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Based on record reviews and interviews, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. This deficient practice was evidenced by the non-physician psychiatric practitioner's failure to ensure patients were clinically stable for discharge. (See findings in Tag A0049).

Based on record reviews and interviews, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. This deficient practice was evidenced by the non-physician psychiatric practitioner's failure to ensure patients were clinically stable for discharge for 2 (#1 & #3) of 2 (#1 & #3) patients reviewed for discharge.
Findings:

Review of the hospital policy number QAPI-00 titled, "Quality Assessment and Performance Improvement (QAPI) Plan" last revised on 06/01/2024 revealed the following:
"Policy: Aligned with the organization's core convictions rooted in the belief that everyone deserves dignity and respect, the hospital is dedicated to delivering safe, compassionate, high-quality care. The plan focuses on the evaluation of the current performance of the hospital and the identification of opportunities for improvement. This involves systemic monitoring, measurement, analysis, and robust action planning using a defined performance improvement methodology to ensure that the hospital delivers high-quality care and meets regulatory requirement. The committee's primary objective is to identify and address any breakdowns that may compromise patient care and safety, striving to continuously improve and promote positive patient outcomes.
2. Medical Staff - The medical staff provides effective mechanisms to monitor, assess, and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to ensure improved performance is achieved and sustained."

Patient #1
Review of Patient #1's medical record revealed she was admitted to the hospital on 05/22/2025 at 1:15 PM with a diagnosis of Dementia with Behaviors from her nursing home.

Review of Patient #1's Psychiatric Provider Notes revealed in part:
Seen by psychiatric provider on: 05/23, 05/24, 05/25, 05/26, 05/27, 05/28, 05/29, 05/30, 05/31, 06/01, 06/02, 06/03, 06/04, 06/05 and 06/06. All visits were completed via telehealth by S11NP who was located in Amarillo, TX.

On 05/24/2025, S11NP noted "Patient #1 was admitted due to aggression, delusional and anxiety. Patient #1 has bruising to the left eye due to fall. The reports fall occurred at about 6:00 this morning. Patient #1 denies any depression or anxiety. Patient #1 is demented which causes impaired insight and judgement. The nurse reports compliance with medications. No reports of aggression in the past 24 hours. Patient #1 is being treated with Macrobid for UTI. Patient #1 denies any SI/HI. She was showing aggression toward others at the nursing facility."

On 05/25/2025, S11NP noted "Patient #1 was showing aggression, delusional behaviors and anxiety at the nursing facility. Patient #1 denies any anxiety or depression. Patient #1 denies any hallucinations or paranoia. Patient #1 says she does not know why she is here. Patient #1 has bruising to the left eye due to fall. The staff reports compliant with medications. The staff denies any aggression in the past 24 hours. Patient #1 denies any SI/HI. Patient #1 has impaired insight and judgement due to dementia."

On 05/26/2025, S11NP noted "Staff documented Patient #1 has been "isolated and withdrawn to room all evening. Not interacting or participating. Sad and depressed. No aggression or anger noted. Remains confused at times." Patient #1 slept 6.5 hours last night. Patient #1 denies feeling anxious or sad. Patient #1 denies thoughts to harm self or others. No psychosis. Patient #1 is being treated for a UTI. Patient #1 says she sometimes hears and see things but when asked to elaborate, she stated "I don't know." Recent changes made 3 days ago to regimen. Will continue to monitor."

On 05/27/2025, S11NP noted "Patient #1 says she is very cold. Patient #1 had a fall over the weekend. Patient #1 has a bruise on her face. Patient #1 doesn't remember falling. Patient #1 is not having any pain on urination. Patient #1 is on an antibiotic for a UTI. Patient #1 is eating well and "every day." Patient #1 hasn't talked to any family, lately. Patient #1 says she wants them to leave her alone, where she lives. Patient #1 says "it is her own business." Patient #1 says it is the other people that live there. We asked her why she is here and Patient #1 says "because y'all got me here." Patient #1 says they got mad at here and were hollering at her. Patient #1 says her meds are working fine. Patient #1 feels she is calmer and her mood is good today. Patient #1 says "they just need to leave me alone and it is always this that or the other and they act like I'm fixing to die." She says it makes me so cotton picking mad and they won't let me do my own hair with the rollers. Patient #1 says she can "do anything I want to do with my hair." Patient #1 continues to have a labile mood and gets upset easily. Will continue titrating meds. Increase Rexulti to 1mg PO QHS. Increase Auvelity to BID."

On 06/03/2025, S11NP noted "Patient #1 says "what time you want me to fill in the spot?" Patient #1 says "someone is going to climb into the box, Beverly." Patient #1 is not having any pain on urination. Patient #1 says she was up for breakfast, but staff doesn't think she has gotten up yet. Patient #1 slept for 8 hours. Patient #1 is agitated with questions today and yelled, "what?" Patient #1 says she feels more confused today. Will get a CBC and UA today. Patient #1 is acting worse today than she has been before. Patient #1 is not oriented and is confused and saying strange things. Increase Rexulti to 1.5mg PO QHS."

On 06/04/2025, S11NP noted "Patient #1's family is ready for her to go back to nursing home, when she is stable. Patient #1 was doing well for a while and then she was having some problems yesterday with orientation and saying some bizarre things. Patient #1 was talking about odd things and not making any sense. Patient #1 was having delusions yesterday. Today Patient #1 is not talking to us very much, but says she is "not really good." Will lower Rexulti tonight. Waiting on her labs. Patient #1 says she does not have pain, sometimes, when she urinates. Patient #1 did get a Norco about an hour before we say her, so her pain med could be causing sedation."

