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Based on interview and review of Medical Staff By-laws/Rules and Regulations and the Triage and Assessment policy and procedure, it was determined the Facility failed to define who was qualified to perform a medical screening exam (MSE). Failure to define who in the Facility was qualified to perform a medical screening exam had the potential to allow unqualified persons to perform medical screening exams which could lead to missed or inaccurate patient assessments. The failed practice affected all patients who presented to the Admission and Referral (A & R) Department of the Facility. Findings follow:

A. Review of the Facility's Medical Staff By-laws/Rules and Regulations received from the Director of HIM (Health Information Management) at 1000 on 06/03/15 revealed no guidelines or definitions of who the Medical Staff had deemed qualified to perform MSE.

B. Review of the Facility's Triage and Assessment policy and procedure received from the Director of HIM at 1125 on 06/03/15 revealed the following under PROCEDURE:#2. A licensed mental health professional will ensure completion of the assessment and appropriate disposition.
#11. The nurse will complete a Medical Screen on the patients including taking vital signs to identify any condition warranting immediate medical attention/intervention.
a. If a medical condition is identified which requires further investigation, the A & R nurse will contact the physician to review the medical screen for further medical clearance and/or diagnostic testing.
#15. Once all the information has been obtained, determination will be made regarding the appropriate level of care needed, based upon Rivendell's admission criteria and the staff member's clinical expertise. If unsure of the appropriate disposition, the staff member should consult with a psychiatrist on staff.
#16. If admission to a Psychiatric Facility is indicated, the A & R staff will determine financial status by obtaining insurance information and verifying benefits and/or court involvement. Business office, during working hours, will discuss the financial status with the client and/or family. A & R staff is to provide financial counseling to the family after business hours.
#17. Once financial status has been determined and the patient/family wants admission at Rivendell, the admission process begins.
C. During an interview with the Director of HIM at 1130 on 06/03/15, she verified the findings in A and B.
D. During an interview with the Chief Executive Officer at 1200 on 06/04/15, he verified the findings in A.



Based on interview and review of patient documents, it was determined the Facility failed to provide a medical screening exam, for one (Patient #1) of one (Patient #1) patient accepted and received from another Facility. Failure to provide and document a medical screening exam did not ensure Patient #1 was stable to return to the Referring Facility. The failed practice affected Patient #1 on 04/04/15. Findings follow:

A. Review of the Referral Call Sheet for Patient #1 revealed no date documented and the time documented as 1700. Patient #1's name was circled and an arrow drawn to the words "Love List". Suicidal ideation, HI (homicidal ideation) and off meds were listed as presenting problems.

B. During an interview with the Director of Admissions at 1215 on 06/03/15, he stated Patient #1 was transferred from (NAMED HOSPITAL). The Director of Admissions stated once Patient #1 arrived at the Facility, the Charge Nurse realized Patient #1 was on the "Love List" and sent Patient #1 back to the Transferring Facility. The Director of Admissions was asked what the "Love List" was and he stated it was a list of patients who have shown aggression to staff in the past. The Director of Admissions stated Patient #1 should have been assessed by an Admission and Referral person. The packet of documents included information from the (NAMED HOSPITAL) but did not include evidence a medical screening exam was performed, that the receiving Facility was called and accepted Patient #1 back, the risks and benefits were not explained to the patient and a transfer form was not completed. There was no evidence a physician was consulted regarding the return of Patient #1 to the referring Facility.
C. During an interview with the Director of Admissions at 1215 on 06/03/15, the findings of A and B were verified.



Based on document review and interviews, it was determined the Facility failed to document who performed the medical screening exam for 6 (#1, #9, #12, #13, #15 and #26) of 11 (#1, #9-15, #18, #21, and #26) patients that arrived at the facility . Failure to document who performed the medical screening exam did not assure the appropriate level of care was recommended. The failed practice affected Patients #1, #9, #12, #13, #15 and #26. Findings follow:

Review of the Referral Call Sheet for Patients #1, #9, #12, #13, #15 and #26 revealed that even though the box "Consultation with physician-Patient referred to outpatient treatment" was marked, there was no documentation the physician was called and their recommendation, the date and time of the call. During an interview with the Director of Admission at 1430 on 06/03/15, he verified the above findings.