The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UMASS MEMORIAL HEALTHCARE-MARLBOROUGH HOSPITAL 157 UNION STREET MARLBOROUGH, MA 01752 July 1, 2013
VIOLATION: ORGANIZATION OF EMERGENCY SERVICES Tag No: A1102
Based on interview, the Hospital failed to ensure that the Hospital's Psychiatric Emergency Service (PES) was under the direction of the Hospital's Emergency Medical Director. Findings include:

The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13 and at 11:10 A.M. on 7/1/13. The Risk Management Director (RMD) said the Psychiatric Nurse Director held responsibility for the PES Contract. The RMD said neither the ED Medical Director, Psychiatric Medical Director nor the Medical Staff Chief held responsibility for the PES Contract or its Quality Assessment Process's Improvement (QAPI) program.

The Surveyor interviewed the Emergency Department (ED) Medical Director at 10:45 A.M. on 6/27/13. The ED Medical Director said she did not have specific responsibility for PES.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record and documents titled "Patient Discharge from Emergency Department (ED) and Follow-Up Care", "Contacting Collaterals" and "Patient Rights" review, the Hospital failed to ensure: (1.) ED physicians and ED staff followed Hospital policies & procedures regarding ED patient discharge and Patient Rights, (2.) The Hospital had access to the Psychiatric Emergency Service (PES) policies and procedures and (3.) ED contracted PES policies and procedures were approved and followed by the Hospital.

(1-A.) Hospital policy and procedure titled "Patient Discharge from Emergency Department and Follow-Up Care" dated 6/18/12 indicated that the patient's medical record shall document that the plan was communicated orally/written to the patient and or as appropriate the family/patient representative.

Patient #1, an adolescent, (MDS) dated [DATE] accompanied by his/her parent, for treatment of drug use and signs of drug withdrawal.

During an interview with the Surveyor at 2:35 P.M. on 6/21/13 Patient #1's parent said that Patient #1's discharge plan for support and guidance was not communicated at the time of discharge from the Hospital ED. The Patient #1's parent said that Patient #1 was discharged from the Hospital ED with his/her eyes uncontrollably twitching and Patient #1 was sleepy. Patient #1's parent said that he/she did not know if the uncontrollable eye twitching and sleepiness were drug withdrawal symptoms and he/she was scared Patient #1 would die.

During an interview with the Surveyor at 10:00 A.M. on 6/26/13 the PES Clinical On-Site Supervisor said the PES Clinician told her (Clinical On-Site Supervisor) that she (the Clinician) was under the impression that Patient #1's parent clearly understood the plan of care documented in the PES Clinician's evaluation.

The document titled "ESP Adult Comprehensive Assessment", documented by the PES Clinician, date and time not documented, indicated that Patient #1 agreed to take his/her Abilify as his/her doctor advised and that the plan for Monday admission was explained to Patient #1's parent. The ESP Adult Comprehensive Assessment also indicated that Patient #1's parent was very frustrated, disappointed in the system and was in fear that something "catastrophic" was going to happen to Patient #1.

The document titled "Emergency Department Nursing Continuation Record" dated 2/1/13 at 7:40 P.M. indicated that Patient #1 was discharged home with oral and written discharge follow-up instructions from PES.

The document titled "Service, Treatment Recommendations or Instructions", documented by PES Clinician, dated 2/1/13 indicated Patient #1's discharge instructions as:
1.) Call PES as needed for emergency phone support, 24 hours a day and 7 days a week.
2.) Follow-up with treatment providers.
3.) Referrals/resources available: Client agrees to treatment, referral has been made, awaiting review.

The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13 and at 11:10 A.M. on 7/1/13. The RMD said that the PES discharge plan for Patient #1's was:
1.) hospitalization on Monday
2.) Restart Abilify (mood stabilizer)
3.) Attend Narcotic Anonymous meeting(s) over the weekend
4.) Check in with PES periodically over the weekend.

