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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 Nov. 22, 2019
VIOLATION: CRITERIA FOR MEDICAL STAFF PRIVILEGING Tag No: A0363
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Bylaws, Rules and Regulations, credentialing file review and medical record reviews, the hospital's medical staff failed to ensure patient care was provided in accordance with the privileges granted for 1 of 1 midlevel provider (NP #1) credentialing file reviewed for 8 of 20 sampled medical records reviewed (#14; #20; #18; #19; #17; #7; #8; and #3).

The findings included:

Review of the "2019 Medical Staff Bylaws, Rules and Regulations" revealed "... The facility will admit (by order of the staff physician) patients suffering from all types and psychiatric illness. Patients may be treated by clinicians who have submitted proper credentials and have been duly appointed to membership of the Medical Staff, or who are receiving temporary privileges, in accordance with the bylaws. ... Each patient, on admission, is to have a psychiatric evaluation including a mental status evaluation and a complete medical history and physical examination accomplished. Both documents must be completed within twenty-four (24) hours of the patient's admission. ... Nurse Practitioners (NPs) or Physician Assistants (PAs) may participate in or complete the Psychiatric Evaluation and/or History and Physical, as allowed by the Hospital's State Scope of Practice requirements and, as credentialed to perform same by the Hospital's Medical Staff. ... Membership to the medical staff includes only those clinical privileges and prerogatives granted to the member by the Governing Board in accordance with these bylaws. ... Each application and reapplication must include a completed form specifically delineating the clinical privileges desired by the applicant. ..."

Review of NP #1's credentialing file revealed the nurse practitioner was licensed as a "Adult Geriatric Nurse Practitioner (AGNP)" with an issue date of 11/29/2019 and expiration date of 11/30/2019. Review of NP #1's application and work history revealed NP #1 had worked in an acute hospital setting since becoming a nurse in December 2013. Review revealed the Nurse Practitioner had worked at an eating disorder hospital from October 2018 until January 2019. Review of the "Specialty of Nurse Practitioner Delineation of Privileges" form revealed "Primary Care Core Nurse Practitioner Privilege; Privileges include but not limited to: Perform history and physical; Apply, remove and change dressing and bandages; Counsel and instruct patients, families and caregivers as appropriate; Direct care as specified by medical staff approved protocols; Initiate appropriate referrals; Make rounds on patients; Order and initial interpretation of diagnostic testing and therapeutic modalities, such as laboratory tests, medications, hemodynamic monitoring, treatments, x-ray, EKG, IV fluids and electrolytes, etc.; Record progress notes." Review of the "Psychiatric and Mental Health Nurse Practitioner Privilege; Privileges include but are not limited to: Perform comprehensive psychiatric evaluation ..." Review of the file revealed NP #1 requested privileges on 01/27/2019 for "Nurse Practitioner Core" for "Adolescents and Adults (13 & above)"; "Adults (18 & above)"; and "Geriatrics (55 & above)." Review of the "Speciality of Nurse Practitioner Delineation of Privileges" form revealed another line to request privileges for "Nurse Practitioner Core (Psychiatric)" that was left blank. Review revealed the Medical Director and Governing Board approved the "Nurse Practitioner Core" privileges on 02/26/2019. Review of a letter dated 02/26/2019 from the hospital's Chief Executive Officer (CEO) revealed a recommendation for approval for a two-year period with clinical privileges as an "Nurse Practitioner / Adult Gerontology."

1. Review of Patient #14's open medical record revealed a [AGE] year-old female admitted under petition for involuntary commitment (IVC) on 11/18/2019 for suicidal ideations, major depressive disorder and substance abuse. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/19/2019 at 1100 by NP #1 and cosigned by MD #2 on 11/19/2019.

Telephone interview on 11/21/2019 at 1028 with the Director of Credentialing and Privileging revealed the staff member was responsible for collecting and verifying all the credentialing paperwork for appointment and privileging. Interview revealed the staff member is located out of state and maintainers a "tangible file" on the medical staff. Interview revealed once the paperwork has been verified, the file information is sent to the hospital staff. Interview revealed hospital staff on site handle the meeting approval process. The staff member reviewed NP #1's file and reported she requested NP Core Privileges for adolescent, adult and geriatric patients. Interview revealed NP #1 did not request privileges as a psychiatric nurse practitioner and was not privileged to perform comprehensive psychiatric evaluations. The staff member stated "She is not Board Certified in Psychiatry. She is not a Psychiatric Nurse Practitioner. She is certified as an Adult Gerontology Nurse Practitioner. She will not be able to do those privileges listed for psychiatric nurse practitioner. She should not be practicing in that area." Interview revealed NP #1 was board certified December 14, 2018 as a Gerontology Nurse Practitioner.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnosed , assessed and educated the patients. Interview revealed NP #1 is on call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

2. Review of Patient #20's open medical record revealed a [AGE] year-old female admitted under petition for involuntary commitment (IVC) on 11/10/2019 for suicidal ideations, bipolar disorder verses major depressive disorder and post traumatic stress disorder (PTSD). Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/11/2019 at 1030 by NP #1 and cosigned by MD #2 on 11/11/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

3. Review of Patient #18's open medical record revealed a [AGE] year-old female admitted under petition for involuntary commitment (IVC) on 11/14/2019 for suicidal ideations and bipolar disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/15/2019 at 1000 by NP #1 and cosigned by MD #2 on 11/15/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

4. Review of Patient #19's open medical record revealed a [AGE] year-old female admitted as a voluntary admission on 11/19/2019 for suicidal ideations and bipolar disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/20/2019 at 1000 by NP #1 and cosigned by MD #2 on 11/20/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

5. Review of Patient #17's open medical record revealed a [AGE] year-old female admitted as a voluntary admission on 11/17/2019 for suicidal ideations and major depressive disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/18/2019 at 1100 by NP #1 and cosigned by MD #2 on 11/18/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.





