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.

JEFFERSON STRATFORD HOSPITAL 18 EAST LAUREL ROAD STRATFORD, NJ 08084 Nov. 28, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of the medical records of 37 patients, review of hospital policies and procedures, interviews with administrative staff, review of staff credentials, and review of related documentation, it was determined that the hospital failed to protect and promote the rights of each patient:

Findings include:

1. The facility failed to ensure that a copy of the patient's rights were provided to each patient. (Refer to Tag A 117)

2. The facility failed to ensure that all posted patient rights signs are accordance with State regulations for hospital patients. (Refer to Tag A 117)

3. The facility failed to ensure that patients had the right to receive care in a safe setting. (Refer to Tag A 144)

4. The facility failed to ensure that the use of restraints was in accordance with the order of a physician or other licensed independent practitioner authorized to order restraint by hospital policy. (Refer to Tag A 168)

5. The facility failed to ensure that restraints were discontinued at the earliest possible time. (Refer to Tag A 174)

6. The facility failed to ensure that patients restrained for violent or self-destructive behavior were seen face-to-face by a physician within one (1) hour of the initiation of restraint. (Refer to Tag A 178)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Cherry Hill
A. Based on medical record review, staff interview, and review of facility policy, it was determined that the facility failed to ensure a copy of the patient's rights is provided to each patient, in ten (10) of seventeen medical records reviewed.

Findings include:

Reference: Facility Policy Number A121, titled, "Patient Rights & Responsibilities" states, "PURPOSE To ensure communication to the patient, and when appropriate, the healthcare representative to promote and support his/her rights when receiving care, treatment, and services within --[Facility name]-- Hospital. POLICY ... A copy of these rights and responsibilities are given to the patient and when appropriate, the healthcare representative ... at the time of admission to our organization. These rights are provided and explained in a manner that the patient (or healthcare representative) can understand. ..."

1. Review of Medical Records #CH6 and #CH9 lacked evidence on the 'PATIENT ACKNOWLEDGEMENT FORM' that a Patient Rights Brochure was given to the patient or the patient's healthcare representative.

a. Medical Record #CH6 indicated the patient was a minor and his/her mother signed the 'PATIENT ACKNOWLEDGEMENT FORM' on 5/21/18 at 0105. The 'yes' or 'no' checkboxes that indicates the provision of the Patient Rights Brochure was not checked off, and was blank.

b. Medical Record #CH9 indicated the patient signed the 'PATIENT ACKNOWLEDGEMENT FORM' on 6/28/18 at 1342. The 'yes' or 'no' checkboxes that indicates the provision of the Patient Rights Brochure was not checked off, and was blank.

2. On 11/28/18 at 3:45 PM, Staff #21 stated during interview that the Patient Rights Brochure is offered to every patient in the Emergency Department (ED) at the time of full registration, and the 'yes' checkbox or 'no' checkbox should be checked to indicate that the patient was offered and received the Patient Rights Brochure, or offered but did not want the brochure. Staff #21 stated there should be a checkmark in either the 'yes' or 'no' box on the 'PATIENT ACKNOWLEDGEMENT FORM' in the patient medical records.





3. Seven medical records were reviewed on 11/28/18: #CH1 (Cherry Hill), #CH3, #CH4, #CH5, #CH7, #CH8, and #CH10.

a. Five out of the seven medical records, #CH1, #CH3, #CH4, #CH5, and #CH7, were not noted on the "Patient Acknowledgement Form" that the patient's had received a patient rights brochure.

b. The above findings were confirmed with Staff #9.





Stratford
4. On 11/28/18, medical record review was conducted at the Stratford (ST) campus and two (2) out of seven (7) medical records lacked documented evidence that patients received a copy of Patient Rights.

a. Medical Record #ST5 lacked any documented evidence that the patient received a copy of Patient Rights.

b. In Medical Record #ST7, the "Patient Acknowledgement Form" dated 5/22/18 at 8:52 PM states, "Patient Rights Brochure - copy given to patient ... No ... Patient unable to consent because: patient in/out consciousness from overdose."

(i) Patient #ST7 regained consciousness and was discharged from the Stratford Emergency Department three (3) hours and ten (10) minutes later. Upon further review, there was no documented evidence that indicated the patient received his/her patient rights at any point during this visit.





Washington Township
B. Based on observation, staff interview, and facility document review, it was determined that the facility failed to ensure that all posted patient rights signs are in accordance with State regulations for hospital patients.

Findings include:

Reference: Facility policy titled, "Patient Rights & Responsibilities" states, "... a copy of these rights and responsibilities are posted in patient rooms and in public areas throughout our campuses ... Hospital Patient Rights ..."

1. On 11/27/18 at 10:00 AM, during a tour of the Washington Township Emergency Department (ED) in the presence of Staff #WA4, #WA5, and #WA8, it was noted that there were Ambulatory Patient Rights signs posted throughout the ED, including but not limited to the ED waiting area/lobby, ED triage Room, ED hallway, and in the ED patient rooms.

a. The approved Hospital Patient Rights were not posted throughout the ED, including but not limited to the ED waiting area/lobby, ED triage room, ED hallway, and ED patient rooms.

b. The above findings were confirmed by Staff #WA4 and Staff #WA5.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Cherry Hill
A. Based on observation, staff interview, medical record review of two (2) of three (3) patients, and review of facility policy and procedure, it was determined that the facility failed to ensure suicide precautions are implemented to ensure a patient's safety.

Findings include:

Reference #1: Facility Policy Number S-8, titled, "Suicide Risk Assessment and Interventions for Adolescent and Adult Patients" states:
"POLICY
To effectively reduce the risk of suicide in the inpatient and emergency department settings; --[facility name]-- hospital identifies patients at risk of suicide and then intervenes to prevent suicide in those patients identified at risk.
...
PROCEDURE:
Suicide Risk Screening and Intervention
STEPS
1. Screen for suicide risk:
* Adolescent and adult emergency department (ED) patients ... are screened for risk of suicide, using the Screening tool Questions
...
2. Obtain Total Score
Initiate interventions based upon total score
Total Score 0 - no further intervention required
Total Score 1 - Notify Physician
.....
Total Score 2 or greater- Notify Physician and implement Suicide Precautions
...
3. Implement Suicide Precautions as Indicated.
* Implement Suicide precautions based upon a Tiered Intervention System (Moderate Risk or High risk) for patients with active suicidal thoughts- total risk assessment screen score 2 or greater.
...
Moderate Risk Suicide Interventions: ...
In addition to orders given by the physician, other interventions to prevent suicide in those patients with increased risk may be implemented:
...
10. During hand-off procedures (from practitioner to practitioner [sic], ... communicate changes in the individual's condition or if the patient exhibits warning signs.
High Suicide Risk Signs or Symptoms: ...
* Thoughts of killing themselves with defined plan (lethality)
...
Aggressive threats/acts
...
High risk Suicide Interventions: ...
...
* Therapeutic Sitter, as ordered (see policy A138)
..."

