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Based on observation, document review, and staff interview, the psychiatric hospital's administrative staff failed to ensure the nursing staff provided nursing services 24 hours a day, 7 days a week to patients in the hospital's Intake Unit [ED]. Failure to provide nursing services 24 hours a day, 7 days a week to the hospital's Intake Unit patient, may result in an unrecognized emergency medical condition, unrecognized and unmet patient care needs, and poor patient outcomes. The hospital's administrative staff reported 738 patients presented to the hospital's Intake Unit [ED] seeking psychiatric care since opening in February 2021.

Findings include:

1. Observations on 11/4/2021 at 10:07 AM in the Intake Unit/ED providers locked office/work area revealed a large monitor screen positioned on a wall with camera views of the Intake Unit's [ED] 4 admit rooms, 2 waiting rooms, and hallway. Waiting room 1 camera showed a young boy and the Director of Assessment and Referral, waiting room 2 camera revealed a young woman quietly seated, and Admit room #3's camera showed 1 young girl talking with a male staff member. An Intake Worker was seated at 1 of 6 cubicles in the office/work area. Further observations revealed the Intake Unit lacked a nurse assigned to the unit and sufficiently free of other duties to provide assistance to the patients in the Intake Unit.

2. Review of the Intake Department's staffing schedules from 10/01/21 - 11/14/21 revealed a nurse was not scheduled to work any shift during the 24 hour period on 10/8/21, 10/22/21, and 11/10/2021. An nurse was scheduled to work 8 hours or less in a 24 hour period on 10/02/21, 10/07/21, 10/14/21, 10/15/21, 10/16/21, 10/17/21, 10/21/21, 10/24/21, 10/27/21, 10/28/21, 10/29/21, 11/03/21/ 11/04/21, and 11/13/21. No date reviewed had nursing coverage for an entire 24 hour period.

3. Review of the House Supervisor schedule and the Intake Unit/ED nurse schedule revealed the Intake Unit [ED] had no nursing staff available to the Intake Unit's patients on 10/16/21 for 1 hour and 45 minutes, 10/17/21 for 2 hours and 45 minutes, 10/20/21 for 4 hours and 45 minutes, 10/22/21 for 24 hours, 10/23/21 for 8 hours, and on 10/24/21 for 7 hours and 45 minutes. There had been no House Supervisor scheduled to work and there had been no Intake nurse scheduled to work during that time period.

4. During an interview on 11/4/21 at the time of the observation, the Director of Assessment and Referral reported a nurse was not scheduled to work and was not present in the Intake Unit/ED. The House Supervisor provided nursing coverage to the intake department and would be notified if a nurse was needed. A nurse may be scheduled to work some shifts in the Intake Unit/ED, but it is not required. All intake staff, which included social workers, counselors, Mental Health Technician's (MHT), and nurses are trained to triage patients by performing a blood pressure check and obtaining pulse, respirations and a pulse oximetry reading (measurement of oxygen in the blood). A nurse would be required to perform a urine drug screen, urine pregnancy test, blood sugar test with a glucometer, or Covid - 19 test if ordered by the physician.

5. Review of the policy "Intake Department Medical Clearance Process," approved 2/2021 revealed in part, "... An assessment will be performed with each patient ... to determine initial screening of the patient's physical functioning. ... Patients who are calling from home, or from any other agency that is not an emergency room, present with an acute medical issue, the case will be reviewed with the admitting physician, admission nurse ... to determine if medical clearance at an emergency room is necessary ... if ... deemed necessary, the intake counselor/RN will refer the patient to their closest emergency room ..."

6. Review of the policy "Plan for the Provision of Care," approved 2/2021 revealed in part, "Inpatient Care is provided on a 24-hour basis, seven days a week, in an acute care psychiatric setting ... [the hospital] is a ... inpatient psychiatric facility ... SERVICES: Screening and Intake ... Qualified clinical staff, social services staff, registered nurse or active member of the medical staff performs Intake Screening and Evaluations, 24 hours per day, seven days per week ... Admission Process In-Patient Unit: ... Assessment and Evaluation Procedures ... Assessment of all patients begins on admission ..." The policy lacked a plan for provision of 24-hour nursing services by a nurse while a patient received services in the Intake Unit [ED].