6. Review of Patient #7's closed medical record revealed a [AGE]-year-old female admitted under petition for involuntary commitment (IVC) on 09/20/2019 for suicidal ideations. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 09/20/2019 at 1600 by NP #1 and cosigned by MD #2 (not dated).

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

7. Review of Patient #8's closed medical record revealed a [AGE]-year-old female admitted under petition for involuntary commitment (IVC) on 09/20/2019 for suicidal ideations. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 09/20/2019 at 1500 by NP #1 and no Physician cosigned.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.





8. Review of Patient #3's closed medical record revealed a [AGE] year old female admitted under petition for involuntary commitment on 09/10/2019 for Suicidal Ideations with ingestion of several Zoloft (antidepressant) pills. Review of a Comprehensive Psychiatric Evaluation revealed the document was completed on 09/11/2019 at 1200 by NP #1 and cosigned by MD #2 on 09/11/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on [DATE] as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a [AGE] year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted . I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

Telephone interview with MD #3 on 11/21/2019 at 1435 revealed he was the Medical Director of the acute hospital and he was the supervising physician for NP #1. Interview revealed there were two types of mid-level practitioners that worked at the hospital. MD #3 reported most of the nurse practitioners managed the medical needs for their patients and NP #1 was the only mid-level that managed the psychiatric needs. Interview revelaed NP #1 has functioned in that role since she started here. The physician stated he initially had meetings with her and reviewed her paperwork weekly for the first month, then monthly for four months. Interview revealed they are now meeting annually. MD #3 stated MD #2 is available and consults with NP #1 when needed. When asked about NP #1's privileges, MD #3 stated he was not aware that she had requested and been approved NP Core Privileges. MD #3 stated that he was not aware that NP #1 was not privileged to perform comprehensive psychiatric evaluations or manage the psychiatric patient needs. MD #3 stated "I don't understand that at all. That is an unfortunate mistake."
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies, medical records, personnel files, and interviews with staff, the facility failed to train and educate nursing staff to provide care to a Diabetic patient on an Insulin pump for 1 of 1 sampled diabetic patient. (Patient #2).

The findings include:

Review of policy titled "Admission and Exclusion Criteria" with revision date of 01/30/2019 revealed "...5. Examples of medical conditions that would need to be assessed individually to determine appropriateness for admission to the psychiatric program are: ...5.1.2 Patients who are insulin dependent with unstable blood sugars or who have an insulin pump...."

Review of a Psychiatric Evaluation dated 08/31/2019 at 1556 revealed Patient #2, a [AGE] year-old female was received as a transfer from local hospital after admission for concerns of SI with plan (Suicide ideations--thoughts of suicide with plan to complete using insulin to overdose), explosive anger, and intrusive thoughts of violent acts including choking her sister and shooting the assistant principal. "Pt admitted SI with plan to OD on insulin everytime she changes out cartridge for insulin pump but has been inconsistent with reports of timeline d/t (due to) memory problems." Review of Admission orders dated 08/31/2019 at 1450 revealed "Pt can use insulin pump and glucose monitoring system during admission. Close observation while awake (due to insulin pump). Pt is allowed to wear glucose monitoring system/keep in pockets while awake..."

Review of a "24 hour Registered Nurse Daily Mental Status Assessment" dated 08/31/2019 at 1340 written by RN #17, revealed "...Sugars have been running high and patient received insulin (Novolog) for coverage....Parents will bring insulin pump...1800 BS 189. pt used Glucose system to administer 8 units of Novolog insulin via pump. FYI: 1630. FS (finger stick blood sugar) 59. 8 ounces of juice (orange and Apple) 1 bag of chips. 1700 FS 79." 08/31/2019 at 2105 revealed "...BG (Blood Glucose) 247. Pt (Patient received 2 units of Novolog via pump." At 2115, BG 284--Pt gave 2 units of Novolog--reports she has 1.6 units 'on board.'" At "2230, BG 243. Finger stick performed. Pt thinks the machine is malfunction BG read 191--Pt programmed the machine. Reports she has 1.65 on board as per the machine, and pt did not need insulin coverage at this time." At 0100, BG 58. Pt denies symptoms. Gave Pt 8 Fl. (fluid) oz (ounces) orange juice."

Interview on 11/21/2019 at 1345 with RN #17 revealed working with this patient's pump was the first one here at this facility. Interview revealed RN #17 has not received any education on insulin pump while employed at this facility. Interview revealed the insulin was administered to Patient #2 using the results on the insulin pump. Interview revealed the facility's glucometer was not used to double-check the results of the fingerstick.

Interview on 11/21/2019 at 1345 with the Director of Pharmacy revealed the facility should not accept patients with insulin pumps. Interview revealed the safety risk of the insulin pump can be a problem.