River Vista Health and Wellness LLC

“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: 21893 Based on record review, interview and policy review, the facility failed to ensure evaluations of nursing care were documented and communicated to the physician. This affected one (Patient #1) of ten medical records reviewed. The facility census was 62. Findings include: Review of the medical record for Patient #1 revealed an admission date of 02/05/25. On 02/08/25 at 11:18 PM, Patient #1 was at the nurse’s station moving a cup of water off the counter and became unsteady with the walker. Patient #1 fell on her buttocks and hit her head on the floor. Patient #1’s blood pressure was 149/69, temperature 97.3, respirations 20, heart rate 119, oxygen level 98 percent, and blood sugar 347. Patient #1 was diabetic and her blood pressure and heart rate were elevated. Patient #1 was alert and oriented times three. Patient #1 reported her head hurt but would not rate the pain. Patient #1 was offered Tylenol and declined it. A neuro check was completed at the time of the fall with a score of 16. Patient #1’s head was observed with no visible injuries at this time. No body injuries observed at this time. Patient #1 was assisted to bed. Patient #1 was educated on proper use of her walker. An order dated 02/08/25 at 11:55 AM stated transfer to hospital for evaluation as patient fell, hit her head, and is on an anticoagulant. An order dated 02/09/25 at 12:43 AM ordered neurological checks every four hours while awake. Review of the “Nursing - Neurological Flow Sheet” revealed multiple neuro checks completed on 02/08/25 and 02/09/25. On 02/08/24 at 11:20 PM and at 12:20 AM on 02/09/25, Patient #1’s neuro checks were fully conscious, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and brisk, and speech clear with a score of 12. On 02/09/25 at 6:40 AM, Patient #1’s neuro checks were fully conscious, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and sluggish, and speech clear with a score of 14. On 02/09/25 at 10:40 AM, Patient #1’s neuro checks were lethargic, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and sluggish, and speech slurred with a score of 16. On 02/09/25 at 2:17 PM, Patient #1’s neuro checks were lethargic, movement of all four extremities, hand grasps equal and strong, bilateral pupils 5 millimeters and sluggish, and speech slurred with a score of 20. On 02/09/25 at 3:20 PM, there was an order to transfer to ER due to high blood pressure and a previous fall. On 02/09/25 at 2:17 PM, the nurse documented received report by night shift that Patient #1 fell on 02/08/25 at 11:18 PM. Neuro checks were initiated every four hours by provider order, but no order to send out was received. Patient #1’s blood pressure was 168/90 an hour after administration of Hydralazine. The provider was notified. Patient #1 refused breakfast and lunch. Pupils were sluggish and Patient #1 was confused with a score of 20 on neuro checks. The provider ordered Patient #1 to be sent out to ER for further evaluation. The medical record lacked documentation of physician or provider notification of the change in Patient #1’s neurological status. During an interview on 02/24/25 at 11:00 AM, Staff C stated that initially the Nurse Practitioner ordered Patient #1 to be sent out non-emergently, but transportation was not available until 8:00 AM. The nurse called the provider back and asked if Patient #1 should be sent emergently, and the provider stated that since Patient #1’s vital signs and neuro check were stable and she was having minimal complaints of pain there was no need to send Patient #1 out emergently. The provider ordered neuro checks every four hours and to monitor Patient #1 and a provider would evaluate Patient #1 in the morning. On night shift, Patient #1 remained stable for neuro checks. Staff C stated that the nurse did not document the conversation with the provider in the medical record and did not discontinue the order to send the patient out. On 02/25/25 at 3:00 PM, the Staff C showed contact information from the Nurse Practitioner that was sent to Staff C’s phone. There was a call from the facility on 02/09/25 at 10:41 AM and a text message at noon on 02/09/25 regarding Patient #1. Staff C verified these notifications were not documented in the medical record. Review of the “Assessment Neurological” policy, revised February 2024, revealed a registered nurse will provide the initial neurological assessment when a neurological deficit is suspected or an assessment is ordered by a provider. Changes will be reported to the provider immediately. Changes from the patent’s baseline are to be communicated to the provider within 30 minutes. Review of the “Change in Patient Condition Chain of Command Notification” policy, revised February 2024 revealed the nurse assigned to a patient is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in patient condition and assuring their is a provider response. The nurse must document all findings in the medical record including patient assessment, interventions, and calls made to both the medical staff and the patient family.