On 06/05/2025, S11NP noted "Staff says Patient #1 slept for 10.5 hours. Patient #1 is walking to day. Patient #1 is using a walker. Patient #1 says she hasn't had breakfast yet, but she is hungry. Patient #1 says she feels "horrible." Patient #1 says it is because "I don't know." Patient #1 has her shirt on backwards. Patient #1 says she is not in any pain. Patient #1 remains confused. Patient #1 says she lives at "I don't even know." Patient #1 says she hasn't seen or talked to her family. Patient #1 had some labs done and we are waiting on those. Patient #1 says she is not mad or sad. Patient #1 says she "just needs to be left alone." Patient #1 is wet, as well. Patient #1 will return to nursing home."

On 06/06/2025, S11NP noted "Discharge plan is in place."

Review of Patient #1's Nursing Shift Assessments revealed in part:
Date: 05/24/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Goal Directed; Mood - Labile; Affect - Anxious; Behavior - Preoccupied
Nursing Note: Patient seen by NP this morning. Patient had a fall at approximately 6AM this morning. Patient family notified by previous nurse. Patient family did call to get an update on patient. Patient vital signs are normal. Patient seen by NP and Dr. this morning. Mood is stable. Patient is pleasant and cooperative.
Signed by: S4RN on 05/24/2025 at 10:30 AM

Date: 05/24/2025
Shift: 7P-7A
Assessment: Daily Meals and Snack Intake: Good; Orientation - Person; Thought Process - Disorganized; Affect - Flat; Speech - Poverty of speech; Behavior - Withdrawn, Isolative, Cooperative; Activity - Isolates, Assisted with ADL's; Sleep - Insomnia, Sleep aide/medication offered, Hours of sleep was 8 hours
Nursing Note: In room, in Gerichair; sleeping. X-ray right knee, negative.
Signed by: S3RN on 05/25/2025 at 8:50 AM

Date: 05/25/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Goal Directed; Mood - Labile; Affect - Anxious
Nursing Note: Patient seen by NP this morning. Patient denies anxiety and depression. Flat affect this morning. Patient reports eating and sleeping well. Patient ambulating in the hallway, withdrawn and isolative to self.
Signed by: S4RN on 05/25/2025 at 12:06 PM

Date: 05/25/2025
Shift: 7P-7A
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Disorganized; Mood - Depressed, Sad; Affect - Flat; Behavior - Withdrawn, Isolative; Sleep - Slept all night, Hours of sleep was 6.5 hours
Nursing Note: Patient sitting in room in Geri-chair. Isolated and withdrawn all evening. Not interacting or participating. Sad and depressed. No aggression or anger noted. Remains confused at times. Medication compliant. Safety precautions intact.
Signed by: S5RN on 05/26/2025 at 6:35 AM

Date: 05/26/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Disorganized; Mood - Depressed, Sad, Irritable; Affect - Blunted, Flat; Behavior - Withdrawn, Guarded; Activity - Self ADL's, Assisted with ADL's, Symptoms interfere with ability to attend group.
Nursing Note: AAOx1. NAD. Condition improved. Denies SI HI and hallucinations.
Signed by: S13RN on 05/26/2025 at 3:40 PM

Date: 06/03/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person, Place; Appearance - Appropriate, bruises left eye area; Thought Process - Disorganized; Mood - Depressed, Sad, Irritable; Affect - Blunted, Flat; Behavior - Withdrawn, Guarded; Activity - Self ADL's, Assisted with ADL's, Symptoms interfere with ability to attend group.
Nursing Note: Patient seen by NP this morning. Patient lying in bed awake. Patient is pleasantly confused. NP wants to repeat CBC and UA. Patient stayed in bed most of the day. MHTs have not been able to obtain UA will attempt again. Patient eating poor today. Attempting to encourage patient to eat and drink.
Signed by: S4RN on 06/03/2025 at 6:29 PM

Date: 06/03/2025
Shift: 7P-7A
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Disorganized; Mood - Sad; Affect - Flat; Behavior - Withdrawn, Cooperative; Sleep - Hours of sleep was 8.3 hours
Nursing Note: Patient lying bed awake. Patient is quiet. SN attempted to include patient in conversation with her roommate however patient remained quiet. No s/s of SI. Bruise noted to her right eye, no s/s of pain. Patient would not take her QHS medications. Safety precautions in place.
Signed by: S14RN on 06/04/2025 at 7:36 AM

Date: 06/04/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person, Place; Appearance - Appropriate, bruises left eye area; Thought Process - Disorganized; Mood - Depressed, Sad, Irritable; Affect -Flat; Speech - Hesitant; Behavior - Withdrawn, Guarded, Cooperative; Activity -Assisted with ADL's, Symptoms interfere with ability to attend group.
Nursing Note: Patient seen in rounds with NP. She was lying in bed with her eyes open. She was slow to respond to her name and light touch. Eventually she did answer a few questions. She has been noted to be disoriented and lethargic at times for a couple of days. CBC and UA obtained last night. Awaiting lab results. Patient is being encouraged to maintain oral intake and to ambulate.
Signed by: S8RN on 06/04/2025 at 3:59 PM

Date: 06/04/2025
Shift: 7P-7A
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person; Thought Process - Disorganized; Mood - Depressed, Sad, Irritable; Affect - Flat; Speech - Hesitant; Behavior - Withdrawn, Guarded, Cooperative; Sleep - Hours of sleep was 10.5 hours
Nursing Notes: Patient is lying in bed awake, patient is slightly lethargic, patient's mood is appropriate, patient is med compliant.
Signed by: S15RN on 06/05/2025 at 5:57 AM