Reference #2: Facility Policy Number A138, titled, "Therapeutic Sitter (1:1) Observation", states:
...
SCOPE
...
2. Definition of Terms:
...
d. Therapeutic Sitter One-to-One (1:1) Sitter: Continuous 1:1 monitoring by a qualified staff member for a patient who presents an immediate or actual threat of harm to themselves and/or others. The patient remains within direct visualization and continuous supervision at all times.
...
POLICY:
...
2. Documentation Requirements include:
a. The Therapeutic Sitter is responsible for documenting on the Patient Observation Checklist every 15 minutes. ...
PROCEDURE:
...
5. The Therapeutic sitter will document on the Patient Observation checklist every 15 minutes. ..."

1. On 11/28/18 at 3:45 PM, at the Cherry Hill Campus, the Emergency Department (ED) was toured in the presence of Staff #CH3 and Staff #CH9. The Behavioral Results Pending (BRP) Room was observed to have three (3) patients. Two (2) of the patients had a hospital staff member assigned to their individual observation.

2. Staff #CH23 was assigned 1:1 observation to Patient #CH11. At 4:05 PM, the surveyor requested from Staff #CH23, the observation form for review. Staff #CH23 stated he/she did not have one, and did not need to document on an observation form, because this room is a safe room. He/She was monitoring Patient #CH11 because he/she was a minor, and his/her parents did not arrive to the ED yet. Staff #CH23 stated the patient was brought in to the ED by the police for acting out at school. Staff #CH23 further stated that the observation checklist is only used for suicidal or homicidal patient observations.

a. Staff #CH25, the Registered Nurse assigned to the BRP room, was interviewed at 4:15 PM. He/She reviewed the two sitters patient assignments stating one was for safety; an elderly patient with dementia and possible falls and elopement risk. The second, Patient #CH11, assigned to Staff #CH23, was a Therapeutic observation for active suicidal ideation (SI).

b. Medical Record #CH11 was reviewed in the presence of Staff #3. The triage notes dated 11/28/18 at 15:08 indicate the patient was brought to the ED by police from school for crisis evaluation. Per the police, the patient wrote a note about being suicidal. Documentation in the Safety Assessment in triage states, "Patient agrees with statement: I would like to kill myself., Risk Level:2, ... Suicide precautions initiated." A physician order for a Therapeutic Sitter (1:1) was evident in the medical record.

3. It could not be determined if proper hand off communication was completed to ensure Patient #CH11's safety in the ED.

a. During interview with Staff #CH23 above, he/she did not communicate knowledge of Patient #CH11's suicide risk.

b. At 4:05 PM, when requested of Staff #CH23, a Patient Observation Checklist for Patient #CH11 was not provided.

4. At 4:20 PM, Staff #CH3 provided a completed Patient Observation Checklist for Patient #CH11, from the time of 1500 [3:00 PM] to 1630 [4:30 PM], with documented checks at each 15 minute intervals by Staff #CH23.

a. The observation checks were not completed at the actual time of the observations.




Washington Township
5. A review of Medical Record #WA1 revealed a "Therapeutic Sitter (1:1)" was ordered starting on November 22, 2018 at 1:07 AM.

a. Documented evidence on the "PATIENT OBSERVATION CHECKLIST" forms lacked evidence of the initials of the observer responsible for Patient #WA1 on the following dates and times:

(i) 11/22/18: 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM, 3:30 AM, 3:45 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:45 AM, 5:00 AM, 5:15 AM, 5:30 AM, 5:45 AM, and 6:00 AM.

(ii) 11/23/18: 2:30 PM

(iii) 11/25/18: 8:15 PM

(iv) 11/26/18: 7:45 AM

6. The above finding was confirmed with Staff #WA8 and Staff #WA12 on 11/27/18 at 10:42 AM.





Stratford
B. Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure that policies related to patient safety are implemented.

Findings include:

Reference #1: A policy authored by the Patient Safety Committee titled, "Reportable Events to Outside Agencies unrelated to The Patient Safety Act", states, " ... Definition A. Reportable Events Requiring Notification of the Department of Health (DOH) no later than three hours after the discovery of the event: ... 7. Criminal Acts ... Note: A health care facility shall immediately report to the appropriate police authorities all criminal acts or potentially criminal acts that occur within a facility and pose a danger to the life or safety of patients or residents, associates, medical staff, or members of the public present in the facility. ...".

Reference #2: A policy authored by Security Leadership titled, "Law Enforcement Notification", states, "... Scope: ... Crimes may consist of ... Possession of certain kinds of weapons/contraband... ".

1. An incident occurred in the Stratford Emergency Department (ST-ED) where local police notification occurred, but the event was not reported to the New Jersey DOH as required by facility policy.

a. Medical Record #ST2, dated and timed 7/28/18 at 3:28 AM, states, "Patient was seen in this ED [Emergency Department] earlier for asthma exacerbation, left AMA [Against Medical Advice] ... Housekeeping staff found patient on the floor in the bathroom with needle [sic] in his/her arm. Patient awoke with sternal rub ... ."

b. The "Safety Event Entry" that was reported on 7/29/18 at 4:32 AM states, " ... Safety Event Classification ... CS/O ____ called Stratford PD [Police Department] to pick up drug items found during a search of belongings for [Patient #ST2] ... [Patient #ST2] belongings being [sic] searched further for any other drugs or needles. Drugs turned over to Stratford Officer ____ and 2 [two] needles thrown into ED sharps container ... ."

c. During an interview with Staff #ST20, it was confirmed that the facility did not report the above incident to the New Jersey DOH.

