HospitalInspections.org

Based on record review and interview, the facility failed to ensure each patient received a nursing assessment to guide initial Emergency Room treatment for 19 (P#1-18, P#20) of 20 (P#1-P#20) patient charts reviewed. This failed practice could potentially result in patients not receiving needed emergency services.
The findings are:

A) Record review of 19 (P#1-18, P#20) medical charts revealed only triage assessments were done. There was no documentation of a full nursing assessment: Head to Toe Assessments including body systems, vital signs, orientation (date, time, place, situation), and a brief mental status exam during Emergency Room visits.

B) On 01/28/2020 at 2:00 pm during interview, S#4 Critical Care Director stated, "nurses should assess patients, I can't speak to why the assessment wasn't done."

C) On 01/28/2020 at 3:42 pm during interview, S#8 RN stated, "as a nurse you should always do a full head to toe assessment, in the perfect setting I would."

D) Record review of [facility's name] Emergency Room Acute Care Guidelines of Patient Care Policy dated 11/2016 revealed, "All patients entering the Emergency Department will have a rapid initial assessment by an ED registered nurse, all patients regardless of acuity will be reassessed a minimum of hourly."

E) Record review of Mosby's Critical Care Nursing sixth edition, Unit 1, Page 24, Foundations of Critical care nursing standards indicated the following: "Nurses caring for acutely and critically ill patients have a duty to assess and analyze the level of care needed by their patient."

Based on record review and interview, the facility failed to inform 1 patient (P#15) of 20 (P#1-P#20) of his rights in a language he could understand and failed to inform 1 patient's representative (P#17) of 20 (P#1-P#20) of the patient's rights, prior to furnishing treatment. This failed practice has the potential to put patients at risk of not receiving proper medical care resulting in unmet patient needs.
The findings are:

A) Record review of P#15's consent forms, Notice of Communication of Accessibility Services, revealed the patient stated Spanish as his preferred language for discussing healthcare, and Spanish as his primary spoken language. The consent form indicated he "needed an oral interpreter, written/printed materials in other formats (i.e. large print, audio, accessible electronic or other formats as available) and written/printed materials in Braille (if available). Other alternatives will be made available to accommodate individuals who are blind or have limited vision."
a. The Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form was written in English, which he signed. The Notice of Patient Rights and Responsibilities was written in English, which he signed.
b. The Discharge paperwork and Education was not written in large font. The font appeared to be written in a 12-point font and what appeared to be a 6 or 8 point font.
c. There was no evidence indicating a Spanish speaking interpreter was utilized.

B) Record review of P#17's Admission form indicated the patient's daughter as her representative/emergency contact. Consent forms revealed:
a. "unable to sign" with no witness signature or reason given the patient was unable to sign on the Education and Information for patients on reporting concerns, abuse, neglect, exploitation or grievances form.
b. "pt unable to sign" with no reason given the patient was unable to sign on the Consent to Medical Treatment for.
c. "pt unable to sign" with no witness signature or reason given the patient was unable to sign on the Notice of Communication Accessibility Services form.
d. "pt unable to sign" with no witness signature or reason given the patient was unable to sing on the BC [Blue Cross] Coordination form of Benefits for [Blue Cross Blue Shield insurance] form.
e. "pt unable to sign" with no witness signature or reason given the patient was unable to sign on the Provider Request for Application on Behalf of a Medicaid Member form.
f. "pt unable to sign" with no reason given the patient was unable to sign on the Patient Rights and Responsibilities form.

C) On 01/29/2020 at 10:00 am during interview, S#1 Quality Director confirmed all patients are educated on their Rights at Registration. She also confirmed there are Spanish speaking staff members but could not speak to whether or not one was utilized for P#15.

Based on record review and interview, the facility failed to allow the patient or his/her representative to make informed decisions regarding his/her care for 11 (P#3 - P#5, P#9 - P#10, P#12 - P#14, and P#16 - P#17 and P#19) of 20 (P#1-P#20) patients. This failed practice has the potential for patients to not participate in the development of his/her plan of care, consent to or refuse, medical or surgical interventions, and plan for care after discharge from the hospital.
The findings are:

A) Record review of consent documentation for P#4 dated 12/22/19, P#5 dated 12/21/19, P#9 dated 12/08/19, P#10 dated 12/17/19, P#12 dated 12/12/19, P#13 dated 11/12/19, P#14 dated 12/14/19, P#16 dated 12/12/19, and P#17 dated 12/14/19, P#19 dated 12/11/19, revealed the patient provided a signature, date, and time on the Notice of Communication Accessibility Services but did not indicate "yes or no" when asked "Do you think you'll need the following services:
a. American Sign Language interpreter
b. Oral interpreter
c. TTY/TTD [TeleTYpe/Telecommunications Device for the Deaf]
d. Hearing-aid compatible telephone receiver with volume control
e. Television closed captioning
f. Written/printed materials in other formats (i.e. large print, audio, accessible electronic or other formats as available)
g. Additional aids and/or services"

B) On 01/29/2020 at approximately 10:00 am during interview, S1 Quality Director confirmed all patients are educated on their rights at Registration and gave no other explanation.

