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Based on review of the facility's policy, Medical Staff Rules and Regulations, medical record review and staff interview, the facility failed to ensure that the medical staff performed a neurological screening examination on admission for 3 of 10 sampled patients (#7, #10, #2).

The findings include:

Review of the facility's "Medical Consultation/History and Physical" policy revised August 2018 revealed "... Every patient admitted to the Hospital will receive a medical consultation/H&P (History and Physical) within 24 hours of admission. ... The history and physical will include, but is not limited to ... examination of cranial nerves 2 - 12 ..."

Review of Medical Staff Rules and Regulations last revised October 2018 revealed "... The attending Physician is responsible for the preparation of a complete, accurate, and legible medical record for each patient ... The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and to document the results accurately including, but not limited to the following: ... History and Physical examination, including past medical history, a review of psychological systems, and findings of assessment; evaluation of the Cranial Nerves. ... As permitted by State law and policy, the performance and reporting of a history and physical examination may be assigned by the attending Physician to another qualified Practitioner. This assignment, however, does not relieve the attending Physician from the ultimate responsibility for the report. A history and physical exam performed in part or all by a Nurse Practitioner must be reviewed and signed by the attending Physician. ..."

1. Review on 02/27/2019 of a closed medical record for Patient #7 revealed a 69 year-old male admitted on 01/31/2019 with schizophrenia, paranoia and delusions. Record review revealed a History and Psychiatric Evaluation had been conducted by a Nurse Practitioner on 02/01/2019 and co-signed by a psychiatrist on the same day. Review of the History and Physical Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Physical Evaluation revealed the Cranial Nerve section of the evaluation had been left blank with "deferred" written beside the neurologic exam.

An interview on 02/27/2019 at 1550 with the facility's Director of Quality revealed a neurological screening examination that included examination of the cranial nerves 2 - 12 was required on all patients upon admission. Interview revealed the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.

2. Review on 02/28/2019 of an open medical record for Patient #10 revealed a 74 year-old female admitted on 02/18/2019 with schizophrenia. Record review revealed a History and Physical Evaluation had been conducted by a Nurse Practitioner on 02/19/2019. Review of the History and Physical Examination revealed it included an examination of the Cranial Nerves. Review revealed the attending psychiatrist signature line was blank. Review revealed no evidence that the physician reviewed and signed the history and physical examination.

Interview on 02/28/2019 at 1625 with the Chief Executive Officer revealed the patient's history and physical examination included and examination of the cranial nerves 2 - 12. Interview revealed the examination could be done by a Nurse Practitioner and it should be reviewed and signed by the physician within 48 hours. Interview revealed the history and physical examination was not reviewed and signed by a physician as of 02/28/2019 (9 days after it was done).



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3. Review on 02/28/2019 of an open medical record for Patient #2 revealed the 32 year-old was admitted on 02/23/2019 with suicidal ideation and major depressive disorder. Record review revealed a History and Physical Examination was conducted by a Nurse Practitioner on 02/24/2019. Review of the History and Physical Examination revealed it included an examination of the Cranial Nerves. Review revealed the attending psychiatrist signature line was signed by another Nurse Practitioner on 02/26/2019 at 1230. Review revealed no evidence that a physician reviewed or signed the History and Physical examination.

Telephone interview on 02/28/2019 at 1650 with Physician #2 revealed a Nurse Practitioner did the initial History and Physical Examination on Patient #2. Interview revealed the physician should review and sign each History and Physical but may not see the patient at that time. Physician #2 stated if the History and Physical was not signed by him, it "got missed".

Interview on 02/28/2019 at 1625 with the Chief Executive Officer revealed the patient's History and Physical examination included an examination of the cranial nerves 2 - 12. Interview revealed the examination could be done by a Nurse Practitioner and it should be reviewed and signed by the physician within 48 hours.

Based on review of the Medical Staff Rules and Regulations, medical record review and staff interview, the facility failed to ensure a psychiatric evaluation was reviewed and signed by a physician for 2 of 10 sampled patients (#10, #2).

