Conway Behavioral Health

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h) A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation .... This Standard is not met as evidenced by: 47891 Based on interview it was determined that the facility failed to have a policy in place to ensure that patients were allowed visitation to patients in the facility. The facility could not ensure that the patients’ visitation rights would be protected, and that unnecessary restrictions and limitations would be prevented. The failed practice had the likelihood of affecting all patients receiving care in the facility. Findings follow: A During interview with Director of Quality on 3/17/2025 at 10:43 AM when questioned if the facility allowed face to face visitation it was stated that, “No we stopped that during covid and it has remained as an infection control issue.” B During the exit interview onj 3/17/2025 at 5:00 PM, when the potenntial failed practice was mentioned the CEO stated that, “We do allow face to face visitation.” When asked if they had a policy concerning visitation the CEO stated that, “No we do not have one.” C Based on review of document titled “Patient and Family Handbook” under section “Visiting Hours an Restrictions’ it was shown that “Our facility values your loved ones’ input in care and encourages their support. However, our immediate concern is to keep our patients and staff safe from the spread of COVID-19. To help us more closely follow the Centeres for Disease Control (CDC) and Arkansas Department of Health recommendations, we are allowing increased phone contact visitation. Phone visitation time is offered daily on the unit as posted on the schedule and is subject to chan ge based on the community’s needs.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 51070 Based on review of policy and procedure, record review and interview it was determined the facility failed to provide a safe environment in that two (#1 and #2) of twenty (#1-#20) patients reviewed were not observed per physicians order every 15 minutes. The failed practice did not ensure that patients were provided care in a safe setting free from harm. The failed practice had the likelihood to affect all patients who had a physician order for observation at timed intervals. Findings follow: A. Review of “Path to Purpose - Onboarding Program for All Employees” on 10-14-24, showed that all employees received education and training regarding “Levels of Observations/ObservSmart” on all levels of observation including “observation - 15 min” during orientation. B. Record review for Patient #1 and Patient #2 showed the patients had physician orders to be observed every 15 minutes. C. Review of “Behavioral Health - Patient Observation Sheet” for Patient #1, reviewed on 10-14-24, showed no evidence that observations had been completed per the physician order for the following dates and times: 1) 9-9-24 at 4:45 PM, and 9-10-2024 at 8:30 PM, 8:45 PM, 9:00 PM, 9:15 PM, and 9:45 PM. 2) Review of Progress note dated 9-10-24 at 8:52 PM, showed that another patient entered Patient #1’s room, and an altercation occurred in which Patient #1 received minor injuries. No evidence was provided that patient observations had occurred since 8:15 PM prior to incident. D. Review of “Behavioral Health - Patient Observation Sheet” for Patient #2, reviewed on 10-14-2024, showed no evidence that observations had been completed per the physician order for the following dates and times: 1) 1-23-24 no observations documented from 12:00 AM to 2:15 AM and 5:15 AM. 2) 1-24-24 at 8:00 PM and 10:00 PM. 3) 1-25-24 at 10:30 AM and 4:00 PM. 4) 1-28-24 at 5:45 PM, 6:00 PM, 6:15 PM, 6:45 PM, 7:00 PM, and 7:15 PM. E. During an interview on 10-15-24 at 10:54 AM with the Director of Nursing, findings in A-D were confirmed.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 51070 Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to: 1. Provide re-evaluation and modification to the discharge plan for two (#1 and #6) of eleven (#1-#11) patients reviewed. 2. Provide re-evaluation and/or modification to discharge plan for one (#1) of eleven (#1-#11) patients in that the facility administered new medication prior to documented discharge time and did not document patient response or condition at discharge. 3. Ensure appropriate arrangements had been made prior to discharge for two (#1 and #6) of eleven (#1-#11) patients in that no scheduled follow-up care or referral was made to address ongoing physical and mental health needs, nor was discharge prescriptions provided or information on how to obtain them. 4. Provide necessary medical information on discharge to representatives accepting care of the discharged patient in two (#1 and #6) of eleven (#1-#11) patients reviewed in that the facility failed to re-evaluate and update patient goals, treatment preferences or provide post-discharge referral or schedule appointments. The failed practice did not allow for modification of discharge planning that met the patients needs. The failed practice had the likelihood of affecting all patients discharging from facility. See A-0802, A-0805 and A-0813 for details.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 51070 Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to provide re-evaluation and modification to the discharge plan for two (#1 and #6) of eleven (#1-#11) patients reviewed. The failed practice did not allow for modifications to meet the patient’s needs. The failed practice had the likelihood to affect all patients discharging from facility. Findings follow: A. Policy titled “Discharge Planning,” approved 4/2020, last reviewed 2/2024, stated that all patients are included in the discharge plan and that discharge planning includes evaluating the needs for professional follow-up, medication needs, family relationships, physical and psychiatric needs, housing needs and placement issues as part discharge planning. The policy further stated that “discharge plans are to be reviewed by and signed by the patient/legal representative.” B. Document titled “Patient Rights/Patient Advocate,” no effective or review date, stated that patients have the right to reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of persons providing care; be informed of continuing health care requirements following discharge from the hospital; have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient. C. A Review of patient #1’s clinical record on 7/31/2024 showed the following: 1) The patient was admitted on 4/19/2024 and administratively discharged on 7/11/2024. 