C) Record review of P#3's medical chart dated 12/16/19 revealed consent forms Rights and Responsibilities, and An Important Message from Medicare About Your Rights. The chart did not contain the following consent forms:
a. Notice of Communication Accessibility Services
b. Waiver of Communication Accessibility Services
c. Inpatient/Outpatient Conditions of Admission and Consent to Medial Treatment

D) On 01/29/2020 at 5:30 pm during interview, S1 Quality Director confirmed all patient charts were complete when asked if all the consent forms were provided.

Based on observation and interview, the facility failed to protect the confidentiality of paper patient clinical records for an undetermined number of patients. This failed practice has the potential for unauthorized patient disclosure of medical information.
The findings are:

A. On 01/28/2020 at 3:07 pm during observation of the facility's Emergency Department Admitting area revealed 7 document archive boxes filled with paper patient charts, consent forms, clinical records, and data, and approximately 5 stacks, approximately 1 - 2 feet high, of loose paper patient charts in an open area on a cart and on top of a desk.

B. On 01/28/2020 at 3:09 pm during interview, S#20 RN, stated "those are patient records" when asked if he knew what was in the boxes and stacked on the cart.

C. On 01/28/2020 at 3:10 pm during interview, S#19 Registration Clerk confirmed the boxes and stacks of paperwork were patient records. She also stated, "those records are supposed to be going to Levi [a storage area for patient records] but we don't use them anymore." When asked how long those records had been there, she stated, "I don't know. For a while. Maybe more than a month. I should probably ask my Supervisor about it."

D. On 01/29/2020 at 9:00 am during interview, S#1 Quality Director confirmed she did not know anything about the boxes and stacks of patient files loose in the Admitting Area of the ED. She confirmed the files should be locked up.

Based on record review and interview the facility failed to supervise 2(P#2 and P#19) of
20(P#1-P#20) patients while in the ER for Suicidal Ideation. This failed practice can lead to patients causing self-harm.
The findings are:

A. Record review of P#2's ER medical charts, dated 04/09/2019, revealed S#9 MD ordered "discharge of patient to be transferred requiring inpatient hospitalization for safety and stabilization of suicidal patient." P#2 waited in ER for transfer from 04/08/19 at 13:01 pm to 04/09/19 at 13:10 pm. No documentation of patient supervision charted from 04/08/19 at 23:03 pm to 04/09/19 at 7:52 am. No documentation of ligature risks removed from patient room.

B. Record review of P#19 ER medical chart dated 12/11/19 revealed S#10 MD ordered discharge of patient to be transferred for suicidal ideation. P#19 waited in ER for transfer from 12/11/19 at 15:30 pm to 12/12/19 at 11:40 am. No documentation of patient supervision charted from 12/12/19 at 1:07 am to 12/12/19 at 8:24 am. No documentation of ligature risks removed from patient room.

C. Record review of [facility's name] Suicide Risk Assessment and Interventions policy dated 02/2011 revealed "psychiatric patients requiring medical care in a non-psychiatric setting (ED, ICU etc.) must be protected when demonstrating suicidal ideation or suicide risk. The protection would be safety measures such as 1:1 monitoring with continuous visual observation and removal of sharp objects from the room/area."

D. On 01/29/20 at 3:42 pm, during interview, S#8 RN stated, "we need more nurses to do charting and take care of patients. One day everyone in ED was suicidal [S#8 RN could not recall the date]. How can the RN do 15 minute checks on every patient, it can't be done. We have no sitters, Security used to help us but now they are not allowed to."

E. On 01/28/20 at 1:10 pm, during interview, S#4 Critical Care Director stated "if patient stays in ER awaiting transfer we feed them and check on them while awaiting transfer, I can't speak to this particular patient [P#2] but vital signs are every shift and should be visually monitored every 15 minutes."