Patient #1's medical record did not indicate the discharge plan described above was communicated orally or in writing to Patient #1 and/or Patient #1's parent. Patient #1's medical record did not contain a copy of the above discharge plan.

The Surveyor interviewed RN #3 at 10:10 A.M. on 6/27/13. RN #3 said the electronic preprinted discharge instructions (Care Notes) had discharge instructions about drug withdrawal symptoms.

During an interview with the Surveyor at 9:00 A.M. on 6/27/13 the RMD said there were no Care Notes for Patient #1.

The Hospital could not provide for Surveyor review, Care Notes specific to symptoms of drug withdrawal, eye twitching or sleepiness.

The Surveyor interviewed Physician #1 at 9:15 A.M. on 6/26/13. Physician #1 said it was her recollection that she discussed with Patient #1's parent about fatigue, to call PCP or return to the ED but did not document the conversation in Patient #1's medical record. Physician #1 said that discharge instructions related to fatigue and withdrawal were generated from the Care Notes, if there was one.

The Surveyor interviewed Physician #2 at 1:10 P.M. on 6/28/13. Physician #2 said she does not document in the patient's medical record if the medical record is not in front of her.

Patient #1's medical record did not indicate discharge instructions about fatigue or actions to take regarding worsening fatigue.

The Surveyor interviewed the ED Medical Director at 10:45 A.M. on 6/27/13. The ED Medical Director said she writes something in discharge box (the instructions portion of the Emergency Department Physician Record, EDPR) patient discharge instructions.

The document titled EDPR contained an area labeled, Instructions. Three of 5 (Patients #'s 1, 2 and 5) medical records reviewed did not indicate complete discharge instructions.

Patient #'s 1 and 5, The EDPR, did not indicate Instructions, i.e. the Instructions section was blank.

Patient #2, Review of the document EDPR, date at 8:45 A.M. dated not documented, indicated the physician's Instructions were Care Notes, although the physician did not indicate which Care Notes instruction documents the physician intended Patient #2 receive.

The document titled " Emergency Department Nursing Continuation Record ", dated at 12:05 P.M. on 2/26/13, indicated the ED staff provided verbal and written discharge instructions, using interpreter services, for Patient #2. The medical record did not indicate verbal instruction content or the specific Care Notes instruction documents, emergency department staff provided to Patient #2.

(1-B.) Hospital policy and procedure titled "Patient Discharge from Emergency Department and Follow-Up Care" dated 6/18/12, indicated that a follow-up care plan would be discussed with and signed by the patient on Care Notes or on the preprinted Discharge Instructions on reverse side of the EDPR. If the patient/family/patient representative was unable to sign, a notation shall be included in the patient's record that indicates the reason the patient was unable to sign.

During an interview with the Surveyor at 11:10 A.M. on 7/1/13, the Risk Manager (RM) said that Hospital policy indicated that a patient signature is required on the discharge instruction form but the practice is inconsistent.

The Risk Manager said that Hospital policy required a patient signature on the Care Notes but not a provider signature; although there is a section on the Care Notes form for a provider signature. The RMD said that a patient signature is required on Care Notes per Hospital policy and a copy of the Care Notes should be part of the medical record.

For one (Patient #2) of 10 medical records reviewed the EDPR did not indicate a patient/family/patient representative signature although the Instructions section indicated Care Notes should be give to Patient #2 but the Instructions section did not indicate which Care Notes the doctor wanted Patient #2 to receive and his/her medical record did not indicate a copy of which, if any, Care Notes were given to Patient #2.

For 4 of 5 medical records reviewed did not indicate a patient signature on the patient signature line provided on the EDPR.

Review of the EDPR (Emergency Department Physician Record, patient discharge instructions), for Patients #2 and #3, indicated there was no date documented on the form as required. For patient #4, the EDPR was dated 2/23/13 and for Patient #5, the EDPR was dated 6/16/13. Neither EDPR for Patient #4 and #5 had patient signatures on the patient signature line as required.