C. Based on observation and staff interviews conducted on 11/27/18, it was determined that the facility failed to ensure a safe and sanitary environment in the Emergency Department (ED) at the Stratford Campus.

Findings include:

1. During a tour of the Stratford ED, the following was observed:

a. Main Nurse's Station:

(i) Heavy accumulation of dust was evident on the top of a black 3-drawer filing cabinet and a small 4-drawer metal cabinet. All drawers inside the black 3-drawer filing cabinet also contained heavy accumulation of dust.

(ii) Heavy accumulation of dust was observed behind all computer monitors and all wiring from the desktop down to its respective wall receptacles.

(iii) Dust, grit, and paper scraps were observed on all floor areas under the desktops, especially in the corners which had heavy dust accumulation.

(iv) Two plastic bins under the counter had dust atop them and inside of the drawers.

(v) The above was confirmed with Staff #ST3 and Staff #ST9.

b. Satellite C Area:

(i) The mattress in an empty patient bay, which had been cleaned after the previous patient had been discharged , had residue of the glue and paper of an EKG lead.

(ii) Dust accumulations were observed in the cabinet shelving and on storage bins located inside of the cabinets.

(iii) The "Respiratory" drawer in a cabinet contained grit, paper scraps, used wrappers, and vial caps.

(iv) During an interview, Staff #ST15 stated that the cabinets are supposed to be cleaned by the Environmental Services department daily, but it does not occur as planned and he/she tries to help when he/she has available time.

(v) The following expired items were stocked in the cabinet and available for patient use:

- Three (3) 18 and 1 -gauge BD Eclipse Needles with expiration dates of "3/18" (3/31/18).

- One (1) 21-gauge BD Eclipse Needle with an expiration date of "10/17" (10/31/17).

- One (1) Kendall 4 (four) inch by 10 (ten) inch Window Transparent Film Dressing with an expiration of "10/2017" (10/31/17).

(vi) The above was confirmed with Staff #S15.

c. Ready Room:

(i) The cabinet adjacent to Room #4 had a visible accumulation of dust on the inside shelves.

(ii) Dust accumulation and orange crumbs were noted inside two (2) drawers adjacent to Room #4.

(iii) A cabinet in the Nurse's Area had a dried, tacky stain on the floor beneath it.

(iv) A cabinet beneath the counter top in the Nurse's Area had heavy dust atop it and a spilled container of orange crackers and crumbs, heavy dust, grit, paper, books, and other refuse beneath and behind it. A tan metal cabinet in the same area had dust atop, on the sides, on the back, and beneath it.

(v) A paper shredder box had spilled liquid, dust, and grit on the floor beneath it.

(vi) A cabinet above the sink in the handwashing station contained one Vaccutainer with an expiration date of "2015-11" (11/30/15).

(vii) The mattress in Bay #3, which had been cleaned after the previous patient had been discharged , had residue of the glue and paper of an EKG lead.

(viii) The "Ebola Closet" contained a red cart with 4 packages of Triflex Orthopedic sterile latex gloves with an expiration date of "2018-10" (10/31/18).

(ix) The above observations were confirmed with Staff #ST14.

d. Waiting Room Rest Room: There was a heavy dust accumulation around the ceiling light and dead insects atop the light cover.

e. Ortho (Orthopedic) Storage Area: There were dead insects atop the light cover.

f. Triage Room:

(i) A travel cup with a swizzle stick coming out of the lid was in a cabinet with lab supplies.

(ii) The glucometer kit had a Level 1 Control container with the discard date worn off of the label.

(iii) There were dead insects atop ceiling light covers.

g. Pantry Area (outside of Bays #3 and #4):

(i) There were food particles and spillage inside and under the microwave oven.

(ii) Inside of the refrigerator was a small, unmarked plastic bottle with a hole in the cap. The bottle contained a clear liquid inside of it.

f. Medication Room:

(i) On the floor, beneath the sink, was one live brown ant, grit, dust, vial caps, and paper scraps.

(ii) Blue bins containing 18, 20, and 22 gauge spiral needles; eye pads; eye shields; and Morgan lenses had heavy dust inside and on the outside of them.

(iii) The Pyxis machine had dust atop it and at the base of the computer screen.

(iv) There was dust on the exterior of the ceiling light covers.

g. Nurses Satellite Area: The "IV" wall cabinet had a tacky substance and a black substance on the bottom shelf.

h. Satellite B Area:

(i) The respiratory drawer had tacky spillage stains, vial caps, wrappers, and grit inside of it.

(ii) There was dust hanging from a wall light and atop it.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Stratford
A. Based on review of the medical record of two of four patients physically restrained, it was determined that the use of restraint was not in accordance with the order of a physician or other licensed independent practitioner authorized to order restraint by hospital policy.

Findings include:

Reference: Policy and procedure titled, "Restraints and Seclusion" states:
"PURPOSE: To guide the appropriate and safe management of patients in restraints.
.....
SCOPE:
.....
D. Order Requirement: An order from the licensed provider is needed prior to the application of restraints or seclusion. .....
.....
PROCEDURE:
.....
4. Steps
The licensed provider writes an order authorizing the use of restraints or seclusion"
Key Points
All physician components on the restraint tool must be completed in its entirety to be considered a valid order.
....."

1. Review of the medical record of Patient #ST13 revealed:

a. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 10/31/18 at 2200 included the entry: "Both." The type of restraints or specific limbs to be restrained were not included in the order.

b. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 11/1/18 at 2:00 AM included the entries: "Both." The type of restraints or specific limbs to be restrained were not included in the order.

c. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 10/31/18 at 6:00 AM included the entries: "Soft" and "Both." The specific limbs to be restrained were not included in the order.

d. Administrator #ST1 agreed with the findings.