Date: 06/05/2025
Shift: 7A-7P
Assessment: Daily Meals and Snack Intake: Fair; Orientation - Person, Place; Appearance - Appropriate, bruises left eye area; Thought Process - Disorganized; Mood - Depressed, Sad, Irritable; Affect -Flat; Speech - Hesitant; Behavior - Withdrawn, Guarded, Cooperative; Activity -Assisted with ADL's, Symptoms interfere with ability to attend group.
Nursing Notes: Patient seen in rounds with NP. She ambulated with walker and standby assist from her room to the T. She was slow to respond to questions, unable to say where she lives. She was provided standby assist to walk back to her room and assisted with a clothing change due to incontinent episode.
Signed by: S8RN on 06/05/2025 at 3:19 PM

Date: 06/05/2025
Shift: 7P-7A
Assessment: Daily Meals and Snack Intake: Good; Orientation - Person; Thought Process - Confused; Thought Content - Confused; Sleep - Hours of sleep was 10 hours
Nursing Notes: Patient is lying in her room awake, patient's mood is appropriate this evening, patient is confused about where she is or where she is going, patient is med compliant.
Signed by: S15RN on 06/06/2025 at 5:12 AM

Review of Patient #1's Discharge Summary revealed it was completed and signed by S11NP on 06/06/2025 at 10:54 AM. Patient #1 was picked up by her nursing home transportation van and discharged from the hospital at 1:42 PM on 06/06/2025.

Review of Patient #1's hospital records from a local hospital emergency room revealed Patient #1 was brought to the emergency room 06/06/2025 following discharge from the facility back to her nursing home. Review of the local hospital emergency room records revealed in part:
Date: 06/06/2025
Imaging: CT Head
Results: Chronic bilateral cerebral convexity subdural hygromas. Small area of acute hemorrhage in left hygroma. Sulci and gyri are well visualized with no severe mass effect.
Impression: 1. Fall with head trauma; 2. Chronic left greater than right cerebra convexity subdural hygromas with a small area of acute hemorrhage on left side

On 06/17/2025 at 3:25 PM, a telephone interview was conducted with S11NP. S11NP stated the family of Patient #1 was pushing for the patient to be discharged from the facility. S11NP stated she had ordered a CBC and UA for Patient #1 which had been collected and was pending results to see if that was the cause of her sudden decline, but ultimately she had shown symptoms prior to admission while at the in the nursing home, along with the CEC expiring and the family was pushing for discharge, she did not see a reason to keep Patient #1 at the facility for further treatment or for her to be sent for higher level of care treatment/medical consult since the labs were collected and pending results and the nursing home would have the results forwarded to them to begin treatment if needed.

Patient #3
Review of Patient #3's medical record revealed he was admitted to the hospital on 05/30/2025 at 5:15 AM with a diagnosis of Dementia with Behaviors from a local hospital emergency room.

Review of Patient #3's Psychiatric Provider Notes revealed in part:
Seen by psychiatric provider on: 05/30; 05/31; 06/02; 06/03; 06/04; and 06/05. All visits were completed via telehealth by S11NP who was located in Amarillo, TX.

On 05/30/2025, S11NP noted "Patient #3 is supposed to go to a program in July. Trinity? Patient #3 sleeps sometimes and he wakes up sometimes and says he doesn't sleep very well. Patient #3 does get sad and "sometimes I don't." Patient #3 says he is not anxious. Patient #3 says he has voices that talk to him and they say, "they are singing." Patient #3 sees things like "ghosts." Patient #3 denies any SI/HI. Patient #3 has advanced dementia. Patient #3 is a very poor historian. Patient #3 is not oriented to situation. Patient #3 came in delusional, aggressive, and was wandering the streets. We will be adjusting his meds while he is here. Social work will find out about his plans for placement at Trinity, possibly. Patient #3 was sent home on Rexulti, last week, but the prescription was $1400.00 and the pharmacy did not accept the manufacturer's coupon for some reason. Risperdal was sent in to pharmacy for daughter to pick up and not sure what happened after that, but he has not been taking it. Start Risperdal 1mg PO BID."

On 05/31/2025, S11NP noted "Patient #3 is confused. Patient #3 sometimes feels depressed. Patient #3 tolerated regiment without unwanted side effects or signs of adverse drug reactions. Sleep and appetite are adequate. Staff documented 7 hours last night. Patient #3 was noted wandering in the halls, anxious, and requesting to leave. Patient #3 denies suicidal or homicidal ideations. Patient #3 denies hallucinations or paranoia.

(Collateral was taken from Psychosocial Assessment)

On 06/02/2025, S11NP noted "Patient #3 says he slept well and doesn't have nightmares or restless legs. Patient #3 denies any side effects from his meds, but says sometimes "I don't know." They bother me sometimes. Patient #3 is eating well. Patient #3 says he hasn't talked to his family on the phone. Patient #3 doesn't know why they brought him here. Patient #3 knows he was here before, but can't remember why. Patient #3 does feel sad sometimes and sometimes I don't. Patient #3 says he worries a lot. Patient #3 worries about his family. Patient #3 came in with auditory hallucinations, seeing ghosts, delusions, aggression, wandering behaviors. Patient #3 is supposed to be getting placement, as his daughter is unable to care for him at home, due to his dementia. Patient #3 does wander the halls and asks when he is leaving. Patient #3 is not oriented to place or situation. We will continue adjusting his medications."

On 06/03/2025, S11NP noted "Patient #3 wanders a lot and asks for his keys to go home. Patient #3 hasn't talked to his daughter, lately. Patient #3 remains very confused and lost. Patient #3 doesn't remember why he is here. Patient #3 has dementia and he needs to either go home with his daughter or go to a long term care facility for his own safety."

On 06/04/2025, S11NP noted "Patient #3 always asks for his keys and is wandering all the time, but he is not disruptive or aggressive. Patient #3 remains confused and is not oriented to place or situation. Patient #3's daughter is unable to take care of him and he needs nursing home placement. Give Uzedy 125mg IM and then stop oral Risperdal. Patient #3 is not med compliant at home."

On 06/05/2025, S11NP noted "Discharge plan is in place."