1-C.) Hospital policy and procedure titled "Patient Discharge from Emergency Department and Follow-Up Care" dated 6/18/12 indicated that if the patient and/or patient's family/patient representative, as appropriate, notifies any professional staff member involved in the patient's care that the patient and/or patient representative does not agree with the discharge plan, the discharge planning coordinator and the patient's physician shall arrange and conduct a meeting with the patient and/or family in an effort to develop a plan that is acceptable. An Emergency Department health care professional may be considered a discharge coordinator and the Emergency Department physician may be considered the patient's physician for this purpose.

During an interview with the Surveyor at 2:35 P.M. on 6/21/13 Patient #1's parent stated s/he disagreed with the discharge plan to take Patient #1 home without a discharge plan for support and guidance.

During an interview with the Surveyor at 8:30 A.M. on 6/26/13 the RMD the PES Clinician and the ED physician stated they knew Patient #1's parent was upset about discharging Patient #1 home.

The Surveyor interviewed the Emergency Department (ED) Nurse Director at 2:10 P.M. on 6/26/13. The ED Nurse Director said that Patient #1's parent was upset.

The Surveyor interviewed the PES Behavioral Health Director at 2:55 P.M. on 6/25/13. The Behavioral Health Director said that if a client disagrees with the plan, the clinician is supposed to present the case to a supervisor. The Director said the PES supervisors reviewed and agreed with discharging Patient #1 home.

Patient #1's medical record did not indicate a conversation/meeting with the ED doctor, PES Clinician, Patient #1 and his/her parent in an effort to develop a discharge plan acceptable to the Hospital, Patient #1 and his/her parent.

1-D.) Hospital policy and procedure titled "Patient Discharge from Emergency Department and Follow-Up Care" dated 6/18/12 indicated that when appropriate, discharge instruction sheet is to be completed by Emergency Department Registered Nurse or designee and discussed with patient and appropriate/responsible parties. One copy (signed)is be placed in the Medical Records and the other is given to the patient.

For 5 of 5 medical records reviewed of patients discharged home, the records did not indicate a nursing form titled Patient Discharge Form. The Discharge Instruction Form was the third page of the Emergency Department Physician Record.

For 5 of 5 medical records reviewed of patients discharged home, the records did not indicate all sections of Discharge Instruction Form were copied for inclusion in the medical records.

1-E.) The PES policy and procedure titled "Contacting Collaterals" dated 2013 (provided by the ED contracted PES) indicated it was the protocol that the evaluating clinician would make every attempt possible to obtain consent to contact collaterals. A collateral was defined as anyone who may have pertinent information about a client's current, recent and historical well-being and safety, for example a patient's Primary Care Physician or community mental health provider.

During an interview with the Surveyor at 2:35 P.M. on 6/21/13 Patient #1's parent said that he/she requested the PES Clinician to contact Patient #1's Psychiatrist and/or Family Therapist, provided their telephone numbers to the PES Clinician, twice. The PES Clinician refused to call.

The Surveyor interviewed the PES Clinical On-Site Supervisor 10:00 A.M. on 6/26/13. The On-Site Supervisor said the PES Clinician did not contact Patient #1's Psychiatrist and/or Family Therapist because their input would not change the fact that Patient #1 required hospitalization and no additional information could be gained.

The Surveyor interviewed the PES Behavioral Health Director 2:55 P.M. on 6/25/13. The Behavioral Health Director said it was the policy and the PES Clinician should have contacted Patient #1's Psychiatrist and/or Family Therapist.

1-F.) The Hospital policy titled "Patient Rights" and Responsibilities dated 9/15/11 indicated that the patient has the right to be informed about procedures and treatments.

The letter from the Hospital to Patient #1's parent, dated 4/5/13, indicated that a physician had provided Patient #1's parent with the urine and EKG results. Review of Patient #1's medical record does not indicate that Patient #1's parent was provided the test results.

Physician #1 said she did not write in Patient #1's medical record that she told Patient #1's parent that the results of Patient #1's EKG test was normal. Physician #1 said that it was her recollection that she discussed with Patient #1's parent about blood testing versus urine testing for illicit drugs, the results of the urine test and normal EKG results, but did not document the conversation in Patient #1's medical record.

