Bridgeway Hospital

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 52740 Based upon review of policy, review of facility personnel records, and staff interviews, it was determined that facility failed to have a procedure to ensure that hospital nursing personnel for whom licensure is required have valid and current licensure. This failed practice had the potential to affect all patients admitted to the facility. Findings follow: A. Review of The Bridgeway Hospital policy “Employment Background Screening” showed, “Professionally certified and/or licensed staff (e.g., Registered Nurse, Certified Addictions and Drug Counselor, Certified Professional Accountant, Drivers, etc.) background searches should include the following: Professional license verification. B. Review of 14 facility personnel files showed that two of ten licensed nursing staff members reviewed had an expired nursing license in their personal file. C. During exit interview on 09/11/2025, Performance Improvement Director confirmed the findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50014 Based on review of policies and procedures, review of medical records, and interviews, it was determined that the Nursing Services failed to ensure an RN evaluated the care document of 3 (#9, #10, and #13) of 14 (#1-#14) patients in that there was no evidence a RN assessed each patient each shift. The failed practice did not assure the immediate availability of a Registered Nurse for the bedside care of any patient. The failed practice affected Patient #9, #10, and #13 and had the likelihood to affect all patients admitted to the facility. Findings follow: A. Review of Nursing Documentation dated 10/2018, showed to “Provide a format for documentation of patient condition and treatment rendered ....staff will follow standard guidelines on documentation to ensure and timely accounting of patient care following Arkansas Administrative Code. General guidelines 1. Narrative charting will be done on all patients by a nurse every shift ... 2. The 24-hour assessment is completed every shift. The RN does an assessment every shift and determines patent’s physical and psychological status, change of condition, and risk factors.” B. Review of medical records on 09/10/25 at 2:00 PM, showed 3 (#9, #10, and #13) of 14 (#1-#14) medical records were missing multiple shift assessments for each patient, for example patient #9 was missing the night shift assessment for 05/23/25, day shift assessment on 06/23/25, and night shift on 07/24/25. C. In an interview with the Director of Quality on 09/10/25 at 3:05 PM, she verified the findings in A and B.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50014 Based on review of policy and procedures, review of clinical records, and interview, it was determined that the facility failed to ensure adherence to the facilities nursing policy and procedures in that the nursing intake assessment for nine patients (#1, #2, #3, #6, #7, #9, #10, #11) out of 11 patients (#1-#11) were not completed. The failed practice did not allow for a comprehensive assessment to determine if the patients met admission criteria. The failed practice had the likelihood of affecting all patients being admitted. Finding follow: A. Review of policy titled “Admission,” with a revision date of 1/17/24, showed that “the assessment and referral staff will review the intake questionnaire Triage Form as well as the registration form prior to beginning initial triage. The assessment and referral staff will direct the individual and/or family to an assessment room to begin the full psychosocial assessment after the Initial Triage has been completed. When a level of care other than Intensive Outpatient Program (IOP), Enhanced Outpatient Program (EOP) or outpatient is indicated, a consultation with the next physician on rotation will take place and a final disposition will be made. The recommendation will be presented to the individual/family by the evaluation staff.” B. Review of Recommendations and Referrals for Services Policy dated 10/18/2018, showed the Assessment and Referral Department was to provide referrals to individuals seeking assessment services based on clinical judgement, geographic proximity, and special needs or concerns evidenced during the assessment. C. Review of the Patient Family Education policy dated 10/2018 showed that “It is the policy of The Bridgeway Hospital to provide education to its patients and, when appropriate, family members to assist in development of knowledge and skills needed to foster rapid stabilization, make informed decisions regarding treatment and aftercare planning, and promote wellness. Patient/family education is based on an assessment of the needs of the individual and his/her family, as well as an assessment of factors and/or barriers that may influence teaching modalities and focus.” D. Review of the Nursing Plan of Care policy, revised on 10/2018, showed the patient and his/her significant others were vital participants in the treatment process. E. Review of the Patient Depression Questionnaire Nine (PHQ-9) total score interpretation shows the following: Interpretation of Total Score Total Score/Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression F. Review of clinical records showed: 1. Patient #1’s Standardized Intake Assessment form showed the patient was currently under the care of a therapist at (Named Facility) on 03/28/2024. Under the question “Psychiatrists/Therapists Seen in the Past” showed “None.” 2. Patient #1, #3, #4, #6, and #7, Triage Form - Assessment and referral forms were blank. 3. Patients #1 - #7 and #9, -#11 Standardized Intake Assessment forms were incomplete. For example, Patient #1 did not have marital status, assessor signature, date, and time completed. 4. Patients #1 and #8’s Medical Clearance Assessment forms were incomplete. For example, Patient #8 did not have documentation of the Registered Nurse Observation of Behavior/Risk Assessment. 5. Patient #1’s Referral Recommendations and Crisis Safety Plan form dated 3/30/24, was not completed by the intake assessment nurse. The verification from “parent, family member, support person/friend for not having access to prescriptions medications for use other than as prescribed; weapons; lethal medications; illegal drugs/alcohol, as applicable; other means of self-harm” was not signed and dated. 6. Patients #1, #2, and #7 had Patient Health Questionnaire-9 (PHQ-9) tools that were calculated incorrectly. For example, Patient #7 had a documented PHQ-9 score of 8 (mild depression) instead of 15 (moderately severe depression). G. In an interview with the Chief Executive Officer (CEO) on 4/30/24 at 1:15 PM, the findings of A through F were confirmed.”