Hendricks Behavioral Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48704 Based on document review, observation, and interview, nursing services failed to enter patient’s room to complete the patient’s assessment in 1 of 30 (Patient 7), failed to complete an initial assessment in 2 of 30 (Patient 2 and 13), and failed to notify the nursing supervisor to consult with the on-call provider after the patient’s initial assessment in of 15 of 30 (Patient 2, 7, 13, 15, 16, 17, 18, 19, 20, 21, 26, 27, 28, 29, 30) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 48704 Based on document review, observation, and interview, nursing services failed to enter patient’s room to complete the patient’s assessment in 1 of 30 (Patient 7), failed to complete an initial assessment in 2 of 30 (Patient 2 and 13), and failed to notify the nursing supervisor to consult with the on-call provider after the patient’s initial assessment in 15 of 30 (Patient 2, 7, 13, 15, 16, 17, 18, 19, 20, 21, 26, 27, 28, 29, 30) medical records reviewed. Findings include: 1. Facility policy titled HBH 950-20 Standby Emergency Medical Screening, effective date 01/2021, indicated under III. Policy: 1. Hendricks Behavioral Hospital is a Standby ED seeing persons in an emergency situation. 2. A qualified registered nurse will conduct an emergency medical and mental health screening. 4. The Nursing Supervisor will contact the physician on-call regarding the initial screening and confer with the on-call physician regarding the patient’s disposition including possible admission to Hendricks Behavioral Hospital or transfer to for follow up emergency treatment. 2. Facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), Policy Number 150-21, reviewed 11/2024, indicated under Purpose: provide access to a physician on-call to provide direction to the staff conducting the assessment; under 2. Psychiatric Emergency, the law requires that a person must be, as a result of a mental disorder, a danger to self, a danger to others, or gravely disabled.; under 3. Examples of Psychiatric Emergency Medical Condition are the following: iv. History of recent suicide attempts or suicidal ideations.; under 4. The Medical Screening Examination, b. The hospital maintains a list of on-call physicians who are responsible to consult on medical screening examinations to determine whether an individual who presents to the hospital has an emergency medical condition. 3. Review of Patient 2’s MR indicated the following: a. The patient arrived at the facility by police for suicidal ideations on 08/04/2025. b. Medical record lacked documentation of an initial assessment by the registered nurse (RN). c. Patient was admitted to the facility on 08/04/2025. 4. Review of Patient 7’s medical record indicated the following: a. The patient presented to the facility on 07/29/2025 at approximately 9:50 a.m. after an argument with spouse, the patient grabbed a gun and was going to shoot themselves and indicated they changed their mind. b. Medical record indicated at 10:02 a.m. P3 (Physician) was consulted regarding the patient’s initial assessment. c. Medical record indicated N3 completed the initial assessment at 10:42 a.m. d. Medical record indicated patient completed intake psychiatric screening assessment with P4 (Licensed Clinical Addiction Counselor). e. Medical record indicated the patient was offered intensive outpatient therapy; patient signed consents and left the facility. f. Patient died by suicide within 24 hours of leaving the facility. 5. Review of Patient 13’s MR indicated the following: a. The patient arrived at the facility by police escort for increased feelings of anxiety on 07/19/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with N2 (Registered Nurse). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/19/2025. 6. Review of Patient 15’s MR indicated the following: a. The patient presented to the facility by police escort for suicidal ideations on 07/10/2025. b. Medical record indicated N1 (Registered Nurse) completed the initial assessment, time unknown. c. Medical record indicated patient completed intake psychiatric screening assessment with a Licensed Clinical Social Worker (LCSW). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/10/2025. 7. Review of Patient 16’s MR indicated the following: a. The patient presented to the facility to determine if they qualified for outpatient services following discharge from another facility on 07/03/2025. b. Medical record indicated N1 completed the initial assessment at 4:31 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/03/2025. 8. Review of Patient 17’s MR indicated the following: a. The patient presented to the facility for drug addiction assistance on 07/01/2025. b. Medical record indicated N1 completed the initial assessment at 1:30 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/01/2025. 