2.) The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13 and at 11:10 A.M. on 7/1/13. The RMD said the Hospital did not have access to the Psychiatric Emergency Service's policies and procedures and would obtain the PES policy regarding contacting patients primary care providers from the PES staff.

3.) Review of PES policies and procedures titled "Contacting Collaterals/2013" and "Consultation Protocol/2013, Psychiatric Emergency Services" did not indicate the Hospital reviewed or approved the policies.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on interview, the Hospital failed to ensure a qualified member of the medical staff supervised the provision of Psychiatric Emergency Services (PES) in the Hospital's Emergency Department to provide direction and oversight during PES operating hours.

Findings include:

The Surveyor interviewed the ED Medical Director at 10:45 A.M. on 6/27/13. The ED Medical Director said she did not have specific responsibility for PES quality monitoring. The ED Medical Director said she monitors ED psychiatric patient transfers with the ED transfer quality monitoring. The ED Medical Director said she was not aware who was responsible for PES quality monitoring.

The Surveyor interviewed the Vice President for Quality and Patient Safety at 1:35 P.M. on 6/25/13. The Vice President said she did not know who reviewed the ED contracted PES QAPI program.

The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13/ The RMD said neither the ED Medical Director, Psychiatric Medical Director nor the Medical Staff Chief held responsibility for the PES Contract.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, medical record and document review the Governing Body (GB) failed to be responsible for the conduct of all the Hospital's operations. Findings include:

1.) There was no member of the medical staff responsible for Quality Assessment Process Improvement (QAPI) of the Emergency Department (ED) contracted Psychiatric Emergency Service (PES).

Refer to A-049 (Medical Staff Accountability).

2.) The Interim President/Chief Executive Officer (CEO)/Chief Operating Officer (COO) lacked knowledge about the quality of care provided to psychiatric patients in the Hospital ED.

Refer to A-057 (CEO)
Refer to A-091 (Emergency Services).
Refer to A-309 (Executive Responsibilities).
Refer to Emergency Services: A-1100 (Condition).


3.) The GB failed to integrate the ED contracted PES into the Hospital's QAPI program.

Refer to A-083 (Contracted Services)
Refer to QAPI: A-0263 (Condition)

4.) The GB failed to ensure appropriate supervision and oversight of the ED contracted PES.

Refer to A-1111 (Emergency Services, Supervision).
Refer to A-309 (Executive Responsibilities).

5.) The GB failed to ensure that ED staff followed Hospital "ED Discharge", "Collateral Contact" and "Patient Rights" policies.

Refer to A-0091 (Emergency Services).
Refer to Emergency Services: A-1100 (Condition)
Refer to A-1104 (Policies & Procedures).
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on interviews, the Hospital failed to ensure a medical staff member was responsible for the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) Quality Assessment Process Improvement (QAPI) program. Findings include:

The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13 and at 11:10 A.M. on 7/1/13. The RMD said the Psychiatric Nurse Director held responsibility for the PES Contract. The RMD said neither the ED Medical Director, Psychiatric Medical Director or the Medical Staff Chief, held responsibility for the PES Contract or its QAPI program.

The Surveyor interviewed the ED Medical Director at 10:45 A.M. on 6/27/13. The ED Medical Director said she did not have specific responsibility for PES quality monitoring. The ED Medical Director said she monitors patient transfers from the ED as a quality outcome and may include some psychiatric ED patients. The ED Medical Director said she was not aware who was responsible for PES quality monitoring.

The Surveyor interviewed a PES Psychiatrist at 2:00 P.M. on 6/25/13. The Psychiatrist said he did not know about the PES QAPI program.

The Surveyor interviewed the Vice President for Quality and Patient Safety at 1:35 P.M. on 6/25/13. The Vice President said she did not know who reviewed the ED contracted PES QAPI program or its review process.