Washington Township
2. A review of Medical Record #WA5 revealed that the patient was placed in restraints for "Violent or Self-Destructive" behavior on 11/24/18 at 5:35 PM.

a. The "RESTRAINT ORDER AND FLOW SHEET" lacked evidence of a physician's signature, date, and time on the "PHYSICIAN ORDER SECTION" of the form.

b. This finding was confirmed with Staff #WA8 on 11/27/18 at 2:15 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Stratford
Based on review of facility policy and procedure and the medical records of five patients who were physically restrained at the Stratford Campus, it was determined that one of five patients did not have restraints discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

Reference: Policy and procedure titled, "Restraints and Seclusion" states:
"PURPOSE: To guide the appropriate and safe management of patients in restraints.
.....
POLICY:
.....
1. As an initial matter, all patients have the right to be free from any form of restraint or seclusion imposed as a means of coercion, discipline, convenience, or retaliation by staff.
2. Restraints or seclusion will only be used as a temporary measure to prevent harm to patients, staff members, or others. Restraints or seclusion must be discontinued at the earliest possible time based upon individual patient assessment and the re-evaluation for resolution of the specific behavioral changes. .....
.....
PROCEDURE:
.....
4. Steps
The licensed provider writes an order authorizing the use of restraints or seclusion"
Key Points
All physician components on the restraint tool must be completed in its entirety to be considered a valid order.
....."

1. Review of the medical record of Patient #ST13 revealed:

a. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 10/31/18 at 2200 included the entry: "Both." The type of restraints or specific limbs to be restrained were not included in the order.

b. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 11/1/18 at 2:00 AM included the entries: "Both." The type of restraints or specific limbs to be restrained were not included in the order.

c. The "Indicate Type of Restraint/Device" section of a RESTRAINT ORDER AND FLOW SHEET dated 10/31/18 at 6:00 AM included the entries: "Soft" and "Both." The specific limbs to be restrained were not included in the order.

d. The "Reason for Restraint (Behaviors that warrant the use)" section of a RESTRAINT ORDER AND FLOW SHEET dated 10/31/18 at 2200 included the entry: "Combative, violent." The RN MONITORING section of a RESTRAINT ORDER AND FLOW SHEET included entries indicating that the patient was "Disoriented" and "Restless" at 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, and 1:45 AM on 11/1/18. There was no evidence that the patient exhibited the behaviors justifying the use of physical restraints at these times and the restraints should have been discontinued.

e. The "Reason for Restraint (Behaviors that warrant the use)" section of a RESTRAINT ORDER AND FLOW SHEET dated 11/1/18 at 2:00 AM included the entry: "Combative, violent." The RN MONITORING section of a RESTRAINT ORDER AND FLOW SHEET included entries indicating that the patient was "Disoriented" and "Restless" every 15 minutes between 2:00 AM and 5:45 AM on 11/1/18. There was no evidence that the patient exhibited the behaviors justifying the use of physical restraints at these times and the restraints should have been discontinued.

f. The "Reason for Restraint (Behaviors that warrant the use)" section of a RESTRAINT ORDER AND FLOW SHEET dated 11/1/18 at 6:00 AM included the entry: "Combative, violent." The RN MONITORING section of a RESTRAINT ORDER AND FLOW SHEET included entries indicating that the patient was "Disoriented" and "Restless" at 6:00 AM, 6:15 AM, and 6:30 AM on 11/1/18. There was no evidence that the patient exhibited the behaviors justifying the use of physical restraints at these times and the restraints should have been discontinued.

2. Administrator #ST1 agreed with the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Washington Township
Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that patients restrained for violent or self-destructive behavior are seen face-to-face by a physician within one (1) hour of the initiation of restraint for two (2) out of two (2) patients reviewed at the Washington Township Campus.

Findings include:

Reference: Facility policy titled, "Restraints and Seclusion", states, "... PROCEDURE: ... 3. ... a. The licensed provider conducts a face-to-face in-person patient assessment (evaluation) within 1 hour of the application of restraints or seclusion for the violent or self-destructive patient and documents required findings within the designated section of the restraint order form. ..."

1. A review of Medical Record #WA1 revealed that the patient was placed in restraints for "Violent or Self-Destructive" behavior on 11/26/18 at 10:30 AM.

a. The physician's face-to-face assessment following the application of restraints lacked evidence of the date and time it was conducted. Therefore, it could not be determined if the assessment occurred within one (1) hour of the initiation of restraints.

2. A review of Medical Record #WA5 revealed that the patient was placed in restraints for "Violent or Self-Destructive" behavior on 11/26/18 at 1:15 PM.

a. The physician's face-to-face assessment following the application of restraints lacked evidence of the date and time it was conducted. Therefore, it could not be determined if the assessment occurred within one (1) hour of the initiation of restraints.

3. The above findings were confirmed with Staff #WA8 on 11/27/18 at 2:15 PM.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on a review of the medical records of 37 patients, interviews with administrative staff, tours of the emergency departments of three campuses, a review of hospital policies and procedures, and a review of related documentation, it was determined that the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice.

Findings include:

1. The facility failed to ensure that emergency services were integrated with other departments of the hospital. (Refer to Tag A 1103)

2. The facility failed to ensure that policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. (Refer to Tag A 1104)
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Stratford
A. Based on a tour of the emergency department at the Stratford Campus, review of hospital policy and procedure, review of a contract, and interview with administrative staff, it was determined that emergency services are not integrated with other departments of the hospital.

Findings include:

Reference #1: Central Processing Department policy and procedure titled, "Preventative Maintenance of CPD (Central Processing Department) Equipment" states:
"PURPOSE: To define a procedure to insure that preventative maintenance of CPD equipment is performed.
RESPONSIBILITIES: It is the responsibility of the CPD Assistant Manager/Supervisor and the BioMed technician to check the dates on the inspection sticker and take corrective action as needed. The Bio-Medical Department representative is responsible for performing the required service inspections as outlined below. The CPD Assistant Manager/Supervisor is responsible for the enforcement of this policy.
.....
POLICY: The Bio-medical Department shall be responsible to provide necessary inspections of Central Processing Department (CPD) equipment to verify accurate functioning and service performance.
PROCEDURE:
1. CPD electronic medical device service and preventative maintenance is overseen by Biomedical Engineering.
.....
b. In order to insure that all medical electronic CPD devices are safe for use:
i. The user verifies that the devices have a valid safety inspection sticker and [sic]
ii. The user performs an operational check prior to use
...
3. Required inspection of services shall be made: [sic]
.....
7. Scheduled/Routine inspection.
8. Process of notification for inspection and services as follows: [sic]
9. CPD shall notify the Bio-Medical Department (via the HELPDESK) of the need for inspection and services for applicable equipment.
10. The Bio-Medical Department shall be responsible to provide a program for scheduled/routine inspection and services at criteria-based maintenance intervals in accordance with the Joint Commission and NJDOH (New Jersey Department of Health) standards.
11. If equipment is under a preventative maintenance contract with the O.E.M. (original equipment manufacturer)
Bio-Medical will notify the O.E.M. for needed repairs and service. The O.E.M. will be responsible for adhering to the preventative maintenance agreement scheduled.
12. Maintenance of records for inspection and services: [sic]
13. CPD and Bio-Medical Departments shall identify all equipment by nomenclature, model number, part number, manufacturer, and the history of services.
14. An 'Inspection Tag' shall be affixed, [sic] by the Bio-Medical Department representative upon completion of said inspection with date, identification of person performing inspection and department.
15. The Inspection tag shall not be removed by anyone other than a representative of the Bio-Medical Department."