Review of Patient #3's Nursing Shift Assessments revealed in part:
Date: 06/02/2025
Shift: 7A-7P
Assessment: LOC - Alert, Responsive; Orientation - Person; Thought Process - Disorganized; Thought Content - Delusions; Mood - Euthymic; Affect - Flat; Behavior - Cooperative, Guarded, Intrusive
Nursing Note: Patient seen by NP this morning. Patient unable to recall reasons for being here. Patient reports depression and sadness that comes and goes.
Signed by: S4RN on 06/02/2025 at 8:17 AM

Date: 06/03/2025
Shift: 7A-7P
Assessment: LOC - Alert, Responsive; Orientation - Person; Thought Process - Disorganized; Thought Content - Delusions; Mood - Euthymic; Affect - Flat; Behavior - Cooperative, Guarded, Intrusive
Nursing Note: Patient seen by NP this morning. Patient reports not side effect from medications. Patient denies voices.
Signed by: S4RN on 06/03/2025 at 7:52 AM

Date: 06/04/2025
Shift: 7A-7P
Assessment: LOC - Alert, Responsive; Orientation - Person; Thought Process - Disorganized; Thought Content - Delusions; Mood - Euthymic; Affect - Blunted; Behavior - Cooperative, Guarded, Intrusive
Nursing Note: Patient seen in rounds with NP. Patient will have Uzedy long-acting injection given tomorrow and ordered every month. He is then planned for discharge back to his home with support from his daughter. He has been encouraged by family and staff to go into the nursing home for care and has refused. There is an open EPS case to follow him.
Signed by: S8RN on 06/04/2025 at 5:52 PM

Review of Patient #3's Psychosocial Assessment completed on 05/31/2025 at 8:36 PM by S16SW revealed in part:
Presenting Problem: Patient #3 with short term recall and requires prompts to answer appropriately AEB patient stated, "I don't know, my family just put me here" however when questioned if he was feeling depressed, patient voiced, "I was really depressed." "I felt like giving up." Patient #3 reports SI, "I think about it but don't do it." Patient #3 reports AH, "They say they are going to hurt me or something." Patient #3 reports VH, "Like something big in front of me like I can't see past them." "I also see things floating in my eyes. Yes they scare me." Patient #3 reports, "I have horrible dreams in my sleep and hear things that come to me so can't sleep." Per nursing intake, Patient #3 scored 4 on Audit C however, Patient #3 reports, "sometimes I drink 2 cans of beer a week. I don't drink no more. Sometimes my wife is supportive, but she works a lot and sometimes I be by myself." Patient #3 reports support from his daughter. Patient #3 acknowledged decline in memory, "I get confused." Patient #3's goal is "to be quiet and relaxed." Patient #3 reports anxious thoughts. Patient #3 reports labile mood, "yes ma'am I get upset then be okay." Patient #3 reported he has been compliant with medications. Patient #3 refused nursing home placement at this time, however stated, "I am willing to live with my daughter." S16SW will follow up with daughter with request. Patient #3 contradicts self AEB later patient also reported, "I have a good marriage." S16SW questioned why patient would desire wife leave and patient responded "because they worry me sometimes but not too much." Patient #3 stated later in session, "I want to go back home with my wife." It was reported in chart that Patient #3's daughter filed a report with EPS with allegations towards wife neglecting patient. Patient #3 reported date at May 1995. Patient #3 reports difficulties with controlling his anger AEB, "I get really mad, but don't hurt nobody." Upon assessment process Patient #3 did present drowsy and struggled to remain awake. Patient #3 report that his wife will not leave home and voiced that EPS and cops have been contacted regarding issue. Patient #3 recently discharged from facility. Patient #3 to benefit from CBT and med management and requested to discharge home upon discharge however it was reported Patient #3's daughter is requesting nursing home placement. S16SW to follow up with family.

Review of Patient #3's Social Work Notes revealed in part:
On 05/31/2025, S16SW noted "Attempted to contact Patient #3's daughter to discuss discharge plans regarding her father. Informant did not answer times two attempts and her voicemail stated it was full. Patient #3 did provide verbal consent to speak to his wife however S16SW does not have wife's contact information in chart. Family discord had been observed between patient's daughter, Patient #3's wife and step children AEB Patient #3's daughter voiced an EPS report made towards Patient #3's wife. It was also stated Patient #3's wife and step children reported to receptionist Patient #3's daughter is the one neglecting Patient #3. Patient did discharge home with his daughter last admission. It is still undetermined if Patient #3 to discharge home vs. nursing home. Patient #3 presents with increased memory decline and short-term recall."

Review of Patient #3's Discharge Summary revealed it was completed and signed by S11NP on 06/05/2025 at 6:21 PM. Patient #3 was picked up and discharged home with his daughter at 10:45 AM on 06/05/2025.

On 06/17/2025 at 3:25 PM, a telephone interview was conducted with S11NP. S11NP stated Patient #3 had refused nursing home placement despite the facility staffs' best efforts which was his right to do so. S11NP confirmed based on her assessment of Patient #3, he was unable to provide care to himself safely and the daughter was unable to provide adequate care for him as well.

Based on record review and interviews, the hospital failed to ensure the patient or his or her representative had the right to make informed decisions regarding his or her care. This was evidenced by the failure to provide informed consent with regard to psychiatric services being offered solely via telehealth.
Findings:

Review of the hospital's policy number RTS-11 titled "Informed Consent, Care Decisions, and Conflicts Resolutions" last revised on 11/01/2024 revealed in part:
"Purpose: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient's family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process.
Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies.
Procedure: Informed Consent -
2. The facility will ensure that during the admission process and at any point, as necessary, in the patient's stay each patient/patient's family, if indicated will receive the following:
- Explanation of care, services and treatment being offered.
- Discussion of reasonable alternatives and the risks, benefits and side effects to such care.
- Explanation of the relevant risks, potential benefits, and side effects of proposed care, including the possible results of not receiving care, treatment, and services.
3. The facility will, during the admission process, obtain signature on informed consent forms. Patient signatures may be obtained by handwritten signature or digitized signature which is an electronic image of an individual's handwritten signature reproduced using a signature pad. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary admission, the facility will follow the policies of the organization related to involuntary admission."