The Surveyor interviewed the Interim President/CEO/COO at 9:30 A.M. on 7/1/13. The Interim President said that the former Psychiatric Nurse Director received PES quality data but could not describe the data or its review process.

Refer to QAPI: A-0263 (Condition).
Refer to A-1111.
Refer to A-1102.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of the document titled "Hospital Performance Improvement and Safety Reporting Structure" and interviews the Hospital failed to ensure that the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) Quality Assessment Process Improvement (QAPI) plan and data was incorporated into Hospital-wide QAPI programs and committees. Findings include:

The document titled "Hospital Performance Improvement and Safety Reporting Structure" indicated a pathway for Hospital-wide QAPI activities communication to the Board of Trustees. Review of the document indicated the reporting structure did not include the ED contracted PES.

The Surveyor interviewed the Hospital Quality Improvement Director at 10:40 A.M. on 7/1/13. The Quality Improvement Director said she did not have quality monitoring data for the ED contracted PES.

The Hospital did not submit for Surveyor review, PES QAPI monitoring activity document(s), Hospital committee minutes or Hospital report(s) confirming a PES QAPI program existed.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on interview, the Interim President/Chief Executive Officer (CEO) /Chief Operating Officer(COO) failed to be responsible for supervision and oversight of the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) to include an active Quality Assessment Process Improvement (QAPI) program. Findings include:

The Surveyor interviewed the Interim Chief Nursing Officer (CNO) at 8:45 A.M. on 6/27/13. The Interim CNO said she started in the CNO position 4 months ago, she was responsible for the contracted PES quality oversight and she was assessing its quality process. However, the CNO could not produce any documentation of an active QAPI program for the ED PES at the Surveyors request.

The Surveyor interviewed the Interim President/CEO/COO at 9:30 A.M. on 7/1/13. The Interim President said that the former Psychiatric Nurse Director had received PES quality data but could not describe the data or its review process.

Refer to A-083 (Contracted Services).
Refer to A-309 (Executive Responsibilities).
Refer to QAPI: A-0263 (Condition).
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on interview and review of the document titled "Clinical Contract Evaluation Form", the Hospital failed to ensure a Quality Assessment Process Improvement (QAPI) program for the Emergency Department (ED) contracted Psychiatric Emergency Service (PES).

Findings include:

1.) The Hospital contracted for psychiatric emergency services for the ED.

2.) The document titled "Clinical Contract Evaluation Form" dated 5/30/12
indicated clinical contract evaluation of the contracted PES with signatures
of the former Chief Nursing Officer (CNO) and the Psychiatric Nurse Director. The document also indicated the Hospital audited the PES.

3.) Neither the Hospital or the ED contracted PES made available PES audit data for Surveyor review since 5/30/12.

4.) The Surveyor interviewed the Risk Management Director (RMD) at 9:35 A.M. on 6/27/13. The RMD said that the former Psychiatric Nurse Director held responsibility for the PES Contract and that the position was vacant for approximately 1 month, but could not remember exactly.

5.) The Surveyor interviewed the Interim CNO at 8:45 A.M. on 6/27/13. The Interim CNO said she started in the CNO position 4 months ago, she was responsible for the contracted PES quality oversight and she was assessing its quality process. When the Surveyor requested QAPI documents the CNO could not produce QAPI documentation.

Refer to QAPI: A-0263 (Condition)
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview the Governing Body (GB) failed to ensure that Hospital Executive Staff assumed full responsibility for the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) Quality Assessment Process Improvement (QAPI) program. Findings include:

The Surveyor interviewed the Vice President for Quality and Patient Safety at 1:35 P.M. on 6/25/13. The Vice President for Quality and Patient Safety said she did not know who reviewed the contracted PES QAPI program or its review process.

The Surveyor interviewed the Interim President/Chief Executive Officer (CEO)/ Chief Operating Officer (COO) at 9:30 A.M. on 7/1/13. The Interim President/CEO/COO said she could not describe the ED contracted PES QAPI data or its review process.