2) The discharge plan implemented on 7/11/2024 at 1:30pm, showed the guardian would pick up the patient later that same afternoon on 7/11/2024. The guardian telephoned the facility and stated she would be unable to pick up the patient due to transportation issues. The patient was transported to a local Department of Human Services office (DHS) on the same afternoon of 7/11/2024. There was no evidence which showed the facility re-evaluated the discharge plan or included the patient, guardian and/or DHS. 3) A review of the discharge form showed the patient was “administratively discharged” and “DHS will make arrangements for this child’s care when placed”. The form did not contain a signature and there was no evidence as to whom the patient was discharged to. D. A Review of patient #6’s clinical record on 8/1/2024 showed the following: 1) The patient was admitted on 4/18/2024, a discharge plan was developed on admission. 2) A progress note dated 5/21/2024 stated that the patient had an involuntary order for court “tomorrow”. 3) A discharge summary dictated on 6/6/2024 by Physician Assistant and countersigned by the Physician on 6/7/2024 stated the patient was administratively discharged on 5/22/2024 to local police for “aggression”. 4) There was no evidence the patient’s discharge plan was re-evaluated or updated to show the patient was to be discharged to the police department. There was no evidence of physician order for discharge. There was no evidence discharge information (medication needs, treatment follow-up, etc..) was provided on discharge to police department or patient representative. There was no evidence to whom the patient was discharged. E. Findings were confirmed for A-D during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am. Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to re-evaluate and modify discharge plans in one (#1) of eleven (#1-#11) patients in that the facility administered new medication prior to documented discharge time and did not document patient response or condition prior to discharge. The failed practice had the likelihood to affect all patients receiving new medications prior to discharging from facility. Findings follow: A. Review of patient #1’s clinical record on 7/31/2024 showed the following: 1) On 7/11/2024, at 1:30 pm, Patient #1’s guardian gave verbal consent for long-acting antipsychotic medication, Invega Sustenna during a discharge planning meeting call. 2) Medication Administration Record showed that Patient #1, was given the oral antipsychotic medication, Zyprexa, at 3:48 pm on 7/11/2024 and was injected with first dose of Invega Sustenna at 3:50 pm. 3) The discharge form showed patient #1 was discharged on 7/11/2024 at 3:55pm. 4) There was no evidence the patient had been re-evaluated following medication administration or that Department of Human Services was provided information on what to monitor for or who to call if adverse reactions occurred. B. A Request was made on 7/31/2024 for a policy on medication administration and/or medication follow-up. There was no policy provided by facility. C. Findings were confirmed for A-B during interview with the Interim CEO and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 51070 Based on review of policy and procedure, clinical records and interview it was determined the facility failed to ensure appropriate arrangements had been made prior to discharge for two (#1 and #6) of eleven (#1-#11) patients in that no scheduled follow-up care or referral was made to address ongoing physical and mental health needs, nor was discharge prescriptions provided or information on how to obtain them. The failed practice did not allow for continuity of care or allow for mitigation of potential risk of adverse health consequences due to unidentified post-discharge needs and follow-up. The failed practice had the likelihood of affecting all patients discharging from facility. Findings follow: A. Policy titled, “Discharge Planning,” last reviewed 2/2024, showed that the Discharge Care Plan and Home Medications form serves as the post-discharge continuing care plan. It includes discharge medications ordered at discharge, next level of care recommendations, discharge diagnosis, scheduled appointments as well as other important discharge information. B. Review of Patient #1’s clinical record on 7/31/2024 showed the following: 1) A review of the Discharge Care Plan and Home Medications form, for patient #1 showed no evidence of follow-up appointments or referral and four discharge medications were to be continued. A second injection of the medication Invega Sustenna, was ordered to be injected in “one week”. 2) No evidence was provided which showed a discharge plan had been provided or medications prescriptions had been provided to the guardian or Department of Human Services (DHS). 3) No evidence was provided which showed how the guardian or DHS should obtain discharge medications or with whom the patient should follow up with to meet ongoing physical or mental health needs. C. A Review of Patient #6’s clinical record on 8/1/2024 showed the following: 1) No evidence was provided of physician discharge order or that a Discharge Care Plan and Home Medications form had been completed. 