Review of the hospital's policy number RTS-01 titled "Patient Rights Louisiana" last revised on 09/01/2023 revealed in part:
"Purpose: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's rights if deemed necessary.
Policy: The organization supports the patient's right to care, treatment, and services within its mission and applicability to law and regulation, and supports and protects the fundamental human, civil, constitutional and statutory rights of each patient. Every patient shall receive a written copy of their rights and responsibilities as a patient as part of the Patient Handbook and shall sign an acknowledgment that they are aware of their rights. The written copy shall include all applicable state and federal rights protections afforded to the patient. The Hospital will ensure that the exercise of patient rights may only be limited by the treating physician who, when possible, will confer with the treatment team, and only to the extent that the restriction is necessary to maintain the patients physical and/or emotional well-being or to protect another person.
Procedure: Treatment - You have the right to refuse treatment. You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care."

Review of the hospital's form titled "Informed Consent for Telehealth Services" signed by patients or their responsible party on admission revealed the following:
"Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. From time to time, Oceans Behavioral Hospital ("Facility") utilizes telehealth services to allow physicians, non-physician practitioner, and registered dieticians in other locations to provide patient care to patients at Facility. The information shared through telehealth may be used for diagnosis, therapy, follow-up and/or education, and my include any combination of the following: (1) patient medical records; (2) medical images; (3) live two-way audio and video; (4) interactive video; and (5) output data from medical devices and sound and video files. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption."

On 06/17/2025 at 9:46 AM, an interview was conducted with S2DON who stated psychiatric providers, physicians and non-physician practitioners, are all remote and provide telehealth services only. She stated there are no psychiatric providers who physically come to the facility to see patients, only the medical providers come to the facility to see the patients for their history and physicals on admission to the facility and then if a consult is ordered for the patient.

On 06/17/2025 at 3:15 PM, an interview was conducted with S1ADM. S1ADM stated there was no specific hospital policy related to telehealth services he was aware of or could find. S1ADM stated if a patient were to refuse psychiatric services provided via telehealth, the patient would need to be transferred to another inpatient psychiatric facility due to his facility not having the capabilities of onsite psychiatry services. S1ADM reviewed the "Informed Consent for Telehealth Services" form which is provided to patients upon admission to the hospital to sign. S1ADM confirmed the form does not inform the patient and/or their responsible party all psychiatric services will be conducted via telehealth therefore allowing the patient and/or responsible party to make an informed decision regarding consent for their psychiatric treatment at the facility.

Based on record review and interviews the facility failed to thoroughly analyze all adverse patient events and implement preventive actions. The deficient practice is evidenced by:
1) failure to update at risk for falls care plan and complete post fall reassessments for 3 (#1-#3) of 3 (#1-#3) patients evaluated for updated fall care plans and post fall reassessments; and
2) failure to ensure all nursing staff were educated on the facility's most current preventive measures and documentation of the use of those measures for each patient on fall precautions.
Findings:

Review of the hospital's policy number AS-12 titled "Fall Assessment/Re-Assessment and Precautions" last revised on 05/01/2025 revealed in part:
"Purpose: To screen patient's potential for falling and decrease the risk of injury.
Policy: Inpatient - 1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls." 2. In the event of a fall occurrence, patients will be reassessed, and additional fall prevention interventions will be implemented. 3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool, will assess/reassess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated.
Procedure: Inpatient - 1. The admitting RN shall complete an initial assessment within 8 hours of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a Fall Risk Score indicates the patient is "at risk for fall," the immediate initiation of fall precautions will occur. 2. If a patient scores as "at risk for falls" during the initial nursing assessment, a Treatment Plan to address the risk for falls will be initiated by the RN. 3. Criteria may be used to determine fall risk: age, mental status, elimination, medications, diagnoses, ambulation/balance/mobility deficits/use of assistive devices, nutrition, sleep disturbances and history of falls. 4. The patient shall be reassessed by the RN for fall risk at a minimum of every 7 days, immediately after a fall, and as needed based on patient's condition. 5. Interventions shall include - Mandatory fall precautions- Interventions for patients "at risk for falls" (must implement all): Apply yellow fall risk arm band, Provide nonskid slipper socks or ensure appropriate skip-proof footwear is used, Provide patient education, and Initiate Fall Risk treatment plan; Additional fall precautions (must select at least 2 additional interventions from below that are appropriate to the patient's individual needs): Bed alarm, Chair alarm, Ambulate with staff assistance, Ensure assistive devices (ex. Eyeglasses, hearing aids) are available, Keep pathways clear, Line of sight observation level, 1:1 observation level, Reclining chair, and/or Assist with ADL's. 6. Post fall interventions shall include - RN physical assessment of the patient, Obtain vital signs including pain assessment, Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury, Notify Physician/Non Physician Practitioner (NPP) and ER orders as needed, Conduct a reassessment of fall risk using the fall risk tool, Implement secondary fall prevention interventions from the additional precautions interventions list and update Fall Risk related Treatment Plan with individualized interventions, and Complete Post Fall Checklist. 8. An incident report will be completed in its entirety and forwarded to the DON after every fall."

1) Failure to update at risk for falls care plan and complete post fall reassessments for 3 (#1-#3) of 3 (#1-#3) patients evaluated for updated fall care plans and post fall reassessments.