Reference #2: A contract titled "ONE YEAR AGREEMENT BETWEEN MAJOR MEDICAL HOSPITAL SERVICES, INC AND Jefferson Memorial Hospital Systems" states that 151 Continuous Suction Regulators and 122 Intermittent/Continuous Suction Regulators at the Stratford Campus would have annual inspection, cleaning, and inventorying. The contract was dated March 1, 2018.

1. A tour of the 'Ready Room' of the Stratford Campus Emergency Department on 11/27/18 revealed:

a. A locked cabinet in Bay #3 contained a suction regulator with a tag indicating that it was calibrated in "4/15" (April 2015) and was due for calibration in "4/16" (April 2016); and a suction regulator with a tag indicating that it was calibrated in "3/17" (March 2017) and was due for calibration in "3/18" (March 2018).

b. A locked cabinet in Bay# 4 contained a suction regulator with a tag indicating that it was calibrated in "4/15" (April 2015) and was due for calibration in "4/16" (April 2016).

2. Administrator #19 agreed with the findings.




Washington Township
B. Based on medical record review and staff interview, it was determined that the facility failed to ensure that there is coordination and communication between the Emergency Department (ED) and the contracted provider for Crisis and emergency intervention services on the Washington Township Campus.

Findings include:

1. During an interview on 11/27/18 at 10:45 AM, Staff #WA4 stated that emergency room patients who require a crisis screening would be seen by a screener from (name of crisis/behavioral health facility).

a. At 11:00 AM, Staff #WA10 stated that the crisis screeners do not chart their findings in the medical record and do not give a written report after speaking with a ED patient that is in crisis.

(i) Staff #WA10 and Staff #WA17 stated that the ED staff will have a discussion with the (name of crisis/behavioral health facility) crisis screener regarding the patient's condition but that the discussion or the crisis screeners findings are not always documented in the medical record.

2. A review of Medical Record #WA6 contained a physician's order, dated 8/24/18, that stated "Medically Cleared for Crisis Screener."

a. Medical Record #WA6 contained a Psychiatric Emergency Screening Center Center - (name of county) Outreach Request Form, requesting a crisis screener see Patient #WA6 for Suicidal ideation's.

(i) There was no evidence that the crisis screener evaluated Patient #WA6 as requested by the physician.






3. A review of Medical Record #WA7 contained evidence that the patient was referred to Crisis for screening related to suicidal ideation on 7/4/18 at 9:43 PM.

a. A nursing note dated 7/5/18 at 12:19 PM states, "Crisis at bedside to eval [evaluate] pt. [patient]."

b. Documented evidence in a discharge note dated 7/5/18 at 3:12 PM states that the patient was discharged home at this time.

(i) The medical record lacks evidence that the patient was cleared for discharge by the Crisis screener performing the evaluation.

c. The above finding was confirmed with Staff #WA13 on 11/28/18.





Cherry Hill
C. Based on document review, staff interviews, and observation, it was determined that the facility failed to integrate and coordinate services provided by other departments of the hospital.

Findings include:

Reference #1: Policy titled "Admission to Behavioral Health Inpatient Services" states, "... Procedure ... 1. Referrals may be taken by a Registered Nurse (RN), Master's Level Clinician (MLC) or Social Worker (SW) ..... 4. Referrals may not be rejected by anyone other than: The Attending Physician/Psychiatric Resident, Nurse Manager, or Clinical/Corporate Director for Behavioral Health Services in consultation with the Attending Psychiatrist/Psychiatric Resident when medical/clinical issues arise, or, The Nurse Manager, Corporate/Clinical Director for Behavioral Health services or designee when operational or service related issues arise ... ."

Reference #2: Policy titled "Admission Criteria Adult Inpatient Mental Health Unit (West Pavilion)" states, "...Policy ... Voluntary Admissions: Individuals must meet the following criteria in order to be admitted to the West Pavilion: 1. A mental disorder (DSM 5 in definition) is present..... 5. One or more of the following are present: ... c. Persistent suicide ideation ..... f. Bizarre behavior, agitation, ... depression ... ."

1. On 11/28/18, the medical record of Patient #CH1 (Cherry Hill) was reviewed. Patient #CH1 presented to the facility emergency department (ED) on 5/24/18 for an evaluation of depression with suicidal ideation. Staff #CH7, an ED nurse, performed a safety assessment at 11:11 AM, and assessed Patient #CH1 with a suicide risk level 1 and suicide precautions were initiated.

a. On 5/24/18 at 11:49 AM, it was noted by Staff #CH29, an ED physician, that the patient stated he/she had a plan, wrote a letter, and had wanted to end his/her life overnight.

(i) Staff #CH29 noted at 11:49 AM that Patient #CH1 appeared agitated and anxious.

(ii) Staff #CH29 also indicated that the patient's symptoms were worsening, were constant, and were associated with suicidal thoughts.

2. A physical exam was conducted at 11:54 AM by Staff #CH29 that indicated that Patient #CH1 was tachycardic, hypertensive, and appeared uncomfortable.

a. Staff #CH29 indicated in the psychiatric portion of the exam that Patient #CH1 was anxious with poor judgement, and had suicidal ideation's present with a plan.

3. Staff #CH14, a master's level clinician, noted on 5/24/18 at 12:11 PM that "...pt [patient] came to the ED... because [he/she] has ongoing depression and suicidal ideations..... Pt's mood is depressed with a flat affect... Pt stated [he/she] has not received any Psychiatric Treatment since Oct [October] 2017..... Pt reports that is [sic] [he/she] would leave the hospital today [he/she] would buy 10 bags of heroin and shoot up and kill [himself/herself]..... Pt's [family member] agrees with pt's statement and stated that [he/she] does not feel pt is safe to leave the hospital at this time and knows that pt will kill [himself/herself] if [he/she] leaves the hospital. ....."

a. There was a lack of documentation in the note that indicated a referral for inpatient admission.

b. There was no order noted in the medical record by a physician for crisis evaluation and/or behavioral health evaluation.

