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Based on review of policy and procedures, review of clinical records, and interview, it was determined that the facility failed to ensure adherence to the facilities nursing policy and procedures in that the nursing intake assessment for nine patients (#1, #2, #3, #6, #7, #9, #10, #11) out of 11 patients (#1-#11) were not completed. The failed practice did not allow for a comprehensive assessment to determine if the patients met admission criteria. The failed practice had the likelihood of affecting all patients being admitted. Finding follow:

A. Review of policy titled "Admission," with a revision date of 1/17/24, showed that "the assessment and referral staff will review the intake questionnaire Triage Form as well as the registration form prior to beginning initial triage. The assessment and referral staff will direct the individual and/or family to an assessment room to begin the full psychosocial assessment after the Initial Triage has been completed. When a level of care other than Intensive Outpatient Program (IOP), Enhanced Outpatient Program (EOP) or outpatient is indicated, a consultation with the next physician on rotation will take place and a final disposition will be made. The recommendation will be presented to the individual/family by the evaluation staff."

B. Review of Recommendations and Referrals for Services Policy dated 10/18/2018, showed the Assessment and Referral Department was to provide referrals to individuals seeking assessment services based on clinical judgement, geographic proximity, and special needs or concerns evidenced during the assessment.

C. Review of the Patient Family Education policy dated 10/2018 showed that "It is the policy of The Bridgeway Hospital to provide education to its patients and, when appropriate, family members to assist in development of knowledge and skills needed to foster rapid stabilization, make informed decisions regarding treatment and aftercare planning, and promote wellness. Patient/family education is based on an assessment of the needs of the individual and his/her family, as well as an assessment of factors and/or barriers that may influence teaching modalities and focus."

D. Review of the Nursing Plan of Care policy, revised on 10/2018, showed the patient and his/her significant others were vital participants in the treatment process.

E. Review of the Patient Depression Questionnaire Nine (PHQ-9) total score interpretation shows the following:
Interpretation of Total Score
Total Score/Depression Severity
1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression

F. Review of clinical records showed:
1. Patient #1's Standardized Intake Assessment form showed the patient was currently under the care of a therapist at (Named Facility) on 03/28/2024. Under the question "Psychiatrists/Therapists Seen in the Past" showed "None."
2. Patient #1, #3, #4, #6, and #7, Triage Form - Assessment and referral forms were blank.
3. Patients #1 - #7 and #9, -#11 Standardized Intake Assessment forms were incomplete. For example, Patient #1 did not have marital status, assessor signature, date, and time completed.
4. Patients #1 and #8's Medical Clearance Assessment forms were incomplete. For example, Patient #8 did not have documentation of the Registered Nurse Observation of Behavior/Risk Assessment.
5. Patient #1's Referral Recommendations and Crisis Safety Plan form dated 3/30/24, was not completed by the intake assessment nurse. The verification from "parent, family member, support person/friend for not having access to prescriptions medications for use other than as prescribed; weapons; lethal medications; illegal drugs/alcohol, as applicable; other means of self-harm" was not signed and dated.
6. Patients #1, #2, and #7 had Patient Health Questionnaire-9 (PHQ-9) tools that were calculated incorrectly. For example, Patient #7 had a documented PHQ-9 score of 8 (mild depression) instead of 15 (moderately severe depression).

G. In an interview with the Chief Executive Officer (CEO) on 4/30/24 at 1:15 PM, the findings of A through F were confirmed.