervention for all patient admitted with psychiatric symptoms.


Findings Include:


Patient 6

Review of P6's medical record showed an admission date of 11/23/21 at 4:30 PM for auditory and visual hallucination that are causing paranoia and delusions, poor interaction and having visual hallucination, possible Lewy body dementia (memory loss) and not eating well.

Review of P6's "Psychiatric Evaluation" found under the H&P/DC tab in the electronic medical record (EMR) dated 11/24/21 at 1:00 PM showed an incomplete psychiatric evaluation. The Psychiatric Evaluation did not include the Review of Systems, Initial Plan of Treatment/Progress, Diagnosis or Discharge Criteria.

During an interview on 12/01/21 at 3:30 PM, the Risk Manager (RM) confirmed P6 did not have a completed psychiatric evaluation within 60 hours of admission.


Patient 10

Review of P10's "Psychiatric Evaluation" found under the H&P/DC tab in the EMR dated 11/05/21 at 8:00 AM showed an incomplete psychiatric evaluation. dementia. The psychiatric evaluation did not include a diagnosis; Reason for Admission; Chief Complaint; or Past Psychiatric history.

During an interview on 12/02/21 at 1:05 PM the RM confirmed P10 did not have a completed psychiatric evaluation within 60 hours of admission as required by the regulations.

During an interview with the CEO on 11/30/21 at 4:00 PM, the CEO stated that the psychiatric evaluation document that had the required regulatory information may not have carried over to the new EMR system that was put into place 11/01/21.

Based on medical record review and interview the hospital failed to ensure the psychiatric evaluation included a history of present illness, onset, precipitating factors, and results of any treatment received for three of 14 patients (Patient (P) 4, P5, P9) medical records reviewed. This had the potential to affect the assessment and care planning for all patients admitted to the facility.

Findings Include:

Patient 4

Review of P4's "Psychiatric Evaluation" found under the H&P/DC (History & Physical/Discharge) Summary tab dated 11/27/21 at 5:35 PM showed paranoid delusions with physical and verbal aggression was the reason for admission but failed to show the history of present illness, including, precipitating factors, and results of any prior treatment received.
During an interview on 12/01/21 at 11:45 PM the Risk Manager (RM) confirmed the above medical record findings.


Patient 5

Review of P5's "Psychiatric Evaluation" found under the H&P/DC tab dated 11/25/21 at 9:00 AM, showed P5 was admitted on 11/23/21 with a medical history (HX) of dementia and a current diagnosis (DX) of generalized anxiety disorder, delusional disorder, and a major depressive disorder with psychotic features. The psychiatric evaluation failed to show the history of present illness, including onset, precipitating factors and results of any treatment received.
During an interview on 12/01/21 at 3:10 PM the RM confirmed the above medical records findings.


Patient 9

Review of P9's "Psychiatric Evaluation" found under the H&P/DC tab dated 11/18/21 at 10:27 AM showed P9 was admitted on 10/16/21 with a DX of depression and anxiety. The psychiatric evaluation failed to show the history of present illness, including onset, precipitating factors and results of any treatment received.
During an interview on 12/02/21 at 12:25 PM the RM confirmed the above medical records findings.