9. Review of Patient 18’s MR indicated the following: a. The patient presented to the facility for thoughts of wanting to hurt self and others on 07/04/2025. b. Medical record indicated N1 completed the initial assessment at 1:49 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with a Licensed Mental Health Counselor (LMHC). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. The patient was admitted to the facility for treatment. 10. Review of Patient 19’s MR indicated the following: a. The patient presented to the facility for thoughts of feeling hopeless and not wanting to live anymore on 07/01/2025. b. Medical record indicated a Registered Nurse completed the initial assessment at 6:11 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. b. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. The patient was admitted to the facility for treatment. 11. Review of Patient 20’s MR indicated the following: a. The patient presented to the facility for substance abuse treatment assistance on 07/02/2025. b. Medical record indicated N6 (Registered Nurse) completed the initial assessment at 9:27 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with Licensed Social Worker (LSW). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. The patient was admitted to the facility for treatment. 12. Review of Patient 21’s MR indicated the following: a. The patient presented to the facility by police escort for suicidal ideations on 07/08/2025. b. Medical record indicated N4 completed the initial assessment at 11:32 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with a Master’s of Social Work. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/10/2025. 13. Review of Patient 26’s MR indicated the following: a. The patient presented to the facility after work referred them to seek mental health services on 07/16/2025. b. Medical record indicated N1 completed the initial assessment, time unknown. c. Medical record indicated patient completed intake psychiatric screening assessment with an LCSW. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. c. Patient was discharged with intensive outpatient services on 07/16/2025. 14. Review of Patient 27’s MR indicated the following: a. The patient presented to the facility for thoughts of self-harm 07/28/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/28/2025. 15. Review of Patient 28’s MR indicated the following: a. The patient presented to the facility for depression on 07/02/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with an LCSW. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/02/2025. 16. Review of Patient 29’s MR indicated the following: a. The patient presented to the facility for suicidal ideations on 07/16/2025. b. Medical record indicated N4 completed the initial assessment at 1:42 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with Master’s of Public Health clinician. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. The patient was admitted to the facility for treatment. 17. Review of Patient 30’s MR indicated the following: a. The patient presented to the facility for panic attacks on 06/23/2025. b. Medical record indicated N3 completed the initial assessment at 3:41 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with N3. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. The patient was admitted to the facility for treatment. 18. Review of video surveillance on 08/07/2025 at approximately 6:25 p.m. indicated patient 7 arrived at facility accompanied by a police officer and taken to intake room by P4 at 9:46 a.m.. Video surveillance indicated N3 (Registered Nurse) did not enter the room during the time patient 7 was at the facility. Video surveillance indicated the patient left the facility at 11:51 a.m. 19. Review of the provider on-call list for 07/29/2025 indicated that P1 (Nurse Practitioner) was the provider on call. 20. Review of the QMP (Qualified Medical Professional) Training dated 05/2025, under Section 4: Steps of the MSE, 7. Contact the provider after assessment complete. 21. Interview with A6 (Director of Intake) on 08/07/2025 at approximately 2:30 p.m. confirmed that patients 2 and 13’s medical record lacked a nursing assessment as part of the medical screening exam. 22. Interview with P1 (Nurse Practitioner) on 08/08/2025 at approximately 10:42 a.m. confirmed they were the provider on call on 07/29/2025; confirmed that they did not receive notification regarding patient 7’s initial screening. 23. Interview with A1 (Director of Risk Management) on 08/11/2025 at approximately 10:20 a.m. confirmed that N3 never entered patient 7’s room on 07/29/2025 during patient’s initial assessment and screenings. 24. Interview with N3 on 08/11/2025 at approximately 11:26 a.m. confirmed he/she did not call the provider for patient 7, and indicated does not call the provider if there is not a serious medical concern or the patient is presently harming themselves. 25. Interview with P3 (Physician) on 08/11/2025 at approximately 2:02 p.m. confirmed the nurses who perform the MSE as qualified medical providers do not call the provider on call unless there is a medical issue that cannot be treated within the facility; medical records that are not transferred would not have had a provider called.”