Based on record review and interview, the facility failed to have a complete medical record for 1 (P#1) of 20 (P#1-P#20) patient medical records that contained information to justify admission and continued hospitalization, support the diagnosis and support P#1's progress. This failed practice caused the patient to be discharged prior to being stabilized.
The findings are:

A. Record review of P#1's medical record dated 12/18/19 at 11:51 am [admission 1st visit] revealed "patient arrived to ER with chief complaint of 'feels like she's crazy and don't (sic) know what is real, denies suicidal and homicidal thoughts.' "

B. Record review of P#1's medical record dated 12/18/19 at 13:48 pm [discharge 1st visit] revealed "Discharged to Home. Impression: Other stimulant abuse with intoxication, unspecified. Condition is Stable. Symptoms are unchanged."

C. Record review of P#1's medical record dated 12/18/19 at 13:53 pm [discharge 1st visit] revealed "Notified called Security due to patient screaming and (sic) RN [Nurse's Name] and refusing to sign her discharge."

D. Record review of P#1's medical record dated 12/18/19 at 13:57 pm revealed "Notified called Dispatch to send an officer [Hobbs PD] due to patient refused to leave the ER." P#1 was taken into custody by law enforcement.

E. Record review of P#1's medical record dated 12/18/19 at 16:51 pm [admission 2nd visit] arrived via EMS revealed, "I am here for blood draw."

F. Record review of P#1's medical record dated 12/18/19 revealed no evidence of EMS records. No records could be provided to Surveyors prior to the end of the survey.

G. Record review of P#1's medical record dated 12/18/19 at 18:14 [admission 3rd visit] revealed, "she told them she is bipolar and been off her meds for one day."

H. Record review of P#1's medical record dated 12/18/19 at 22:00 [psych consult note for 3rd visit] S#21 LMSW documented, "Patient's brother states he feels she [P#1] needs help. She [P#1] needs rehab." S#21 LMSW also charted, "pt does not meet criteria for inpatient mental heath care. Physician contacted for review of data gathered: [physician name] S#22 Physician 12/18/19 at 23:14." Surveyors were told S#22 was a Psychiatrist.

I. On 01/28/2020 at 1:00 pm during interview, P#1's brother stated, "The Psychiatrist [S#21 LMSW] asked if something was wrong with her head or heart. She [P#1] said, 'Head. I need a CT scan. I just need help.'" The brother further stated, "She [P#1] said, 'I see angels and demons.' Approximately 10-15 minutes later a different Charge Nurse came in with discharge paperwork."

J. On 01/29/2020 at 1:00 pm during interview S#4 Director of Critical Care confirmed she would provide S#22's personnel file. The file could not be provided prior to end of survey.

K. Record review of P#1's medical record dated 12/18/19 revealed no record of S#22's Physician's notes. No evidence could be found that S#22 Physician ever met with or assessed P#1. No Physician notes were provided prior to end of survey.

L. On 01/29/2020 at 1:00 pm during interview, S#4 Director of Critical Care confirmed there was no evidence that the Physician ever met with or assessed P#1. She further stated, "We have no charted communication between doctors."

Based on record review and interview the facility failed to provide adequate training for 5 (S#13, S#15, - S#18) of 10 (S#8-S#18) nurses to meet the needs of suicidal patients in the Emergency Room. This failed practice can lead to unqualified staff that are unable to anticipate the medical needs of patients.
The findings are:

A. Record review of staffing schedule for Emergency Room dated 12/08/19 and 12/09/19 revealed S#13 assigned as Charge RN.

B. Record review of S#13 RN job description signed 01/03/19 does not include Charge RN in description and competency level of S#13 RN is blank. No training for suicidal ideation provided.

C. Record review of staffing schedule for Emergency Room dated 12/14/19 and 12/20/19 revealed S#15 assigned as Charge RN.

D. Record review of S#15 RN job description signed 08/22/19 does not include Charge RN in description and competency level of S#15 is marked level 3. No training for suicidal ideation provided.

E. Record review of staffing schedule for Emergency Room dated 12/16/19 and 12/17/19 revealed S#16 assigned as Charge RN.

F. Record review of S#16 RN job description signed 04/17/19 does not include Charge RN in description and competency level of S#16 is blank. No training for suicidal ideation provided.

G. Record review of staffing schedule for Emergency Room dated 12/24/19 and 12/29/19 revealed S#17 assigned as Charge RN.

H. Record review of S#17 RN job description signed 09/09/19 does not include Charge RN description and competency level is blank. No training for suicidal ideation provided.