(i) There was a lack of documentation that the patient had been medically cleared for a crisis and/or a behavioral health evaluation.

4. Staff #CH7 assessed Patient #CH1 at 12:18 PM and noted that suicidal ideations were present.

5. Staff #CH14 noted at 1:42 PM, "...INTERVENTIONS: Consulted with ED Provider/Interdisciplinary Team, Met with patient, Met with parent/Family/Caregiver....."

a. There was a lack of documentation of what interventions were provided at that time.

6. Staff #CH14 indicated in a note written at 1:42 PM that the patient was denied inpatient admission at the facility, and that the patient and family felt that the patient had stabilized and was no longer suicidal.

a. It was unclear why Patient #CH1 was denied inpatient admission to the facility.

(i) There was a lack of evidence of referrals made to other facilities.

b. Staff #CH14 also indicated in the note that Patient #CH1 would be discharged to home-no services needed.

c. It was unclear what interventions were provided, and by whom, that had stabilized Patient #CH1 during the 1 hour and 29 minutes in between the notes written by Staff #CH14.

7. Patient #CH1 was discharged on [DATE] at 1:59 PM.

a. Staff #CH29 indicated in a note written at 1:52 PM, "...I expressed my concerns and explained to return to the ED at any time....."

(i) There was a lack of evidence that indicated Patient #CH1 was stable for discharge home.

8. The facility was unable to provide the following evidence of the referral process pertaining to Patient #CH1 for inpatient services:

a. The facility was unable to provide evidence that a psychiatrist evaluated the patient.

b. The facility was unable to provide evidence of who rejected the inpatient referral.

c. The facility was unable to provide evidence of the reasons why the referral was rejected.

9. Staff #CH9 confirmed the above findings.

D. Based on medical record review and staff interview, it was determined that the facility failed to ensure that there is coordination and communication between the Emergency Department (ED) and the contracted provider for Crisis and emergency intervention services on the Cherry Hill Campus.

Findings include:

1. During an interview with Staff #CH3, Staff#CH4, and Staff #CH8, it was stated that emergency room patients who require a crisis screening would be seen by a screener from (name of crisis/behavioral health facility).

a. It was also revealed in an interview with Staff #CH3 and Staff #CH4 that a crisis screening/evaluation would be physician order driven.

b. Staff #CH3 and Staff #CH8 stated that the (name of crisis/behavioral health facility) crisis screeners do not chart their findings in the medical record and do not give a written report after speaking with a ED patient that was in crisis.

c. Staff #CH3 and Staff #CH8 stated that ED providers should document that the patient was screened by crisis.

2. A review of four (4) medical records (#CH4, #CH5, #CH6 and #CH7) that were evaluated by crisis revealed that the evaluation was not placed in the medical records.

a. Patient #CH4 had a physician's order that indicated medically cleared for behavioral health evaluation, but it noted that the patient was seen by crisis.

(i) Staff #CH30 indicated in a note written on 6/26/18 at 7:39 PM that the patient's disposition was placed per crisis recommendations.

(ii) The medical record lacked documentation of the crisis recommendations.

b. Patient #CH5 had a physician's order that indicated that the patient was medically cleared for a crisis screener.

(i) Staff #CH31 indicated in a note that the patient's disposition was made by crisis.

(ii) The medical record lacked evidence of the crisis recommendations and disposition.

c. A physician order dated 5/21/18 in Medical Record #CH6 directed that the patient was "Medically cleared for Crisis Screener."

(i) A note by the ED physician at 0453 on 5/21/18 stated, "Patient seen and evaluated by crisis. Disposition placed per crisis recommendations."

(ii) The medical record lacked evidence of the crisis recommendations and disposition.

(iii) On 11/28/18 at 2:00 PM, Staff #9 obtained and provided from the Crisis Unit staff, the crisis notes for patient #CH6's visit on 5/21/18.

d. Patient #CH7 had a physician's order written on 8/15/18 at 12:47 PM that indicated that the patient was medically cleared for a crisis screener.

(i) The medical record revealed a note written by Staff #CH12 on 8/15/18 at 1:15 PM of a behavioral health assessment. Staff #CH12 is not a crisis screener.

(ii) There was no documented evidence in the medical record of Patient #CH7 that indicated the patient was seen by a crisis screener as requested by the physician.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Cherry Hill
A. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure patients identified as at risk for suicide, had their belongings checked for contraband in accordance with facility policy, in two (2) of three (3) medical records reviewed at the Cherry Hill campus on 11/28/18 (Medical Records #CH6 & #CH9).

Findings include:

Reference: Facility Policy Number S-8, titled, "Suicide Risk Assessment and Interventions for Adolescent and Adult Patients," states, "POLICY To effectively reduce the risk of suicide in the inpatient and emergency department settings; --[facility name]-- hospital identifies patients at risk of suicide and then intervenes to prevent suicide in those patients identified at risk. ... PROCEDURE: ... 3. Implement Suicide Precautions as Indicated. [bullet] Implement Suicide precautions based upon a Tiered Intervention System (Moderate Risk or High risk) for patients with active suicidal thoughts- total risk assessment screen score 2 or greater. ... Moderate Risk Suicide Interventions: ... In addition to orders given by the physician, other interventions to prevent suicide in those patients with increased risk may be implemented: 1. Inventory patient belongings 2. Check the patient for contraband ... 4. Create a safe environment. Belongings secured. ..."

1. A review of Medical Record #CH6 indicated per the triage notes dated 5/21/18 at 00:01 that the patient was sad all the time, had thoughts of hurting himself/herself, and was currently suicidal without a plan. Documentation in the Safety Assessment section of triage notes states, "Patient agrees with statement: I would like to kill myself., (sic) Risk Level: 2, ..."

a. There was no evidence in the medical record of an inventory of the patient's belongings for contraband.

b. On 11/28/18 at 2:20 PM, Staff #CH3 confirmed the above. Staff #CH3 stated that there was no evidence in the medical record that the patient was provided with green scrubs to change in to, and there was no evidence of a Patient Search Form.