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 32088 Based on medical record review, policy review, and staff interview, it was determined the facility failed to follow their policy to ensure complaints were properly logged and investigated. This affected two (Patient #1 and #3) of three medical records reviewed for complaint investigation process. The census was 54. Findings include: Review of the complaint log on 01/07/25 revealed no complaint from Patient #1 or Patient #3. 1. Review of Patient #1’s medical record revealed an involuntary admission date of 12/06/24 for severe depression, inability to contract for safety, and to benefit from stabilization at an inpatient hospital. The patient was admitted to the Sage Unit at 4:00 PM from the hospital after being assessed and or medically cleared for transient left sided facial droop, altered mental status, confusion, and a saccular aneurysm. Review of the transferring hospital discharge information stated the patient had opioid dependence and was being seen in the community by a methadone clinic. Further review of the transferring hospital discharge revealed a list of all at home and inpatient medications, which included methadone (drug used for addiction to block the high from opioids drugs) 60 milligrams (mg) by mouth once a day. The discharge information also stated Patient #1’s methadone was decreased at the previous hospital to 60 mg because she had taken all the methadone was provided to last her through 12/10/24. The last dose of methadone 60 mg was administered on 12/05/24 at 11:12 AM at the hospital prior to admission at River Vista. Review of provider note dated 12/07/24 at 11:02 AM revealed the patient was requesting methadone and reported she could not eat without taking it. The provider noted the patient had been seen at a hospital on 11/27/24 for concerns of encephalopathy due to opioid withdrawal. Review of nursing note dated 12/07/24 at 10:33 PM revealed the patient complained of abdominal pain and shortness of breath. The nurse notified the on-call provider and was ordered to continue monitoring the patient. Vital signs were obtained and within normal limits. Review of a nursing note dated 12/08/24 at 7:44 PM revealed the patient told the nurse her stomach hurt and she was having a hard time breathing. The nurse practitioner was notified at 12:39 PM and ordered an electrocardiogram (EKG), Bentyl for abdominal pain, and Imodium for diarrhea. Review of nursing note dated 12/08/24 at 6:25 PM revealed the patient was having issues regarding withdrawal symptoms, complaining of stomach pain and nausea. The nurse noted the patient was previously on methadone and the psychiatric nurse practitioner was awaiting confirmation from the methadone clinic to confirm her dosage and “As this was not done the previous day.” The nurse noted the methadone clinic was Googled and was listed as closed on Sundays and did not open again until Monday 12/09/24. The psychiatric nurse practitioner was notified of this on 12/08/24 and ordered Suboxone (medication used to treat narcotic dependence) 8 mg/2 mg by mouth. The Suboxone was given at 9:15 AM on 12/08/24 and the nurse noted there were no issues immediately after taking the medication. The nurse noted later the patient came out of her room, lowered herself to the floor, and laid down. The nurse practitioner was notified. The nurse noted later that same day the patient lowered herself to the floor again complaining of stomach pain. Vital signs were obtained and the health nurse practitioner was notified. It was not advised to send the patient out at that time. At 3:05 PM the nurse noted she contacted the psychiatric nurse practitioner who stated he had spoken with the health nurse practitioner and they decided Bentyl and Flexiril could be given to help the patient. At 3:58 PM a Code Blue was called for the patient. Cardiopulmonary resuscitation (CPR) was initiated and emergency medical services (EMS) arrived at 4:10 PM. EMS continued CPR and gave the patient epinephrine with a pulse regained. EMS then transported the patient to the hospital. The nurse noted while the code was going on the patient’s family, to include a daughter, was at the hospital for a visitation. The daughter stated she had called this hospital on Friday, 12/06/24, and whoever she spoke to already knew her mom was on methadone. The nurse noted the daughter stated her mom had been at the facility on 12/06/24 at approximately 3:00 PM and she did not understand why the medication had not been verified by 12/08/24. The nurse noted she explained to the family that even though it was on her medication list it had to be verified by the methadone clinic. Interview on 01/07/25 at 3:30 PM, Nurse Manager Staff F stated she was not sure why the concerns the daughter had voiced were not on the complaint log. 2. Review on 01/07/25 at 2:08 PM of Patient #3’s medical record revealed the patient was admitted on 09/25/24 from another hospital with a diagnosis of schizophrenia. She was sent to the hospital from her group home for a psychiatric evaluation and possible medication adjustments. The presenting problems were listed as homicidal ideation, agitation, and audio and visual hallucinations. Review of the Initial Medical Screen dated 09/25/24 revealed the patient was independent with physical care including toileting and hygiene. There was no more mention of Patient #3’s skin. Review of the Patient Valuables and Belongings Inventory dated 09/25/24 at 10:27 PM revealed the patient did not require