2) No evidence was provided that showed communication of post-discharge physical and mental health needs, or continuing medication needs to the patient or representative at discharge. 3) No evidence was provided to whom the patient was discharged as there was no patient or representative signature. D. Findings were confirmed for A-C during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 51070 Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to provide necessary medical information on discharge to representatives accepting care of the discharged patient in two (#1 and #6) of eleven (#1-#11) patients reviewed in that the facility failed to re-evaluate and update patient goals, treatment preferences and/or provide post-discharge referral or scheduled appointments. The failed practice had the likelihood of affecting all patients discharging from facility. Findings follow: A. Policy titled, “Discharge Planning,” last reviewed 2/2024, showed the Discharge Care Plan and Home Medications form serves as the post-discharge continuing care plan which communicates key components such as discharge medications or no medications if none are ordered at discharge, next level of care recommendations and referral, discharge diagnosis, scheduled appointments as well as other important discharge information. B. Document titled “Patient Rights/Patient Advocate,” no effective or review date, stated that patients have the right to reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of persons providing care; be informed of continuing health care requirements following discharge from the hospital; have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient. C. Review of patient #1’s clinical record on 7/31/2024 showed the Discharge Care Plan and Home Medications form dated 7/11/2024 timed 3:55pm, showed no evidence that form which communicated necessary information was provided at discharge or to whom Patient #1 was discharged, as the signature line has “administrative discharge” written in place of patient/representative signature. D. A review of patient #6’s clinical record on 8/1/2024 showed no evidence was provided that necessary medical information was provided on 5/22/2024, to the patient or a representative at discharge. E. Findings were confirmed for A-D during interview with the Interim Chief Executive Officer (CEO) and Director of Clinical Services on 7/31/2024 at 11:30 am, and again with Interim CEO on 8/1/2024 at 11:52 am.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47891 Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. See A2403 and 2409 for details”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 47891 Based on clinical record review and interview, it was determined that the facility failed to maintain records for 19 (#6-#24) patients that presented to the facility for treatment. By not maintain these records the facility was not keeping an accurate record of the patient’s course of treatment and care. The failed practice had the likelihood to affect all patients treated at the facility. A. Review of facily’s EMTALA (Emergency Medical Treatement and Labor Act) logs dated from 01/2024 to 07/01/2024 showed 24 patients were transferred out to other facilities prior to admission to the facility. All 24 clinical records were requested. There was no evidence of clinical records provided for Patients #6-#24. B. The findings in A were confirmed in interview with the Interim Chief Executive Officer on 08/01/2024 at 9:15 AM.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47891 Based on clinical record review and interview, it was determined that the facility failed to ensure that 2 (#1 and #4) of 24 (#1-#24) patients received an appropriate transfer in that the physician or mid-level practitioner did not sign the transfer form when transferring patients to outside facilities. Failure to ensure that the appropriate practitioners signed the transfer form did not ensure that the transfers were safe and appropriate. The failed practice had the likelihood to affect all patients needing a transfer out of the facility. Findings follow: A. Review of Patient #1-#24’s clinical record showed that Patients #1and #4 had been transferred to outside facilities and were marked as transfer out of the facility on the facilities EMTALA log. B. Review of Patient #1, and #4 clinical records showed a Memorandum of Transfer (EMTALA) revised date of 12/2021. There was no evidence a physician or mid-level practitioner signed the Memorandum of Transfer. The signatures on the forms were of the facility’s Registered Nurse Supervisor. C. On 08/01/2024, a request was made to the Interim Chief Executive Officer (ICEO) for a policy regarding EMTALA transfers. There was no evidence of a policy on EMTALA transfers was provided. D. The findings in A, B, and C were confirmed in interview with ICEO on 08/01/2024 at 9:45 AM. Based on clinical record review and interview, it was determined that the facility failed to ensure that 3 (#2, #3 and #5) of 24 (#1-#24) patients had an appropriate transfer paperwork in the clinical record. Failure to ensure that the transfer form was a part of the clinical record did not ensure the transfer was appropriate, safe, or medically necessary. The failed practice had the likelihood to all patients transferred out of the facility. Findings follow: A. Review of facility’s EMTALA log showed that Patients #2, #3, and #5 were transferred out of the facility. B. Review of clinical records for Patients #2, #3, and #5 showed there was no evidence of transfer documentation. C. On 08/01/2024, a request was made to the Interim Chief Executive Officer (ICEO) for a policy regarding EMTALA transfers. There was no evidence of a policy on EMTALA transfers was provided. D. The findings in A and B were confirmed in interview with ICEO on 08/01/2024 at 9:45 AM”