Patient #1
Review of Patient #1's medical record revealed she was admitted to the hospital on 05/22/2025 at 1:15 PM from her nursing home for Dementia with Behaviors.

Review of Patient #1's Fall Risk Assessment revealed in part:
Date/Time of Assessment: 05/22/2025 at 4:42 PM
Age: 80 and over
Mental Status: Confusion/Disorientation
Elimination: Incontinent but Ambulates Independently
Medications: Cardiac Medications; Psychotropic Medications (Including benzodiazepines and antidepressants)
Diagnosis: Dementia/Delirium
Ambulation: Independent/Steady gait/Immobile
Nutrition: No apparent abnormalities with appetite
Sleep disturbance: No sleep disturbance
History of Falls: No history of falls
Fall Risk Score: 90 or above
Assessment Total Score: 105
Electronically Signed by: S8RN

Review of Patient #1's Plan of Care revealed in part:
Date: 05/22/2025
Problem: At risk for falls related to cognitive deficit as evidenced by poor judgement and impulse.
Interventions: 1. Required Implement Mandatory Fall Precaution Protocol including: complete fall risk assessment every 7 days, apply yellow fall risk arm band, provide nonskid slipper socks or ensure appropriate nonskid footwear is used, provide patient education regarding fall prevention, notify staff. 2. Keep pathways clear. 3. Choose at least 3 of the following individualized interventions: Ambulates with staff assistance, Assist with ADL's, Edmonson Fall Risk Assessment weekly.
Resolution Date: 06/06/2025
By: S9SW

Review of Patient #1's Incident Report revealed in part:
Date/Time of Incident: 05/26/2025 at 5:50 AM (per interview with S1ADM and S2DON, review of the facility incident log and all of Patient #1's medical records, incident actually happened on 05/24/2025, date for actual incident report was entered incorrectly and was confirmed by S1ADM and S2DON on 06/17/2025 at 9:30 AM.)
Occurrence: Incident
Category: Fall
Severity: Temporary Harm
Location: Patient Room
Brief Description of Incident: S6LPN noticed bruising and laceration by left eye, also redness of left eye, bruise left antecubital area. After final clarification from Patient #1, she stated she fell out of her bed, glasses were in place causing the trauma to left eye.
Follow Up/Resolution (DON): bruising to face noted
Incident Report Electronically Signed by: S2DON 05/28/2025 at 12:34 PM

Injuries Entered into Wound Diagram:
Type of Injury: Site of Injury: Location: Comments:
Bruise Other N/A Left side of face and around eye
Bruise Other N/A Left antecubital
Laceration Other N/A Left brow

Review of Patient #1's medical record revealed no post fall score reassessment was completed and no updates were made to the care plan.

On 06/17/2025 at 12:50 PM, an interview was conducted with S2DON. S2DON reviewed Patient #1's medical record and confirmed no post fall score reassessment had been completed and no updates were made to Patient #1's plan of care after her fall on 05/24/2025 and should have been according to hospital policy.

Patient #2
Review of Patient #2's medical record revealed he was admitted to the hospital on 05/23/2025 at 2:40 PM from a surrounding area hospital emergency room for Bipolar Mixed Episodes Disorder.

Review of Patient #2's Plan of Care revealed in part:
Date: 05/23/2025
Problem: At risk for falls related to cognitive deficit as evidenced by incidence of falling prior to admit, poor judgement and impulse.
Interventions: 1. Required Implement Mandatory Fall Precaution Protocol including: complete fall risk assessment every 7 days, apply yellow fall risk arm band, provide nonskid slipper socks or ensure appropriate nonskid footwear is used, provide patient education regarding fall prevention, notify staff. 2. Choose at least 2 of the following individualized interventions: Keep pathways clear, Assist with ADL's, Edmonson Fall Risk Assessment weekly.

Review of Patient #2's Incident Report revealed in part:
Date/Time of Incident: 05/28/2025 at 5:15 PM
Occurrence: Incident
Category: Fall
Severity: Temporary Harm
Location: Patient Room
Brief Description of Incident: Patient had unwitnessed fall. Patient stated "I fell on side the bed trying to get up." Patient has skin tear to the right eye, right elbow, and right knee.
Incident Report Electronically Signed by: S2DON

Review of Patient 2's medical record revealed no updates were made to the risk for falls care plan following his fall on 05/28/2025.

On 06/16/2025 at 2:50 PM, an interview was conducted with S1ADM. S1ADM reviewed Patient #2's medical record and confirmed no updates were made to Patient #2's plan of care after his fall on 05/28/2025 and should have been according to hospital policy.

Patient #3
Review of Patient #3's medical record revealed he was admitted to the facility on 05/30/2025 at 5:15 AM from a local hospital emergency room for Dementia with Behaviors.

Review of Patient #3's Fall Risk Assessment revealed in part:
Date/Time of Assessment: 05/30/2025 at 9:39 AM
Age: 50-79
Mental Status: Confusion/Disorientation
Elimination: Independent with control of bowel/bladder
Medications: Cardiac Medications; Psychotropic Medications (Including benzodiazepines and antidepressants)
Diagnosis: Dementia/Delirium
Ambulation: Independent/Steady gait/Immobile
Nutrition: No apparent abnormalities with appetite
Sleep disturbance: No sleep disturbance
History of Falls: No history of falls
Fall Risk Score: 0-89
Assessment Total Score: 85
Electronically Signed by: S3RN

Review of Patient #3's Plan of Care revealed in part:
Date: 06/02/2025
Problem: At risk for falls related to cognitive deficit as evidenced by limited mobility, shuffling gait, or unsteady gait, poor judgement and impulse, wandering behaviors.
Interventions: 1. Required Implement Mandatory Fall Precaution Protocol including: complete fall risk assessment every 7 days, apply yellow fall risk arm band, provide nonskid slipper socks or ensure appropriate nonskid footwear is used, provide patient education regarding fall prevention, notify staff. 2. Choose at least 2 of the following individualized interventions: Keep pathways clear, Assist with ADL's, Edmonson Fall Risk Assessment weekly.