The findings include:

Review of Medical Staff Rules and Regulations last revised October 2018 revealed "... The attending Physician is responsible for the preparation of a complete, accurate, and legible medical record for each patient ... The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and to document the results accurately including, but not limited to the following: ... Comprehensive Psychiatric Evaluation. ... Clinical entries in the patient's medical record shall accurately dated, timed, and authenticated. At a minimum, the following must be authenticated: ... Comprehensive Psychiatric Evaluation ... "

1. Review on 02/28/2019 of an open medical record for Patient #10 revealed a 74 year-old female admitted on 02/18/2019 with schizophrenia. Record review revealed a Comprehensive Psychiatric Evaluation had been conducted by a Nurse Practitioner on 02/19/2019. Review revealed the attending psychiatrist signature line was blank. Review revealed no evidence that the physician reviewed and signed the Comprehensive Psychiatric Evaluation.

Telephone interview on 02/28/2019 with Physician #2 revealed a Comprehensive Psychiatric Evaluation should be reviewed and authenticated by the patient's physician within 24 hours.

Interview on 02/28/2019 at 1625 with the Chief Executive Officer revealed the patient's Comprehensive Psychiatric Evaluation could be done by a Nurse Practitioner and it should be reviewed and signed by the physician within 48 hours. Interview revealed the Comprehensive Psychiatric Evaluation was not reviewed and signed by a physician as of 02/28/2019 (9 days after it was done).



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2. Review on 02/28/2019 of an open medical record for Patient #2 revealed the 32 year old was admitted on 02/23/2019 with suicidal ideation and major depressive disorder. Record review revealed a Comprehensive Psychiatric Evaluation had been signed by a Nurse Practitioner on 02/24/2019 at 1455. Review revealed no evidence that the physician reviewed and signed the Comprehensive Psychiatric Evaluation.

Telephone interview on 02/28/2019 at 1650 with Physician #2 revealed a Comprehensive Psychiatric Evaluation should be should be reviewed and authenticated by the patient's physician within 24 hours.

Interview on 02/28/2019 at 1625 with the Chief Executive Officer revealed the patient's Comprehensive Psychiatric Evaluation could be done by a Nurse Practitioner and it should be reviewed and signed by the physician within 48 hours.

Based on the facility's policy, medical record review and staff interview, the facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 2 of 10 sampled patients (#7, #10).

The findings include:

Review of the facility's "Treatment Planning - Philosophy and Purpose" policy revised January 2019 revealed "... A Treatment Plan review/update that evaluates patient response to goals and interventions will be revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services. If there is no appreciable change in the patient's condition, goals and objectives will be reevaluated and revised on a weekly basis at a minimum for inpatient ..."

1. Review on 02/26/2019 of a closed medical record for Patient #7 revealed a 69 year-old male admitted on 01/31/2019 with schizophrenia, paranoia and delusions. Review of the "Multidisciplinary Treatment Plan" dated 01/31/2019 revealed the plan included two identified problems with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for each of the problem areas that included the type of intervention, frequency and responsible individual. Review revealed an additional problem was identified on 02/01/2019 related to restraint use. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals. Review revealed the patient discharged home on 02/13/2019 (14 days after admission).

Interview on 02/26/2019 at 1700 with Therapist #1 revealed an evaluation of the treatment plan intervention and progress toward goals was completed every seven days and more frequently as needed. The staff member reviewed Patient #7's medical record and stated the evaluation "was not completed." The therapist reported the facility policy was not followed.

2. Review on 02/28/2019 of an open medical record for Patient #10 revealed a 74 year-old female admitted on 02/18/2019 with schizophrenia. Review of the "Multidisciplinary Treatment Plan" dated 02/19/2019 revealed the plan included two identified problems with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for each of the problem areas that included the type of intervention, frequency and responsible individual. Review revealed an additional problem was identified on 02/22/2019 related to generalized pain. Review of the record on 02/28/2019 revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals (10 days after admission).

Interview on 02/28/2019 at 1625 with the Director of Social Services revealed an evaluation of the treatment plan intervention and progress toward goals was completed every seven days and more frequently as needed. The staff member reviewed Patient #10's medical record and stated the evaluation "was not completed." The director reported the facility policy was not followed.

NC00148085