“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: 48704 Based on document review, observation and interview, it was determined that 9 of 30 (Patient 7, 13, 15, 16, 17, 21, 26, 27, and 28) medical records reviewed of patients who presented to the hospital requesting services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a complete medical screening exam. Findings Include: 1. See findings cited at 42 CFR 489.24, A2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48704 Based on document review and interview, facility failed to enter patient’s room to complete the patient’s assessment in 1 of 30 (Patient 7) patient medical records reviewed; failed to complete an initial assessment in 1 of 30 (Patient 13) patient medical records reviewed; failed to notify the on-call provider after the patient’s initial assessment in 9 of 30 (Patient 7, 13, 15, 16, 17, 21, 26, 27, and 28) patient medical records reviewed; and failed to ensure that approved personnel were completing Medical Screening Exams (MSE) for 5 of 30 (Patient 7, 15, 21, 26, and 28) patient medical records reviewed. Findings include: 1. Facility policy titled HBH 950-20 Standby Emergency Medical Screening, effective date 01/2021, indicated under III. Policy: 1. Hendricks Behavioral Hospital is a Standby ED seeing persons in an emergency situation. 2. A qualified registered nurse will conduct an emergency medical and mental health screening. 4. The Nursing Supervisor will contact the physician on-call regarding the initial screening and confer with the on-call physician regarding the patient’s disposition including possible admission to Hendricks Behavioral Hospital or transfer to for follow up emergency treatment. 2. Facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), Policy Number 150-21, reviewed 11/2024, indicated under Purpose: provide access to a physician on-call to provide direction to the staff conducting the assessment; under 2. Psychiatric Emergency, the law requires that a person must be, as a result of a mental disorder, a danger to self, a danger to others, or gravely disabled.; under 3. Examples of Psychiatric Emergency Medical Condition are the following: iv. History of recent suicide attempts or suicidal ideations.; under 4. The Medical Screening Examination, b. The hospital maintains a list of on-call physicians who are responsible to consult on medical screening examinations to determine whether an individual who presents to the hospital has an emergency medical condition. 3. Review of Patient 7’s medical record indicated the following: a. The patient presented to the facility on 07/29/2025 at approximately 9:50 a.m. after an argument with spouse, the patient grabbed a gun and was going to shoot themselves and indicated they changed their mind. b. Medical record indicated at 10:02 a.m. P3 (Physician) was consulted regarding the patient’s initial assessment. c. Medical record indicated N3 (Registered Nurse) completed the initial assessment at 10:42 a.m. d. Medical record indicated patient completed intake psychiatric screening assessment with P4 (Licensed Clinical Addiction Counselor, [unauthorized by policy to complete MSE]). e. Medical record indicated the patient was offered intensive outpatient therapy; patient signed consents and left the facility. f. Patient died by suicide within 24 hours of leaving the facility. 4. Review of the provider on-call list for 07/29/2025 indicated that P1 (Nurse Practitioner) was the provider on call. 5. Review of video surveillance on 08/07/2025 at approximately 6:25 p.m. indicated patient 7 arrived at facility accompanied by a police officer and taken to intake room by P4 at 9:46 a.m.. Video surveillance indicated N3 did not enter the room during the time patient 7 was at the facility. Video surveillance indicated the patient left the facility at 11:51 a.m. 6. Interview with P1 on 08/08/2025 at approximately 10:42 a.m. confirmed they were the provider on call on 07/29/2025; confirmed that they did not receive notification regarding patient 7’s initial screening. 7. Interview with A1 (Director of Risk Management) on 08/11/2025 at approximately 10:20 a.m. confirmed that N3 never entered patient 7’s room on 07/29/2025 during patient’s initial assessment and screenings. 8. Interview with N3 on 08/11/2025 at approximately 11:26 a.m. confirmed he/she did not call the provider for patient 7, and indicated does not call the provider if there is not a serious medical concern or the patient is presently harming themselves. 9. Review of Patient 13’s MR indicated the following: a. The patient arrived at the facility by police escort for increased feelings of anxiety on 07/19/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with N2 (Registered Nurse). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/19/2025. 