Review of Patient #3's Incident Report revealed in part:
Date/Time of Incident: 06/01/2025 at 9:00 AM
Occurrence: Incident
Category: Fall
Severity: No harm
Location: Hallway
Notifications:
Brief Description of Incident: Patient #3 was observed in the hallway waiting for 9:00 AM medications. His hands were on the ledge running along the wall, facing forward with his back to the wall. He fell to the floor and hit his head on the floor. He was assisted from the floor and had SBA ambulating to his room. Upon assessment by S10LPN, he had no acute injuries and no reported pain. Patient #3 did not lose consciousness. S7MD was here doing assessments and gave order to send him to ER for assessment due to his head hitting the floor. Patient #3 was unable to identify cause of fall. Ambulance was called to transport patient to a local hospital for evaluation. Report called to the local hospital emergency room and packet sent with Patient #3's required documents.
Incident Report Electronically Signed by: S2DON on 06/02/2025 at 10:16 AM

Review of Patient #3's Nursing Shift Assessments revealed in part:
Date: 06/02/2025
Shift: 7A-7P
Assessment: Fall Precautions in Place - No
Signed by: S4RN on 06/02/2025 at 8:17 AM

Date: 06/03/2025
Shift: 7A-7P
Assessment: Fall Precautions in Place - No
Signed by: S4RN on 06/03/2025 at 7:52 AM

Date: 06/04/2025
Shift: 7A-7P
Assessment: Fall Precautions in Place - No
Signed by: S8RN on 06/04/2025 at 5:52 PM

Review of Patient #3's medical record revealed no post fall score reassessment was completed and no updates were made to the fall risk care plan.

On 06/17/2025 at 12:50 PM, an interview was conducted with S2DON. S2DON reviewed Patient #3's medical record and confirmed no post fall score reassessment had been completed and no updates were made to Patient #3's plan of care after his fall on 06/01/2025 and should have been according to hospital policy.

2) Failure to ensure all nursing staff were educated on the facility's most current preventive measures and documentation of the use of those measures for each patient on fall precautions.

On 06/16/2025 at 2:50 PM, an interview was conducted with S1ADM. S1ADM stated he was unaware significant updates had been made to the organization-wide policy numbered AS-12 titled "Fall Assessment/Re-Assessment and Precautions" last revised on 05/01/2025. He further stated he had not seen a "Post Fall Checklist" before and confirmed his staff had not been educated on the most current policy requirements.

Based on record reviews and interviews, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital. This deficient practice was evidenced by:
1) failure to ensure RNs performed every two hour observation rounds on 2 (#1 & #3) of 3 (#1 - #3) patients reviewed for observations; and
2) failure to ensure RNs properly documented daily shift skin assessments on 1 (#1) of 3 (#1 - #3) patients reviewed for daily shift skin assessments.
Findings:

Review of the hospital's policy number CS-23 titled "Level of Observations" last revised on 03/01/2023 revealed in part:
"Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety.
Policy: Three levels of observation are utilized: every 15-minutes (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels - Every 15 Minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities.
Procedure: 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant, (i.e. water offered, activities of daily living). The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form. 4. Every 15 Minute Observations - RN makes observations at least every 2 hours during the shift and initials the RN observations on the close observation sheets."

Review of the hospital's policy number NSG-02 titled "Documentation" last revised on 01/01/2023 revealed in part:
"Purpose: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as a part of a legal document.
Policy: Inpatient nursing personnel document patient's progress every 12-hour shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record.
Procedure: Inpatient - Daily- The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 1. All notes must be related to the patient's problems on the treatment plan. Routine- 1. RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs (i.e. falls, etc.) in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician practitioner (NPP), as applicable. The daily nurse note is only for daily assessment and expected daily occurrences. 2. Documents nursing groups provided on the Nursing Shift Assessment. 4. Documents pertinent and factual information including assessment, interventions, education, and outcome."

Review of the hospital's policy number NSG-39 titles "Skin/Wound Care" last revised on 10/01/2023 revealed in part:
"Purpose: To identify patients at risk for skin breakdown and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment and treatment of such.
Policy: The hospital recognizes the importance of managing skin integrity throughout a patient's stay. Nursing, in collaboration with the healthcare team, will assess and managed skin integrity for all patients upon admission and throughout their stay.
Procedure: Skin Assessment - 1. A skin assessment is completed by the registered nurse on all patients at admission, weekly, after a fall/injury, upon new skin findings and at discharge. 2. Description of skin abnormalities should be documented according to assessed findings including the initiation of the impaired skin integrity treatment plan. 3. Wound care protocol/prevention will be implemented as applicable and as ordered by the Physician/Non-Physician Practitioner (NPP). Wound Care Procedure - 1. If a patient is identified to have a wound, wound photography is performed and documentation of the wound is completed on the hospital skin assessment wound care documentation form, or in the designated portion of the electronic medical record (EMR), as applicable. 2. The Start of Care Skin Care guidelines may be initiated for newly developed skin alterations and/or when provider orders have not yet been received. 3. The registered nurse initiates a skin integrity treatment plan. 5. Nursing will utilize the skin assessment wound care documentation guidelines to describe and document the wound in a consistent and accurate manner. The description will include, as relevant, the location, type, where acquired, stage, length, width, depth, drainage amount/description, description of wound bed and peri-wound area, etc. Wound Care Documentation - 1. Individual patient's wound care needs are compiled for follow up of wound care needs and risks. The patient Medical Record is used to house all patient's wound care interventions and/or wound care prevention plans being implemented."