I. Record review of staffing schedule for Emergency Room dated 12/14/19 and 12/21/19 revealed S#18 assigned as Charge RN.

J. Record review of S#18 RN job description signed 03/19/19 does not include charge RN description and competency level is level 2. No training for suicidal ideation provided.

K. On 01/28/20 at 3:42 pm during interview S#8 RN stated in regards to suicidal patients, "We have limited training and just not enough education. The Charge Nurse usually takes care of patients with suicide ideation but nobody ever oriented me to Charge Nurse position, one day they just told me to do Charge Nurse."

L. On 01/28/20 at 05:30 PM during interview S#18 RN confirmed there is not enough staff to monitor the patients who present with psychological problems and additional training is needed to deal with psych patients.

M. On 01/28/20 at 2:27 pm during interview S#11 NP stated "I didn't receive a formal orientation per se, I don't know if the hospital offers any type of training."

N. On 01/29/20 at 3:00 pm during interview S#4 Director of Critical Care stated "I can't speak to what qualifies a nurse to be Charge RN, they should have level 4 competency."

Based on record review and interview the facility failed to provide a psychiatric assessment including a medical history for 1 (P#1) of 20 (P#1-P#20) patients. This failed practice resulted in the patient not receiving appropriate assessment and resulted in being improperly discharged.
The findings are:

A. Record review of P#1's medical record dated 12/18/19 at 11:42 am revealed the patient arrived in the ER with chief complaint of "feels like she's crazy and don't (sic) know what is real, denies suicidal and homicidal thoughts."

B. Record review of P#1's medical chart revealed S#11 NP documented on 12/18/19, "HPI 12:26 pm patient [P#1] presents to ED with complaints of Psych problem. Patient states that she has recently used methamphetamines, has not slept much over the past few days, and feels anxious. She denies being Suicidal or Homicidal. She does admit that she was recently did (sic) to [Name of City] Psychiatric Inpatient treatment facility but will not tell me what she was admitted for. Patient is not wanting to answer questions and will not provide me any other information other than what's previously noted. She denies the need for any tests. She states she does not want me to do anything at this point."

C. Record review of P#1's medical chart dated 12/18/19 revealed no evidence of a psychiatric evaluation and medical history was done.

D. Record review of [Facility name] Adult Mental Health Nursing Care and Documentation Guidelines of Care Policy Stat ID #4557828 dated 02/2018 revealed, "Guidelines for Assessment and Reassessment:
Problem Identification
Problem Identification and Ongoing Needs
Patient problems will be identified and prioritized by the RN with collaboration of the Mental Health team (MD, RN, LPN/LVN, PCT, and Therapist/Counselor upon patient admission and on a continued basis.

Problems/diagnoses will be identified on the Plan of Care and documented under Multidisciplinary Care Plan and the Interdisciplinary Care Plan. Patient problems will be identified and updated in conjunction with clinical changes and in collaboration with the physician, the patient and family, and other health care professionals.

Global Interventions
Patients will receive the appropriate interventions to meet their individualized needs. Nursing interventions should be:
A. Consistent with multidisciplinary team approach and individualized patient care plan, provide continuity of care and be in accordance with established policy and procedures. Performed with safety, efficiency, and compassion.
The nurse or designee will perform interventions to meet the individualized needs and problems of the patient.

Critical Episode Management
The patient can expect timely and safe interventions in the event of a critical episode. The nursing staff will utilize:
A. Anticipate and recognize potential/impending critical episodes, respond quickly and effectively (including timely notification of physician).
B. Provide interventions that are efficacious, timely and directed at preventing undue crisis to the extent possible given patient's condition.

Documentation Minimum Guidelines
Nursing documentation for Mental Health Patients
The patient can expect documentation to be completed in just in time format and consistent with regulatory compliance.
Documentation will follow at a minimum the following:
A. Nursing Admission Assessment:
B. Therapist/Counselor/Social Worker to be documented upon admission
1. Psy - Psychosocial Assessment
F. Shift initial assessment at start of shift:
1. Document under:
a. Psy - Psychiatric Shift Note
c. Psy - Patient Crisis Prevention- Safety Plan
3. Patients with admission of substance abuse use history or withdrawal:
a. Psy - DC-Substance Abuse Psychosocial Assessment"

E. On 01/28/2020 at 2:27 pm during interview, S#11 NP stated, "I don't believe I need any Psych training to deal with patients. I don't feel I needed it. I am not Psych trained."