7. Review of Patient #6's Intake medical record revealed Patient #6 presented to the hospital's Intake Unit/ED with complaints of suicidal thoughts and struggling with bipolar disorder symptoms on 10/21/2021, accompanied by their mom. Intake Worker P documented Patient #6's Blood Pressure as 140/83, Temperature 97.5 [degrees Fahrenheit]. Patient #6's pulse, respirations, pain score were not assessed and recorded. Allergies recorded as "yes," but no allergies were listed. "Medical Screen" documented as completed by Intake Worker P on 10/21/21, time left blank. "Triage" was completed by Intake Counselor S, 10/21/21 at 2:55 PM. The section of the form titled "ACTIONS To be TAKEN to MANAGE RISK UPON ADMISSION: (Patient Specific precautions, nursing interventions, safety planning, referrals/resources, consultations, special precautions)" and "Signature of RN reviewer at the time of the Initial Nursing Assessment:" was not completed. Intake Counselor S contacted Psychiatrist B by phone on 10/21/21 at 3:30 PM. Psychiatrist B determined Patient #6 required inpatient acute care, identified inability to sleep and inability to care for self, indicative of need for 24 hours monitoring and assessment due to severe deterioration in level of functioning and required medication stabilization. The Intake Unit [ED] record for Patient #6 lacked documentation of a nursing assessment, reassessments, medication administration, evaluation, and supervision of care provided to Patient #6 by a nurse for approximately 23 hours while present in the Intake Unit [ED].

8. Review of Patient #8's Intake medical record revealed Patient #8 presented to the Intake Unit [ED] accompanied by law enforcement officer, on 9/8/21, time of arrival not documented. A "Standardized Intake Assessment" was initiated at 5:45 PM and partially completed by Intake Counselor EE (4 hours after the hospital staff documented they reviewed the intake assessment with Psychiatrist D). A section of the "Standardized Intake Assessment" titled "ACTIONS To be TAKEN to MANAGE RISK UPON ADMISSION: Patient specific precautions, nursing interventions, safety planning, referrals/resources, consultations, special precautions" lacked signature of RN reviewer at the time of the Initial Nursing Assessment. Patient # 8's vital signs; blood pressure, temperature, pulse, respirations, or pain score are not documented. Patient #8's assessment was reviewed with Psychiatrist E via phone on 9/8/21 at 1:00 PM. Psychiatrist D ordered Patient # 8 to be admitted to Inpatient Service and indicated "without hospitalization, there would be an exacerbation of symptoms" and that "Symptoms/behaviors indicative of need for 24 hours monitoring and assessment of the patient's condition". The medical record lacked documentation of when the hospital staff admitted Patient #8 to the Intake Unit and to the inpatient mental health unit, along with Patient #8's medical record lacking documentation of an initial nursing assessment, reassessments or care interventions by a nurse while Patient #8 was present in the Intake Unit [ED].

9. Review of Patient #13's Intake medical record revealed Patient #13 presented to the Intake Unit[ED] on 11/10/21 at approximately 10:26 PM with suicidal ideation. A "Standardized Intake Assessment" was initiated at 10:40 PM and partially completed by Intake Counselor EE. Vital Signs were obtained and a medical screening performed by Intake Counselor EE at 10:50 PM. Triage documented as completed by Intake Counselor EE at 11:09 PM. A section of the "Standardized Intake Assessment" titled "ACTIONS To be TAKEN to MANAGE RISK UPON ADMISSION: Patient specific precautions, nursing interventions, safety planning, referrals/resources, consultations, special precautions" lacked date, time, and "Signature of RN reviewer at the time of the Initial Nursing Assessment". Intake Assessment is reviewed with Psychiatrist B at 11:25 PM and order obtained for Patient #13 to be admitted to the inpatient service. The medical record lacked documentation of when the hospital staff admitted Patient #13 to the Intake Unit and to the inpatient mental health unit, along with Patient #13's medical record lacking documentation of an initial nursing assessment, reassessments, or care interventions by a nurse while Patient #13 was present in the Intake Unit [ED].


10. During an interview on 11/09/2021 at 4:33 PM, the hospital's CEO acknowledged that the the nursing staff failed to ensure that a nurse was available and sufficiently free from other duties to provide immediate nursing care to all patients in the Intake Unit.

Based on document review and staff interviews the psychiatric hospital's administrative staff failed to ensure all medications were prepared and administered on the orders of a physician responsible for the patients care and accepted standards of practice for 2 of 2 of the Intake Unit's [ED] closed medical records reviewed (Patient #6 and Patient #10). Failure to obtain a doctor's order may result in a patient receiving medication not in alliance with the doctor's plan for medical treatment and not be the appropriate medication type, dose, route, and time potentially resulting in a severe adverse reaction and/or death. The hospital's administrative staff identified 738 patients presented to the Intake Unit [ED] since February 2021.

Findings include: Ordering and Dispensing

Review of the "Medical Staff Rules and Regulations," adopted and approved by the medical staff and governing body 2/19/21, revealed in part, "Medications prescribed will specify dosage, frequency, route of administration and date. Medication prescribed for as needed ... administration will identify the symptoms for which the medication should be administered ... Medications will not be administered in any levels of care other than inpatient or Residential Care ..."