1) Failure to ensure RNs performed every two hour observation rounds on 2 (#1 & #3) of 3 (#1 - #3) patients reviewed for observations.

Patient #1
Review of Patient #1's medical record revealed she was admitted to the hospital on 05/22/2025 at 1:15 PM with a diagnosis of Dementia with Behaviors from her nursing home on a PEC.

Review of Patient #1's physicians' orders revealed an order dated 05/22/2025 for Q15 minute observation.

Review of Patient #1's Observation Check Sheets for 05/22/2025 to 06/06/2025, the dates of her stay at the hospital, revealed the following:
05/30/2025 - No RN signature at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM or 5:00 PM
06/04/2025 - No RN signature at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM or 5:00 PM
06/05/2025 - No RN signature at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM or 5:00 PM
06/06/2025 - No RN signature at 7:00 AM, 9:00 AM, 11:00 AM, or 1:00 PM

On 06/17/2025 at 10:00 AM, an interview was conducted with S2DON. S2DON reviewed the Observation Check Sheets for Patient #1 for above dates and confirmed the day shift RN signatures were missing.

Patient #3
Review of Patient #3's medical record revealed he was admitted to the hospital on 05/30/2025 at 5:15 AM with a diagnosis of Dementia with Behaviors from a local hospital emergency room on a PEC.

Review of Patient #3's physicians' orders revealed an order dated 05/30/2025 for Q15 minute observation.

Review of Patient #3's Observation Check Sheets for 05/30/2025 to 06/05/2025, the dates of his stay at the hospital, revealed the following:
06/04/2025 - No RN signature at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM or 5:00 PM

On 06/17/2025 at 12:15 PM, an interview was conducted with S2DON. S2DON reviewed the Observation Check Sheets for Patient #3 for above date and confirmed the day shift RN signatures were missing.

2) Failure to ensure RNs properly documented daily shift skin assessments on 1 (#1) of 3 (#1 - #3) patients reviewed for daily shift skin assessments.

Review of Patient #1's nursing notes dated 05/24/2025 at 5:50 AM by S3RN revealed in part "Med nurse, S6LPN, noticed bruising and laceration to left eye, redness of left eye, bruise in left antecubital area of arm. Patient #1 presented as confused, but was able to tell nurses and staff she fell out of bed with her glasses in place. Observed blood on her glasses which caused the trauma to her left eye. First aid administered. Cleansed left eye with normal saline, dried with gauze, and steri strips put in place."

Review of Patient #1's nursing shift assessments revealed the following:
Date: 05/24/2025
Shift: 7A-7P
Assessment: Skin Assessment Frequency - Shift assessment; Skin Color - Normal; Findings - No Issues/Skin Intact; Wounds - No wounds
Nursing Note: Patient had a fall at approximately 6:00 AM this morning.
Signed by: S4RN on 05/24/2025 at 10:30 AM

Date: 05/24/2025
Shift: 7P-7A
Assessment: Skin Assessment Frequency - Shift Assessment; Skin Color - Normal; Findings - No issues/Skin Intact; Wounds - No Wounds
Signed by: S3RN on 05/25/2025 at 8:50 AM

Date: 05/25/2025
Shift: 7A-7P
Assessment: Skin Assessment Frequency - Shift Assessment; Skin Color - Normal; Findings - No Issues/Skin Intact; Wounds - No wounds
Signed by: S4RN on 05/25/2025 at 12:06 PM

Date: 05/25/2025
Shift: 7P-7A
Assessment: Skin Assessment Frequency - Shift Assessment; Skin Color - Normal; Findings - No issues/Skin Intact; Wounds - No Wounds
Signed by: S5RN on 05/26/2025 at 6:35 AM

Review of Patient #1's Skin & Wound Assessment Report revealed the following:
Date: 05/26/2025
Location of Skin Issue: Left side of face
Wound Type: Other, bruising and laceration
Measurements: Laceration is 2.54 cm x 0.1 cm x 0 cm, fell getting out of bed
Drainage: Yes
Drainage Description: Bright red blood from laceration
Odor: No
Color of Wound: Reddish purplish bruising
Surrounding Skin Color: Normal for Skin
Dressing Required: Yes, cleansed with NS and steri strips applied to laceration

On 06/17/2025 at 10:00 AM, an interview was conducted with S2DON. S2DON confirmed there was no documentation of Patient #1's wounds from the fall documented until the wounds were entered into the Skin & Wound Assessment Report section of Patient #1's EMR on 05/26/2025, two days after the fall. She confirmed wound documentation should have been entered immediately following the fall and assessed each shift after.

Based on record review and an interview, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination for 1 (#3) of 3 (#1 - #3) patient records reviewed for a completed neurological examination at the time of the admission physical examinations.
Findings:

Review of the hospital's policy number AS-02 titled "Medical History and Physical Examination" last revised on 10/01/2024 revealed in part:
"Purpose: To serve as a mechanism for medical assessment, planning for care, and reviewing progress in treatment toward individualized medical goals.
Policy: The history and physical examination are a component of the facility's Bio-psycho-social and Multidisciplinary Treatment Integration process policy and is documented in the medical record.
Procedure: Inpatient Admissions - 1. The Physician or Non Physician Practitioner (NPP) - Conducts a physical examination, a review of systems, and a neurological evaluations with gross testing of cranial nerves I-XII and how there were assessed. Statements such as "cranial nerves II to XII intact" are not acceptable."

Review of Patient #3's medical record revealed a history and physical dated 05/30/2025 at 4:25 PM was completed by S7MD. Further review revealed no neurological assessment and no documentation of a cranial nerve exam had been completed or documented.

On 06/17/2025 at 12:50 PM, an interview was conducted with S2DON. S2DON reviewed Patient #3's history and physical completed by S7MD on the above mentioned date and confirmed there was no documentation of a neurological assessment or cranial nerve exam.