2. A review of Medical Record #CH9 indicated per the triage notes dated 6/28/18 at 11:21, in the Safety Assessment section, that the "Patient admits thoughts to kill self, but denies willingness to act., (sic) Risk Level: 1, ... Suicide precautions initiated. ..."

a. There was no evidence in the medical record of an inventory of the patient's belongings for contraband.

b. On 11/28/18 at 2:30 PM, Staff #CH3 confirmed the above.





Washington Township
B. Based on medical record review, staff interview, facility policy review, it was determined that the facility failed to ensure that all patients receive discharge instructions upon discharge.

Findings include:

Reference: Facility policy, "Discharge Instructions" states, "... POLICY: Prior to discharge from the Emergency Department, each patient will receive written instructions regarding their diagnosis, treatment and follow-up care. ... PROCEDURE: [bullet} or patient representative signs the instructions indication [sic] that the patient/rep. (representative) understands treatment and follow-up care ..."

1. Medical Record #WA12 contained a Discharge Instruction Receipt, dated 4/18/18.

a. The patient signature section that indicated that the patient received the discharge instructions was left blank.

2. On 11/28/18 at 1:40 PM, Staff #WA10 confirmed the above findings.

Cherry Hill
C. Based on staff interview, it was determined that the facility failed to ensure that there was a policy and protocol in place that addresses the roles and involvement of hospital health professionals in the care of a behavioral health patient.

Findings include:

1. A tour of the Cherry Hill Emergency Department (ED) was conducted on 11/27/18 in the presence of Staff #CH3, Staff #CH4, and Staff #CH5. The following was noted:

a. Interviews with Staff #CH3, Staff #CH5, and Staff #CH9 confirmed that the facility has its own behavioral health team for ED evaluations as well as a contracted crisis service for ED psychiatric evaluations.

(i) Upon request, the Cherry Hill facility was unable to provide a policy or protocol that would address the individual roles of the behavioral health team and the crisis team in evaluating behavioral health patients.

(ii) Staff #8 stated during interview on 11/27/18 at 11:00 AM, that the physician will enter an order for Crisis to see a patient or for Behavioral Health. Staff #8 stated the order is specified by the doctor as to who the doctor wants to evaluate the patient; Crisis or Behavioral Health.

2. Review of two (2) out of three (3) medical records (#CH2, and #CH9) at the Cherry Hill campus of patients that the ED physician ordered to be evaluated by Crisis, lacked evidence that the patients were seen by Crisis, but were evaluated by the ED's behavioral health team as follows:

a. Documented evidence in the triage notes, on 4/13/18, in Medical Record #CH2 stated, "pt [patient] reports struggling with post partum depression and today feels suicidal with plan to take a bath and cut her wrists. ...". The Doctor's notes state, "... rev with pt need for medical eval. rev that ED does medical clearance and that crisis will eval for what services may be offered /needed regarsding (sic) acute emotional issue. pt ok with plan."

(i) The medical record contained evidence that the patient was seen and evaluated by Staff #CH12, a Social Worker (SW) from the facility. Staff #CH12 documented that the patient could plan for safety outside the hospital, did not need inpatient psychiatric treatment as she was not a danger to herself/others at this time, and planned for the patient to attend outpatient group therapy.

(ii) Staff #CH12 stated in an interview on 11/27/18 at 11:55 AM, that he/she reviews who is coming to the ED to see if he/she can see the patient instead of Crisis, because Crisis is usually very busy. He/she will see the patients that may be seeking voluntary psychiatric level of care. Staff #CH12 stated he/she is not a licensed screener so he/she cannot see involuntary type patients.

b. Documented evidence in the triage notes, on 6/28/18, in Medical Record #CH9 stated, "... Patient admits thoughts to kill self, but denies willingness to act. ...". The ED physician evaluated the patient and ordered "Medically Cleared for Crisis Screener."

(i) The medical record contained evidence per a digital signature by Staff #CH12, that the patient was seen and evaluated by him/her, however, the documented notes by the SW were from previous admissions on 6/20/18, and 6/12/18. There was no documented assessment of Patient #CH9 by the SW for this ED visit on 6/28/18.

(ii) A disposition note by an attending ED physician stated, "Patient was seen by BH Specialist who deemed patient safe for discharge."

(iii) There was no evidence in the medical record that Patient #CH9 contracted for safety prior to his/her discharge. This was confirmed by Staff #CH3 on 11/28/18 at 2:00 PM.

Washington Township
3. On 11/27/18 at 11:00 AM, upon request, Staff #WA14 was unable to provide a policy and procedure that would address the individual roles of the behavioral health team and the crisis team in evaluating behavioral health patients.





Washington Township
D. Based on medical record review, facility policy review, review of medical staff bylaws, and staff interview, it was determined that the facility failed to ensure that policies and procedures governing emergency medical care are implemented by the medical staff.

Findings include:

Reference #1: Facility policy titled, "Response Obligations for Physicians Covering ED [Emergency Department] Unassigned Patients EMTALA," states, "... Any patient presenting with an emergency medical condition must receive treatment, within the capability of Kennedy, to stabilize the emergent condition. ..."

Reference #2: Facility Medical Staff Bylaws state, "... 4. An emergent medical condition is defined as a life threatening condition manifesting itself by acute symptoms of severity (including pain or behavioral disorder) that could result in: a. Placing the health of the individual in serious jeopardy ..."

1. A review of Medical Record #WA8 revealed that the patient did not receive treatment for an emergency medical condition, as follows:

a. The patient was triaged in the ED on 7/27/18 at 12:42 PM.

(i) A triage note at this time states, "PT [patient] TEARFUL IN TRIAGE .PT [sic] REPORTS [he/she] IS "BASICALLY HOMELESS NOW", WAS LIVING WITH [his/her] UNCLE THEN GIRLFRIEND STATES [he/she] TRIED HANGING [himself/herself] YESTERDAY "I FEEL LIKE I WANT TO DIE" BECAUSE [he/she] HAS A LOT GOING ON. ..."