10. Review of Patient 15’s MR indicated the following: a. The patient presented to the facility by police escort for suicidal ideations on 07/10/2025. b. Medical record indicated N1 (Registered Nurse) completed the initial assessment; time unknown. c. Medical record indicated patient completed intake psychiatric screening assessment with a Licensed Clinical Social Worker (LCSW, [unauthorized by policy to complete MSE]).). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/10/2025. 11. Review of Patient 16’s MR indicated the following: a. The patient presented to the facility to determine if they qualified for outpatient services following discharge from another facility on 07/03/2025. b. Medical record indicated N1 completed the initial assessment at 4:31 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/03/2025. 12. Review of Patient 17’s MR indicated the following: a. The patient presented to the facility for drug addiction assistance on 07/01/2025. b. Medical record indicated N1 completed the initial assessment at 1:30 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/01/2025. 13. Review of Patient 21’s MR indicated the following: a. The patient presented to the facility by police escort for suicidal ideations on 07/08/2025. b. Medical record indicated N4 completed the initial assessment at 11:32 p.m. c. Medical record indicated patient completed intake psychiatric screening assessment with a Master’s of Social Work (unauthorized by policy to complete MSE). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/10/2025. 14. Review of Patient 26’s MR indicated the following: a. The patient presented to the facility after work referred them to seek mental health services on 07/16/2025. b. Medical record indicated N1 completed the initial assessment; time unknown. c. Medical record indicated patient completed intake psychiatric screening assessment with an LCSW (unauthorized by policy to complete MSE). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. c. Patient was discharged with intensive outpatient services on 07/16/2025. 15. Review of Patient 27’s MR indicated the following: a. The patient presented to the facility for thoughts of self-harm 07/28/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with P4. d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/28/2025. 16. Review of Patient 28’s MR indicated the following: a. The patient presented to the facility for depression on 07/02/2025. b. Medical record lacked documentation of an initial assessment by a Registered Nurse. c. Medical record indicated patient completed intake psychiatric screening assessment with an LCSW (unauthorized by policy to complete MSE). d. Medical record lacked documentation that the nursing supervisor was notified to consult with the on-call provider after the patient’s initial assessment. e. Patient was discharged with intensive outpatient services on 07/02/2025. 17. Review of the provider on-call list for 07/29/2025 indicated that P1 (Nurse Practitioner) was the provider on call. 18. Review of the QMP (Qualified Medical Professional) Training dated 05/2025, under Section 4: Steps of the MSE, 7. Contact the provider after assessment complete. 19. Interview with A6 (Director of Intake) on 08/07/2025 at approximately 2:30 p.m. confirmed that patient 13’s medical record lacked a nursing assessment as part of the medical screening exam. 19. Interview with P3 (Physician) on 08/11/2025 at approximately 2:02 p.m. confirmed the nurses who perform the MSE as qualified medical providers do not call the provider on call unless there is a medical issue that cannot be treated within the facility; medical records that are not transferred would not have had a provider called.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 41134 Based on document review and interview, the F1 staff failed to provide the spouse of a psychiatrically incapacitated patient, information required to make informed decisions about the patient’s care of 1 of 10 medical records reviewed. (P10) Findings Include: 1. P10’s medical record (MR) indicated that the patient was admitted on 04/19/2024 on an emergency detention order (EDO). P10’s facesheet indicated that C1, Complainant was the emergency contact and spouse of P10. Upon admission, the patient refused to sign treatment consent, or provide a release of information authorization to the facility. On 04/20/2024 a psychiatric evaluation was conducted and P10 was found to be confused, tangential, disorganized, with racing thoughts. 2. At 1459 hours on 05/23/2024, per interview with S5, Milieu Coordinator, confirmed that on 04/21/2024 they did speak with C1, Complainant, regarding their concerns about receiving patient treatment information as the spouse of P10. S5 did not accept the assertion of C1 being the spouse of the patient, requiring additional supporting documentation. and did not provide any patient information to C1. 3. At 1550 hours on 05/23/24, per interview with C1, confirmed that on 04/21/2024 they spoke with S5 identifying themselves as the spouse of P10, and requested information regarding the patient’s care. S5 assisted, but did not provide any patient information regarding the hospitalization of P10.”