The Surveyor interviewed the Interim Chief Nursing Officer (CNO) at 8:45 A.M. on 6/27/13. The Interim CNO said she was responsible for the contracted PES quality oversight and did not know who monitored the PES quality improvement plan or the PES QAPI process.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on record review and interview the Hospital failed to meet the emergency needs for 5 (Patients #1, #2, #3, #4 and #5) of 10 medical records reviewed, in accordance with acceptable standards of practice. Findings include:

1.) the Hospital failed to ensure that the Hospital's Psychiatric Emergency Service (PES) was under the direction of the Hospital's Emergency Medical Director.

Refer to A-1102 (Organization of Emergency Services)

2.) The Hospital failed to ensure: (1.) ED physicians and ED staff followed Hospital policies & procedures regarding ED patient discharge and Patient Rights, (2.) The Hospital had access to the Psychiatric Emergency Service (PES) policies and procedures and (3.) ED contracted PES policies and procedures were approved and followed by the Hospital.

Refer to A-1104 (Emergency Services Policies)

3.) The Hospital failed to ensure a qualified member of the medical staff supervised the provision of Psychiatric Emergency Services (PES) in the Hospital's Emergency Department to provide direction and oversight during PES operating hours.

Refer to A-1111 (Supervision of Emergency Services)
VIOLATION: EMERGENCY SERVICES Tag No: A0091
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the Hospital failed to provide Emergency Department (ED) services for 1 (Patient #1) of 10 medical records reviewed. Findings include:

1.) Patient #1, an adolescent, (MDS) dated [DATE], accompanied by his/her parent, for treatment of drug use and signs of drug withdrawal.

2.) During an interview at 2:35 P.M. on 6/21/13, the parent of Patient #1 complained that:

A.) He/she disagreed with Patient #1's discharge from the ED,
B.) The ED refused to contact Patient #1's Psychiatrist and or his/her Family Therapist as requested by Patient #1's parent and
C.) The ED failed to communicate Patient #1's test results to Patient #1's parent.

A-1.) Record review of the document titled "Service, Treatment Recommendations or Instructions", documented by the ED contracted Psychiatric Emergency Service (PES) Clinician, dated 2/1/13, indicated Patient #1's discharge instructions as:
a.) Call PES as needed for emergency phone support, 24 hours a day and 7 days a week.
b.) Follow-up with treatment providers.
c.) Referrals/resources available: Client agrees to treatment, referral has been made, awaiting review.

A-2.) During an interview on 6/27/13 at 9:30 A.M., the Risk Management Director (RMD) said that the Psychiatric Emergency Service (PES) discharge plan for Patient #1's was:
a.) hospitalization on Monday,
b.) Restart Abilify (mood stabilizer),
c.) Attend Narcotic Anonymous meeting(s) over the weekend and
d.) Check-in with PES periodically over the weekend.

A-3.) Patient #1's medical record did not indicate the discharge plan described above was communicated orally or in writing to Patient #1 and/or Patient #1's parent. Patient #1's medical record did not contain a copy of the above discharge plan.

B-1.) The Surveyor interviewed the PES Clinical On-Site Supervisor at 10:00 A.M. on 6/26/13. The Clinical On-Site Supervisor said the PES Clinician did not contact Patient #1's Psychiatrist and/or Family Therapist because their input would not change the fact that Patient #1 required hospitalization and no additional information could be gained.

B-2.) The Surveyor interviewed the PES Behavioral Health Director at 2:55 P.M. on 6/25/13. The Behavioral Health Director said it was PES policy and the PES Clinician should have contacted Patient #1's Psychiatrist and Family Therapist.

C-1.) During an interview with the Surveyor, on 6/26/13 at 9:15 A.M., Physician #1 said she did not document in Patient #1's medical record that she told Patient #1's parent that the results of Patient #1's EKG test was normal. Physician #1 said it was her recollection that she discussed with Patient #1's parent about blood testing versus urine testing for illicit drugs and the results of the routine urine test and the normal EKG results. Physician #1 said she did not not document the conversation in Patient #1's medical record.