a bin for her belongings as there were pink shoes, a tan bra, black pants and a gray shirt. Glasses were not listed on the form. Review of the Initial Nursing Assessment, including the skin assessment, dated 09/26/24 at 12:40 AM revealed the patient had redness under right breast and to left groin area. Review of the General Progress Note dated 09/26/24 at 3:00 PM noted by Staff G, a licensed social worker (LSW), revealed he spoke with the patient’s caretaker regarding the patient’s needs while in the facility. The needs they spoke of were not documented in the note. Review of the discharge summary dated 10/03/24 revealed the patient was admitted for psychosis, unspecified mood disorder, depression and anxiety. The provider noted the patient was able to perform activities of daily living to include grooming and hygiene. Interview on 01/08/25 at 11:50 AM with Staff F stated Patient #3’s group home had called and said the patient had not showered and did not have her glasses. She stated she pulled the shower logs and the patient had showered on 09/26/24 at 7:00 PM and 09/30/24 at 6:20 PM. She stated the hospital pulled the camera recordings to verify the patient was showered. Staff F verified the patient did not have on glasses on admission as per her admission picture, nor was it noted in the inventory paperwork. She stated the hospital pulled the camera recordings to see the patient being admitted and there were no glasses present. Staff F verified that the concerns raised about Patient #3 were not on the complaint log. Staff F verified that some sort of investigation had been completed already and stated she did not know why this was not on the complaint log. Review of the hospital policy titled “Patient Complaints and Grievances,” dated 01/23, revealed any complaint received by a staff member will be appropriately documented and an attempt to resolve the concern must be made if possible. If the concerns cannot be resolved at that time, the complaint will be referred to the patient advocate or designee. Any complaint or grievance received after the patient is no longer in the facility should be documented by the staff member receiving it and forwarded to the patient advocate or designee. The patient advocate or designee will review and attempt to resolve the grievance within seven business days. All other grievances will be followed up with a letter within 30 days of the facilities decision. The complaint/grievance and resolution should be documented on the complaint log.”

“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: 32088 Based on medical record review and staff interview, it was determined the facility failed to ensure medication was administered as ordered. This affected one (Patient #1) of three medical records reviewed for medication. The census was 54. Findings include: Review of Patient #1’s medical record revealed an involuntary admission date of 12/06/24 for severe depression, inability to contract for safety, and to benefit from stabilization at an inpatient hospital. The patient was admitted to the Sage Unit at 4:00 PM from the hospital after being assessed and or medically cleared for transient left sided facial droop, altered mental status, confusion, and a saccular aneurysm. Review of the transferring hospital discharge information stated the patient had opioid dependence and was being seen in the community by a methadone clinic. Further review of the transferring hospital discharge revealed a list of all at home and inpatient medications, which included methadone (drug used for addiction to block the high from opioids drugs) 60 milligrams (mg) by mouth once a day. The discharge information also stated Patient #1’s methadone was decreased at the previous hospital to 60 mg because she had taken all the methadone was provided to last her through 12/10/24. The last dose of methadone 60 mg was administered on 12/05/24 at 11:12 AM at the hospital prior to admission at River Vista. Review of the medical record revealed the methadone had not been administered during the patient’s stay. Review of a nursing note dated 12/08/24 at 7:44 PM revealed the patient told the nurse her stomach hurt and she was having a hard time breathing. Review of nursing note dated 12/08/24 at 6:25 PM revealed the patient was having issues regarding withdrawal symptoms, complaining of stomach pain and nausea. The nurse noted the patient was previously on methadone and the psychiatric nurse practitioner was awaiting confirmation from the methadone clinic to confirm her dosage and “As this was not done the previous day.” The nurse noted the methadone clinic was Googled and was listed as closed on Sundays and did not open again until Monday 12/09/24. The psychiatric nurse practitioner was notified of this on 12/08/24 and ordered Suboxone (medication used to treat narcotic dependence) 8 mg/2 mg by mouth. The Suboxone was given at 9:15 AM on 12/08/24 and the nurse noted there were no issues immediately after taking the medication. On 12/08/24 at 3:05 PM the nurse noted she contacted the psychiatric nurse practitioner who stated he had spoken with the health nurse practitioner and they decided Bentyl and Flexiril could be given to help the patient. On 12/08/24 the patient was transferred to the hospital following a Code Blue with resuscitation. The nurse noted