Based on record review and interview, the facility failed to provide an appropriate medical screen examination to determine if an emergency medical condition existed prior to discharging the patient in 1 (P#1) of 20 (P#1-P#20) patients. This failed practice resulted in the patient not being properly treated.


The findings are:


A. Record review of P#1's medical record dated 12/18/19 at 11:42 am revealed, the patient arrived to ER with chief complaint of "feels like she's crazy and don't (sic) know what is real, denies suicidal and homicidal thoughts."


B. Record review of P1's medical chart revealed, S#11 NP charted on 12/18/19, "HPI 12:26 pm patient [P#1] presents to ED with complaints of Psych problem. Patient states that she has recently used methamphetamines, has not slept much over the past few days, and feels anxious. She denies being Suicidal or Homicidal. She does admit that she was recently did (sic) to Roswell Psychiatric Inpatient treatment facility but will not tell me what she was admitted for. Patient is not wanting to answer questions and will not provide me any other information other than what's previously noted. She denies the need for any tests. She states she does not want me to do anything at this point."


C. Record review of P#1's medical chart dated 12/18/19 at 12:28 pm revealed S#11 NP documented, "behavior/mood is cooperative, anxious. Constitutional: anxious, in obvious distress, mildly distressed."


D. Record review of P#1's medical record dated 12/18/19 at 13:11 pm revealed S#8 RN documented, "patient's brother states his mom called him due to her [P#1] using drugs and being paranoid she thinks her boyfriend is out to get her."


E. Record review of P#1's medical record dated 12/18/19 T 13:42 pm revealed S#8 RN documented, "she [P#1] wanted a blood draw so when I attempted to draw from the left hand she pulled away and said 'you're not going to draw my blood from the artery. I explained to her it was not an artery, it was a vein, she refuses blood draw again."


F. Record review of P#1's medical record dated 12/18/19 at 13:48 pm revealed, S#11 documented, "discharged to home. Impression other stimulant abuse with intoxication. Condition is stable. Symptoms are unchanged." No evidence of reassessment, psychosocial, psychological, or functional needs could be found to address P#1's chief complaint that she "feels like she's crazy and don't (sic) know what is real."


G. Record review of P#1's medical record dated 12/18/19 at 13:57 pm revealed S#8 RN documented, "patient [P#1] refuses treatment, denies being suicidal and she is now refusing discharge papers and refusing to leave."


H. Record review of P#1's medical record dated 12/18/19 at 14:00 revealed S#8 RN documented, "Hobbs PD notified of patient refusing to leave the ER." PD was notified 3 minutes after patient refusing blood draw treatment. No evidence of attempts at de-escalation, Mental Health consultation, psychosocial, environmental, financial or functional needs, or any other interventions were done could be found.


I. On 01/28/2020 at 2:27 pm during interview, S#11 NP stated, "I'm a relatively laid-back person. Usually I can just sit with somebody. If I'm not able to calm the situation, I will draw labs, call the Mental Health counselors or recommend in-patient treatment. Our Mental Health counselors are always here. Acceptance in an in-patient treatment facility is done very quickly."


J. Record review of [facility name] Discharge Planning/Patient Care Policy dated 04/20/13 reveals, "The discharge planning evaluation will include at a minimum: a review of physiological, psychosocial, environmental, financial, and functional needs."

Based on record review and interview, the facility failed to medically stabilize P#1 and failed to honor the patient's representative's request for transfer to a higher level of care. This failed practice resulted in the patient being arrested and incarcerated which resulted in unmet patient needs.


The findings are:


A. Record review of P#1's medical record dated 12/18/19 at 11:51 am [admission 1st visit] revealed "patient arrived to ER with chief complaint of 'feels like she's crazy and don't (sic) know what is real, denies suicidal and homicidal thoughts.' "


B. Record review of P#1's medical record dated 12/18/19 at 18:14 [admission 3rd visit] revealed, "she told them she is bipolar and been off her meds (sic) [medications] for one day."


C. Record review of P#1's medical record dated 12/18/19 at 22:00 [psych consult note for 3rd visit] S#21 LMSW documented, "Patient's brother states he feels she [P#1] needs help. She [P#1] needs rehab." S#21 LMSW also charted, "pt does not meet criteria for inpatient mental heath care. Physician contacted for review of data gathered: [physician name] S#22 Physician 12/18/19 at 23:14."


D. Record review of P#1's medical record dated 12/18/19 at 13:11 pm revealed S#8 RN documented, "patient's brother states his mom called him due to her [P#1] using drugs and being paranoid she thinks her boyfriend is out to get her."