1. 1. Review of Patient #6's Intake medical record revealed Patient #6 presented to the hospital's Intake Unit/ED with complaints of suicidal thoughts and struggling with bipolar disorder symptoms on 10/21/2021, accompanied by their mom. Intake Worker P documented Patient #6's Blood Pressure as 140/83 mmHg (millimeters of mercury), Temperature 97.5 [degrees Fahrenheit]. Patient #6's pulse, respirations, pain score were not assessed and recorded. Allergies recorded as "yes," but no allergies were listed. "Medical Screen" documented as completed by Intake Worker P on 10/21/21, time left blank. "Triage" was completed by Intake Counselor S, 10/21/21 at 2:55 PM. The section of the form titled "ACTIONS To be TAKEN to MANAGE RISK UPON ADMISSION: (Patient Specific precautions, nursing interventions, safety planning, referrals/resources, consultations, special precautions)" and "Signature of RN reviewer at the time of the Initial Nursing Assessment:" was not completed. No nurse assessed Patient #6 while in the Intake Unit [ED]. Intake Counselor S contacted Psychiatrist B by phone on 10/21/21 at 3:30 PM. Psychiatrist B determined Patient #6 required inpatient acute care, identified inability to sleep and inability to care for self, indicative of need for 24 hours monitoring and assessment due to severe deterioration in level of functioning and required medication stabilization. Patient # 6 remained in the Intake Unit until 10/22/21 at 12:30 PM when Patient #6 was admitted to the inpatient unit. The Intake Unit [ED] record for Patient #6 lacked documentation of a nursing assessment, evaluation of medication allergies, medication administration, and reassessments, Patient #6 by an nurse for approximately 23 hours while present in the Intake Unit [ED].

2. Review of an Incident Report completed by Pharmacist AA on 10/22/21 revealed Ativan 2 mg and Haldol 5 mg (chemical sedation used for acute agitation) had been administered intramuscularly (IM) to Patient #6 at 10:20 PM by House Supervisor (HS) RN BB without a doctors order. Pharmacist AA documented that the daily report provided by the OmniCell (an automated medication dispensing system which allows a nurse to remove ordered medications for patients, and allows a nurse to withdraw medications if a physician orders medication for a patient and the patient requires the medication prior to a pharmacist entering the medication into the OmniCell system) that a nurse had removed the medications from the OmniCell and then failed to document they administered the medication to Patient #6 in Patient #6's Intake Unit/ED medical record.

3. During an interview on 11/1/21 at 2:20 PM with Psychiatrist B, who was responsible for the care of Patient #6 on 10/21/21, verified they did not order Ativan 2 mg or Haldol 5 mg for Patient #6. Psychiatrist B reported they do not feel it is safe to order medication for patients in the Intake Unit, due to the potential for the patient to experience an adverse reaction to the medication and the lack of RN patient assessment, monitoring and supervision .

4. During an interview on 11/3/21 at 3:55 PM, HS RN BB verified they administered Ativan 2 mg and Haldol 5 mg IM at 10:20 PM to Patient #6. HS RN BB reported she received a phone call from Intake staff Mental Health Technician (MHT) V shortly after 8:00 PM requesting Ativan 2 mg and Haldol 5 mg be administered IM to Patient #6. RN HS BB reported she went to the Omnicell Medication Administration System to pull the requested medications. HS RN BB was not able to locate Patient #6 in the patient listing. HS RN BB talked with RN DD regarding the inability to find Patient #6 in the OmniCell list of patients. RN DD told HS RN BB that sometimes the hospital's electronic medical record goes down and then does not always link with OmniCell. When that happened, the nurses override the Omnicell and pull the drug anyway. HS RN BB reported they were unable to locate Patient #6 with the doctor's order for the medication, so she and RN DD completed the process for a medication override and pulled the medications HS RN BB had been asked to give by Intake MHT V.

HS RN BB took the medication to the Intake Unit to administer to Patient #6. HS RN BB revealed she found Patient #6 sitting calmly in the room and Patient #6 refused the medication, so HS RN BB did not administer the medication at that time. Approximately 2 hours had passed when HS RN BB was notified by Intake Counselor EE that Patient # 6 had requested the medication. HS RN BB went into Patient #6's room in Intake and found Patient #6 lying quietly on a mattress, with Patient #6's mother rubbing their back. Patient #6 requested the medication to reduce anxiety and help them sleep. HS RN BB administered Ativan 2 mg and Haldol 5 mg IM into Patient #6's right deltoid (shoulder) muscle. HS RN BB reported there is nowhere in the Intake medical record to document medication administered or to record a doctor's order. HS RN BB revealed she had been instructed by Intake Coordinator RN CC to document medication administered to patients in Intake on a paper log taped to Intake Coordinator RN CC's desk wall in the Intake workers locked office area. The medication log required date, time, patient requiring medication, ordering provider, and the name of the nurse receiving order and administering to patient. HS RN BB asked the Intake Unit staff the name of the doctor who ordered the medication. HS RN BB discovered no order had been written or a verbal order obtained by a nurse for the medication administered to Patient #6. HS RN BB acknowledged at no time during the 2 hour period between pulling the drug from the OmniCell and administering the drug, did she attempt to verify that a valid doctor's order for the requested medications had been obtained and documented.