(ii) A safety assessment, which included a suicide risk assessment, was conducted at 12:53 PM and states, "...SAFETY ASSESSMENT: Patient agrees with statement: I would kill myself if I had the chance., ... Suicide precautions initiated. ..."

b. A physician performed a physical exam at 1:16 PM, which states, "... PSYCHIATRIC: ... Affect, flat, tearful, Suicidal ideations present, no plan, denies willingness to act while in the ED, Homicidal ideations present, without plan."

c. An assessment by Behavioral Health at 2:48 PM states, "ASSESSMENT: Notes: Behavioral Health Nurse Case Manager: Pt. was referred for assessment after [he/she] came to the ED reporting that [he/she] attempted to hang [himself/herself], is homeless and has no where to go. ... UDS [urine drug screen] is (+) [positive] cocaine. ... will be referred to [name of substance abuse counselors]. [He/She] states that [he/she] is tired of living this way and doesn't want to go on anymore. Dual bed search initiated. Chart will be faxed to [Facility name] for review. Pt presents with blunted affect and depressed mood. Dr. [Name] informed of same."

(i) The medical record lacks evidence that the patient was transferred to an inpatient facility as per the intent of the Behavioral Health Case Manager.

d. A nursing assessment at 3:04 PM states, "Psychiatric/social assessment findings include affect, crying, depressed, tearful, ... Suicidal ideations present, no homicidal ideations, Notes: pt states [he/she] is depressed and suicidal, feels as though [he/she] is not 'worth it'."

e. A physicians note at 3:15 PM states, "NOTES: Patient seen and evaluated by crisis, cleared for discharge home. Denies any suicidal or homicidal ideation. Given referrals."

(i) The medical record lacks evidence that the patient was seen and evaluated by crisis.

(ii) The medical record lacks evidence that Behavioral Health informed the physician that the patient was appropriate for discharge.

(iii) This note is inconsistent with the nursing note entered 11 minutes prior which stated that the patient was suicidal.

f. A discharge note from the registered nurse at 3:26 PM states, "DISCHARGE: Patient discharged to home, ambulating without assistance, transported via taxi, unaccompanied, ... Taxi voucher given to patient, Patient treated and evaluated by physician."

(i) The patient being discharged to "home" is inconsistent with documentation that the patient was homeless.

2. During an interview on 11/28/18 at 1:30 PM, Staff #WA21 stated that based on Patient #WA8's attempt at suicide, he/she should have been admitted as an inpatient. Staff #WA21 stated that the meaning of a "dual bed search" was to find an inpatient placement that would treat the patient's substance abuse and depression. Staff #WA21 stated that the patient should not have been discharged while awaiting his/her chart to be reviewed by an inpatient facility. Staff #WA21 stated that he/she checked with the facility substance abuse counselors referenced above and they did not have a record of the patient.

3. The ED physician (Staff #WA25) who treated Patient #WA8 on 7/27/18 was interviewed on 11/28/18 at 2:04 PM. Staff #WA25 stated that he/she could not remember this particular patient, but based on his/her notes in the medical record, Staff #WA25 believed that the patient was going to a rehab (rehabilitation) facility and was cleared for discharge.

4. The above findings were confirmed with Staff #WA8, Staff #WA13, Staff #WA14, and Staff #WA21 on 11/28/18 at 2:00 PM.





Cherry Hill
E. Based on document review and staff interview, it was determined that the facility failed to ensure that policies are in place to create a safe environment for the behavioral health patient.

Findings include:

Reference: Facility Policy, "Suicide Risk Assessment and Interventions for Adolescent and Adult Patients," states, "... PURPOSE Suicide risk assessment aids in identifying patients that may present an imminent or actual threat of harm to themselves. Environmental safety measures are implemented to minimize risk. .... Procedure: ... Moderate Risk suicide Interventions: ... 4. Create a safe environment. ..."

1. A tour of the emergency department (ED) was conducted on 11/27/18 in the presence of Staff #CH3, Staff #CH4, and Staff #CH5. The following was noted:

a. An interview with Staff #CH3 and Staff #CH4 indicated that there were no designated behavioral health rooms in the ED, and that each of the ED rooms could be converted into a safe room by removing items in the room.

b. Upon request, the facility was unable to provide a policy or procedure for creating a safe environment for converting the rooms for the behavioral health patients in the ED that would guide nursing practice.




Stratford
F. Based on medical record review, staff interview and review of facility documents, it was determined that the facility failed to ensure that psychiatric screening services are provided at all times in the Stratford Emergency Department (ED).

Findings include:

Reference: Facility Job Description for "Behavior Health Case Manager" states, " ... Minimum Knowledge, Skills & Abilities ... Education required: Masters in Social Work, Counseling, Human Services Field. Three years experience in behavioral health case management required ... Job/Unit Specific Functions 1. Non Violent CRISIS Intervention. 2. Proficient in providing psychosocial assessment of patients in relation to their illness and health maintenance needs ...".

1. A review of Medical Record #ST6 indicated that the Behavioral Health Screening was completed on 5/22/18 by a Registered Nurse.

a. The physician's ROS (Review of Systems) timed 10:22 AM states, " ... Psychiatric: ... Historian reports depression ... Historian reports suicidal ideation ...".

b. An order placed at 11:44 AM states, "Medically Cleared for Behavioral Health Evaluation".

c. The "Doctor Notes" timed for 1:15 PM states, "Re-evaluation ... Evaluated by ___ Mental Health Screener. No suicidal or homicidal ideation ... Stable for discharge ... ."

d. Under the "Nursing Procedure: Transition Care Team" documentation, it states,"... Assessment: Notes: Behavioral Health Nurse Case Manager: ... Pt [Patient] admits to feeling depressed due to [his/her] mother dying 8 years ago ... Pt denies suicidal thought or intent ...".

e. The above was confirmed with Staff #ST7.

2. During an interview on 11/28/18, Staff #ST7 revealed the following:

a. There is no policy for Behavioral Health evaluations, it is a process, and the Behavioral Health Case Managers are responsible for completing the Behavioral Health Evaluation when the patient is not in Crisis.

b. It was confirmed that Staff #ST21, who completed the Behavioral Health Evaluation on Patient #ST6, was not Master's prepared in Social Work, Counseling, or Human Services Field, as required by the facility's job description.

c. Behavior Health Case Managers are not available during the full 24 hours of a day. If a psychiatrist consultation is needed for a patient's evaluation, an "informal process" is in place to contact a Psychiatrist.

(i) Upon request, an on-call list for a covering Psychiatrist was not provided.