E. On 01/28/2020 at 1:00 pm during interview, P#1's brother stated, "The Psychiatrist [S#21 LMSW] asked if something was wrong with her head or heart. She [P#1] said, 'Head. I need a CT scan. I just need help.'" The brother further stated, "She [P#1] said, 'I see angels and demons.' Approximately 10-15 minutes later a different Charge Nurse came in with discharge paperwork." There was no evidence, indication, or discussion was made about transferring the patient.


F. Record review of P#1's medical chart revealed S#11 NP documented on 12/18/19, "HPI 12:26 pm patient [P#1] presents to ED with complaints of Psych problem. Patient states that she has recently used methamphetamines, has not slept much over the past few days, and feels anxious. She denies being Suicidal or Homicidal. She does admit that she was recently did (sic) to [Name of City] Psychiatric Inpatient treatment facility but will not tell me what she was admitted for. Patient is not wanting to answer questions and will not provide me any other information other than what's previously noted. She denies the need for any tests. She states she does not want me to do anything at this point."


G. Record review of P#1's medical chart dated 12/18/19 at 12:28 pm revealed S#11 NP documented, "behavior/mood is cooperative, anxious. Constitutional: anxious, in obvious distress, mildly distressed."


H. Record review of P#1's medical chart dated 12/18/19 revealed no evidence of a psychiatric evaluation and medical history was done.

I. Record review of P#1's medical record dated 12/18/19 revealed no record of S#22's Physician's notes. No evidence could be found that S#22 Physician ever met with or assessed P#1. No Physician notes were provided prior to end of survey.


J. On 01/29/2020 at 1:00 pm during interview, S#4 Director of Critical Care confirmed there was no evidence that the Physician ever met with or assessed P#1. She further stated, "We have no charted communication between doctors."


K. Record review of P#1's medical record dated 12/18/19 at 13:53 pm [discharge 1st visit] revealed "Notified called Security due to patient screaming and (sic) RN [Nurse's Name] and refusing to sign her discharge."


L. Record review of P#1's medical record dated 12/18/19 at 13:57 pm revealed "Notified called Dispatch to send an officer [Hobbs PD] due to patient refused to leave the ER." P#1 was taken into custody by law enforcement.


M. Record review of P#1's medical record dated 12/18/19 at 14:00 revealed S#8 RN documented, "Hobbs PD notified of patient refusing to leave the ER." PD was notified 3 minutes after patient refusing blood draw treatment. No evidence of attempts at de-escalation, Mental Health consultation, psychosocial, environmental, financial or functional needs, or any other interventions were done could be found.

N. Record review of P#1's medical record dated 12/18/19 revealed no evidence of EMS records indicating a transfer was requested. No records could be provided to Surveyors prior to the end of the survey.


O. Record review of [Facility name] Adult Mental Health Nursing Care and Documentation Guidelines of Care Policy Stat ID #4557828 dated 02/2018 revealed:

Global Interventions

Patients will receive the appropriate interventions to meet their individualized needs. Nursing interventions should be:

A. Consistent with multidisciplinary team approach and individualized patient care plan, provide continuity of care and be in accordance with established policy and procedures. Performed with safety, efficiency, and compassion. The nurse or designee will perform interventions to meet the individualized needs and problems of the patient.


Critical Episode Management

The patient can expect timely and safe interventions in the event of a critical episode. The nursing staff will utilize:

A. Anticipate and recognize potential/impending critical episodes, respond quickly and effectively (including timely notification of physician).

B. Provide interventions that are efficacious, timely and directed at preventing undue crisis to the extent possible given patient's condition.


P. Record review of P#1's medical record dated 12/18/19 at 13:48 pm revealed S#11 documented, "discharged to home. Impression other stimulant abuse with intoxication. Condition is stable. Symptoms are unchanged." No evidence of reassessment, psychosocial, psychological, or functional needs could be found to address P#1's chief complaint that she "feels like she's crazy and don't (sic) know what is real."


Q. On 01/28/2020 at 2:27 pm during interview, S#11 NP stated, "I'm a relatively laid-back person. Usually I can just sit with somebody. If I'm not able to calm the situation, I will draw labs, call the Mental Health counselors or recommend in-patient treatment. Our Mental Health counselors are always here. Acceptance in an in-patient treatment facility is done very quickly."


R. Record review of [facility name] Discharge Planning/Patient Care Policy dated 04/20/13 reveals, "The discharge planning evaluation will include at a minimum: a review of physiological, psychosocial, environmental, financial, and functional needs."