5. During an interview on 11/1/21 at 1:45 PM, Pharmacist AA reported she ran a medication override report every day to assure that all medications administered to the hospital's patients had a valid doctor's order. Pharmacist AA's investigation revealed no doctor's order had been obtained and/or written. Pharmacist AA discussed the findings with the CNO. The CNO confirmed to Pharmacist AA that the medication had been given without a doctor's order. Pharmacist A verbalized the hospital staff did not think of a patient in the Intake Unit as a "patient" until the patient is admitted to an inpatient unit. Only patients admitted to an inpatient unit have a medical record number, an electronic medical record to document orders, and do not have a medication administration record to document medications received. Pharmacist AA completed an incident report of the event that should not have happened and identified that the hospital needed to develop a clear processes to guide medication use in the Intake Unit. Pharmacist AA related she was aware a nurse is not always scheduled in the Intake Unit. Pharmacist AA completed an incident report that HS RN BB had performed an override procedure to pull a medication from the OmniCell medication system and administered the medication to a patient in the Intake Unit without a doctor's order. Pharmacist AA revealed the hospital staff are working to address the use of medications with "non-patients" within the Intake Unit.

6. Review of Patient #10's medical record revealed Patient #10 was admitted to an acute inpatient unit on 11/9/21 at 10:30 AM with a diagnosis of major depressive disorder. Patient #10 presented through the acute hospitals Intake Unit [ED], and the medical screening exam is initialed by Intake RN FF on 11/8/ 21 at 11:10 PM, approximately 12 hours prior to admission. Intake RN FF called Psychiatrist B on 11/9/21 at 12:30 AM and received a phone order to admit Patient #10 to the hospital's Inpatient Service. Intake RN FF documented in the nursing notes that Intake RN FF received a verbal order (v.o.) from Psychiatrist B for Trazodone 50 milligrams (mg) PO (by mouth) every night for sleep as needed, once the hosptial staff admitted Patient #10 to an inpatient behavioral health unit (as opposed to the Intake Unit). Intake RN FF documented in the nursing notes the Trazodone 50 mg was administered at 2:00 AM by the House Supervisor (HS) RN GG while Patient #10 was still waiting in the Intake Unit. The medication administered was not documented on a medication administration record (MAR). The verbal order lacked a signature by Psychiatrist B to verify that Psychiatrist B had given the verbal order as written by Intake RN FF. The "Standardized Intake Assessment" lacked an identified area for doctors' orders to be documented.

7. Review of an Incident Report completed by Pharmacist AA on 11/9/21 revealed a medication error report had been made regarding the administration of Trazodone to Patient #10. Patient #10 had been given Trazodone 50 mg at 3:00 AM in the Intake Unit. An Omnicell Medication Dispensing Unit report showed Trazodone 50 mg had been removed at 2:35 AM by HS RN GG. Pharmacist AA documented "Per discuss with [Psychiatrist B] can give Trazodone 50 mg if admitted to floor. Pt. currently sleeping in admitting". Trazodone 50 mg had not been ordered for Patient #10 in the Intake Unit.

8. During an interview on 11/2/21 at 12:00 PM, the Director of Admissions and Referral reported the Intake Unit lacked Unit specific policies, but that the Intake Unit followed the hospital's policies. The Director of Admissions and Referral acknowledged the Corporate Office and Administration did not want medications administered in the Intake Unit, but did not identify the reason.

9. Review of the policy "Medication Administration - Guidelines," approved 6/2021, revealed in part, "... Medications are only given with a physician/APRN order ... Physician/APRN orders must be checked against Medication Administration Record before preparing a new, stat [immediate], or one-time order ... All indications for the use of the medication will be documented in the Medication Administration Record as well as the physician order ... nurse verifies the order in the patient's electronic medical record ... five (5) rights of medication administration will be followed ... 1. the right amount 2. the right medicine 3. the right patient 4. the right time 5. the right route .... if giving a patient sedating medication ... patient is observed by nursing staff every 15 minutes ... medications will be dispensed from the nurse's station ... all medications are documented on the Medication Administration Record with the EMR, immediately after the are given ... PRN [as needed] medications require reassessment to determine effectiveness of medication ...".

10. Review of the policy "Nursing Standards of Practice," approved 2/2021, revealed in part, "... nursing staff of the hospital seeks to provide the highest quality psychiatric nursing services to all individuals ... on a 24 hour basis in a consistent, safe, and manner ... Nursing practice at [hospital] is grounded in an understanding of ... appropriate interventions, safety, and security for all aspects of the healthcare organization."