while the code was going on the patient’s family, to include a daughter, was at the hospital for a visitation. The daughter stated she had called this hospital on Friday, 12/06/24, and whoever she spoke to already knew her mom was on methadone. The nurse noted the daughter stated her mom had been at the facility on 12/06/24 at approximately 3:00 PM and she did not understand why the medication had not been verified by 12/08/24. The nurse noted she explained to the family that even though it was on her medication list it had to be verified by the methadone clinic. Interview on 01/07/25 at 3:30 PM with Nurse Manager Staff F revealed when patients come to the hospital on methadone the hospital staff must verify the dose from the methadone clinic who is following the patient. Staff F stated the providers are not allowed to order the methadone. Staff F stated the methadone clinics hours are short, Monday through Friday from 6:00 AM through 1:00 PM and from 6:00 AM through 9:00 AM Saturdays, and closed Sundays. Staff F stated medications should be reconciled in 24 hours and verified the patient arrived between 3:00 PM and 4:00 PM on Friday, 12/06/24. Staff F stated the nurse practitioner did not come in on 12/07/24 until after the methadone clinic closed, around 11:00 AM. Interview on 01/08/25 at 4:00 PM with Staff H (Pharmacist) revealed when a patient is admitted on methadone nursing staff or the provider will need to call the methadone clinic to verify the dose the next time the clinic is open. Staff H stated since the methadone clinics do not report to Ohio Automated Record Reporting System (OARS) you can’t verify the dose there. Staff H stated the medications should be reconciled within 24 hours. Staff H stated methadone is available in the hospital pyxis.”

“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: 19966 Based on record review, interview and policy review, the facility failed to ensure a patient’s responsible party was notified of a change in condition and subsequent transfer to an outside hospital. This affected one (Patient #1) of ten records reviewed. The census was 45. Findings include: Record review revealed Patient #1 was admitted on 08/04/24 as a direct admit from a nursing home. The progress note documented Patient #1 had physical combativeness towards caregivers and has recently escalated to physical aggression. Patient #1 was on hospice for end stage dementia. Review of a medical progress note dated 08/07/24 documented the nurse practitioner (NP) saw Patient #1 due to a rapid decline, not eating or drinking. Patient #1 was lying in bed with his legs hanging over the side and was not able to tell the NP his name, where he was, year or why he is here. He reported bilateral foot pain and had an episode of bladder incontinence. Patient #1 appeared to be uncomfortable and restless. Review of a general progress note dated 08/07/24 for 12:56 PM revealed the NP wrote an order for Patient #1 to be sent to the hospital for failure to thrive. Review of a general progress note dated 08/08/24 for 5:00 PM documented the nurse was able to reach the staff at an outside hospital emergency department and Patient #1 was admitted for delirium. There was no documentation Patient #1’s responsible party was notified of his change in condition or subsequent transfer to an outside hospital. During an interview on 11/19/24 at 1:51 PM, Staff C verified there was no documentation that Patient #1’s responsible party was notified of his change in condition or transfer to an outside hospital. Review of the policy titled “Change in Condition Chain of Command Notification:l dated February 2024, stated at the time of admission, the patient and their family (if present) will be informed of how to seek assistance when they have concerns about the patient condition. The nurse assigned to a patient/client or supervising the care of a patient is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the patient condition and for assuring that there is provider response. Changes in the condition of the patient are determined by assessments utilizing defined parameters, current and past medical condition, medical orders, and or patient safety factors. Examples of change of condition may include patient transfer.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 42492 Based on interview, record review, review of facility EMTALA logs, and review of facility policies, the facility failed to ensure medical records were complete, accurate and retained for each individual seeking treatment at the facility. This affected 17 (Patients #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) of 25 patients reviewed. Findings include: 1. Review of the Emergency Medical Treatment and Labor Act (EMTALA) log dated 11/02/23 revealed Patient #2 presented to the hospital on 11/02/23 at 8:28 A.M. per car, received medical screening at 8:30 A.M., and was referred to another hospital at 9:40 A.M. Review of form titled “Medical Send Out and EMTALA” dated 11/02/23 revealed Patient #2 presented for complaints including alcohol detoxification, Suicidal Ideation (SI), and psychotic behaviors, vital signs were assessed, and the patient left in serious condition per scheduled medical transport to another hospital emergency department (ED) due to the hospital was at capacity and there were no beds available for admission. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 2. Review of the EMTALA log dated 110/0/23 revealed Patient #10 presented to the hospital on 11/08/23 at 1:50 P.M. per car with complaints of SI and psychotic behaviors, received medical screening at 2:00 P.M. and was transferred to another hospital in fair condition via 911/EMS personnel. Further review of the medical record revealed there was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 3. Review of the EMTALA log dated 11/02/23 revealed Patient #11 presented to the Hospital on 11/02/2203 at 11:48 AM via car with complaints of paranoia and other psychotic behaviors, received medical screening at 11:50 A.M., and was transferred to another hospital ED at 1:01 P.M. via 911/EMS personnel. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 4. Review of the EMTALA log revealed Patient #12 presented to the hospital on 11/01/23 at 9:29 A.M. via car with complaints of Homicidal Ideation (HI) and SI with a plan, was medically screened at 9:30 A.M., and was transferred at 10:40 A.M. in fair condition to unidentified ED via 911/EMS personnel. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 5. Review of the EMTALA log revealed Patient #13 presented to the hospital on 11/02/23 at 1:26 P.M. per walk-in with complaints of cocaine relapse, received medical screening at 1:30 P.M., and was transferred at 2:14 P.M. in fair condition via EMS/911 personnel to an unidentified ER. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 6. Review of the EMTALA log revealed Patient #14 presented to the hospital on 10/25/23 at 2:22 P.M. per walk-in with complaints of HI with a vague target and SI with a plan, received medical screening at 2:23 P.M., and was transferred at 3:28 P.M. in fair condition to another facility for treatment via a private vehicle. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 7. Review of the EMTALA log revealed Patient #15 presented to the hospital on 11/25/2203 at 8:00 A.M. via walk-in with complaints of depression, anxiety, substance abuse. The patient received medical screening at 8:05 A.M. and was transferred to another facility for treatment via private vehicle at 9:05 A.M. in fair condition. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 8. Review of the EMTALA log revealed Patient #16 presented to the hospital on 11/25/23 at 4:40 A.M. via car with complaints of SI with a plan, received medical screening at 4:45 A.M., and was transferred in fair condition to another hospital via scheduled medical transport. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 9. Review of the EMTALA log revealed Patient #17 presented to the hospital on 12/17/23 at 6:47 P.M. via car with complaints of SI and HI, received medical screening at 6:52 P.M., and was transferred in fair condition via 911/EMS personnel at 12:15 A.M. to an unspecified destination. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 10. Review of the EMTALA log revealed Patient #18 presented to the hospital on 11/28/23 at 12:53 P.M. via walk-in with complaints of SI, received medical screening at 12:55 P.M., and was transferred in fair condition at 7:10 P.M. via scheduled medical transport to another hospital. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 11. Review of the EMTALA log revealed Patient #19 presented to the hospital on 01/25/23 at 2:15 P.M. via car with unspecified complaints, received medical screening at 2:18 P.M., and left in good condition in a private vehicle. The patient did not meet criteria for admission. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 12. Review of the EMTALA log revealed Patient #20 presented to the hospital on 10:25 A.M. via car with complaints HI/SI and psychotic behavior, received medical screening at 11:00 A.M., and was transported in fair condition via 911/EMS at 12:45 P.M. to an unspecified ED. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 13. Review of the EMTALA log revealed Patient #21 presented to the hospital on 01/08/24 at 8:30 P.M. via walk-in with complaints of alcohol detox, received medical screening at 8: 32 P.M., and was transferred via 911/EMS personnel in serious condition to another ED. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 14. Review of the EMTALA log revealed Patient #22 presented to the hospital on 12/05/23 at 5:45 P.M. via walk-in with complaints of SI, received medical screening at 5:50 P.M., and was transferred via scheduled transport in fair condition to another ED. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 15. Review of the EMTALA log revealed Patient #23 presented to the hospital on 12/04/23 at 2:30 P.M. via walk-in with complaints of SI, received medical screening at 2:35 P.M., and was transferred via scheduled medical transport in fair condition to an unidentified location. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 16. Review of the EMTALA log revealed Patient #24 presented to the hospital on 11/08/23 at 2:33 P.M. via car with complaints of SI/HI with a plan and psychotic behaviors, received medical screening at 2:36 P.M., and was transferred in fair condition vie 911/EMS personnel to another hospital. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. 