Refer to QAPI: A-0263 (Condition).
Refer to Emergency Services: A-1100 (Condition).
VIOLATION: QAPI Tag No: A0263
Based on interview and document review the Hospital failed to ensure that the Quality Assessment Performance Improvement (QAPI) program reflected the complexity of the hospital's organization and services; by involving all hospital departments and services including those services furnished under contract or arrangement. Findings include:

1.) The Hospital failed to maintained a Quality Assessment Process Improvement (QAPI) program for the Emergency Department (ED) contracted Psychiatric Evaluation Service (PES) that measured, analyzed and tracked quality indicators.

Refer to A-273 (Program Scope & Program Data).

2). The Hospital failed to ensure that the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) Quality Assessment Process Improvement (QAPI) plan and data was incorporated into Hospital-wide QAPI programs and committees.

Refer to A-308 (QAPI).

3.) The Governing Body failed to ensure that Hospital Executive Staff assumed full responsibility for the Emergency Department (ED) contracted Psychiatric Emergency Service (PES) Quality Assessment Process Improvement (QAPI) program.

Refer to A-309 (Executive Responsibilities).
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and review of the following documents titled: (1.) "Clinical Contract Evaluation Form", (2.) "Psychiatric Evaluation Services Agreement" and "Psychiatric Evaluation Services Agreement" the Hospital failed to maintained a Quality Assessment Process Improvement (QAPI) program for the Emergency Department (ED) contracted Psychiatric Evaluation Service (PES) that measured, analyzed and tracked quality indicators. Findings include:

The Surveyor interviewed the Quality Improvement Director at 10:40 A.M. on 7/1/13. The Quality Improvement Director said she did not have quality monitoring data for the ED contracted PES.

Review of the document titled "Clinical Contract Evaluation Form" dated 5/30/12 indicated the Hospital audited the ED contracted PES by signatures of the former CNO and Psychiatric Nurse Director. The document also indicated the Hospital audited the PES for:
1.) Direct observation of provision of care,
2.) Input from staff and patients and
3.) Documentation including cases and patient records.

The Hospital was not able to provide the Surveyor any further documentation of audits completed since 5/30/12.

During an interview with the Surveyor at 12:10 P.M. on 6/27/13 the Interim Chief Nursing Officer (CNO) said the Hospital did not have PES QAPI data, for review by the Surveyor.

During an interview with the ED Nurse Director at 2:10 P.M. on 6/26/13, the ED Nurse Director said the Psychiatric Nurse Director had responsibility for the PES contract and quality program. The ED Nurse Director said the Psychiatric Director monitored quality data regarding patient timeframe's. The ED Nurse Director said he could not elaborate on what patient timeframe's were monitored nor did he have access to PES quality data. The ED Nurse Director said the Psychiatric Nurse Director position was vacant and the Interim CNO held responsibility for the PES contract.

The Surveyor interviewed the PES Behavioral Health Director at 2:55 P.M. on 6/25/13. The Behavioral Health Director said the PES Clinical On-Site Supervisor could address the PES quality plan.

The Surveyor interviewed the PES Clinical On-Site Supervisor at 10:00 A.M. on 6/26/13. The Clinical On-Site Supervisor said she had no knowledge of PES QAPI activities and referred the Surveyor to the PES Behavioral Health Director.

The Surveyor interviewed the Risk Management Director (RMD) at 9:00 A.M. on 6/27/13 and at 11:10 A.M. on 7/1/13. RMD said she repeatedly called the PES Behavioral Health Director to interview about PES quality monitoring but the PES Director did not return the telephone calls.

The document titled "Psychiatric Evaluation Services Agreement" dated 5/18/06 indicated that the company will assist the Hospital in meeting applicable accreditation and licensing standards relating to face-to-face evaluations, and participate as reasonably necessary in the accreditation and licensing survey process.

The Hospital did not submit for Surveyor review, PES QAPI monitoring activity document(s), Hospital committee minutes or Hospital report(s) confirming a PES QAPI program existed.