17. Review of the EMTALA log revealed Patient #25 presented to the hospital on 12/12/23 at 2:19 P.M. via car with complaints of SI and substance use, received medical screening at 2:20 P.M., and was transferred in fair condition via 911/EMS personnel to another hospital. There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record. During an interview on 02/08/23 at 12:21 P.M. Staff E stated every individual who presented for emergency treatment was logged into the EMTALA log. Walk-in patients signed a consent for assessments and a Urine Drug Screen. Nurse were required to complete a medical screening examination with vital signs within 15 minutes of each patient’s arrival. Intake staff completed a Level Of Care (LOC) assessment which included the presenting problems and medical history. After the assessment, staff called the provider to see if the patient was approved for admission. If the patient did not meet criteria for admission, staff determined if the individual had an outpatient provider or assisted to set up outpatient services as applicable, and everything was documented in the medical record. Medical records were filed in filing cabinet and kept for one month before moved to medical records. During an interview on 02/08/23 at 12:30 P.M. Staff A verified there were 17 patient records that were incomplete and the only record of visits for Patients #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25 were what was include on the EMTALA logs and on the Medical Send Out/EMTALA forms. Staff A stated there had been recently hired staff who had confusion about how files were stored and had shredded parts of the medical records. Review of policy titled “Emergency Medical Treatment and Active Labor Act” dated 03/23 revealed a medical record was established for each individual seeking emergency treatment including documentation of the individual’s medical and psychiatric history, screening examination, diagnosis (if determined), treatment rendered, response to treatment, and disposition of case. Additionally, any conclusions or findings that indicated the individual did not have a medical emergency condition were documented in the medical record. The facility maintained medical records and documentation associated with the appropriate transfer of patient, including the log for seven years.”

“Primarily Engaged in Psych Services CFR(s): [Psychiatric hospitals must] Be primarily engaged in providing, by or under the supervision of a doctor of medicine or osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons. This Standard is not met as evidenced by: 40471 Based on record review and interviews, the facility failed to ensure a physician performed the initial psychiatric evaluation of admitting patients. This affected ten (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) of ten records reviewed. The census was four. Findings include: 1. Review of patient records for Patient #2 revealed an admission date of 09/09/23 and a discharge date of 09/21/23 with diagnosis including schizophrenia. Review of admission documentation, Patient #2’s initial Psychiatric Evaluation dated 09/09/23 was signed by APRN N, no physician signature was noted on the initial psychiatric evaluation. 2. Review of records for Patient #1 revealed an admission date of 10/05/23 with diagnosis of major depressive disorder. Patient #1’s initial mental psychiatric evaluation was performed by a nurse practitioner (NP) not a physician. 3. Review of records for Patient #3 revealed an admission date of 08/13/23 with diagnosis of suicidal ideation. Patient #3’s initial mental psychiatric evaluation was performed by a NP on 08/13/23, not a physician. 4. Review of records for Patient #4 revealed an admission date of 08/09/23 with diagnoses of bipolar and borderline personality disorder. Patient #4’s initial psychiatric evaluation was performed by a NP on 08/10/23, not a physician. 5. Review of records for Patient #5 revealed an admission date of 08/13/23 with a diagnosis of bipolar disorder, manic with severe with psychotic features. Patient #5’s initial psychiatric evaluation was performed by a NP on 08/13/23, not a physician. 6. Review of records for Patient #6 revealed an admission date of 07/30/23 for suicide attempt. Patient #6’s initial psychiatric evaluation was performed on 07/31/23 by a NP, not a physician. 7. Review of records for Patient #7 revealed an admission date of 07/18/23 with a diagnosis of homicidal ideation. Patient #7’s initial psychiatric evaluation was performed by a NP on 07/18/23, not a physician. 8. Review of records for Patient #8 revealed an admission date of 08/07/23 with a diagnosis of major depressive disorder. Patient #8’s initial psychiatric evaluation was performed on 08/08/23 by a NP, not a physician. 9. Review of records for Patient #9 revealed an admission date of 10/11/23 with a diagnosis of bipolar disorder, manic. Patient #9’s initial psychiatric evaluation was performed by a NP on 10/12/23, not a physician. 10. Review of records for Patient #10 revealed an admission date of 09/15/23 with a diagnosis of dementia. Patient #10’s initial psychiatric evaluation was performed by a NP on 09/15/23, not a physician. During an interview on 11/20/23 at 1:34 P.M. APRN D stated she reached out to MD C almost daily to collaborate. APRN D stated that she performed the initial assessment on Patient #10. She stated that MD C sometimes attended the treatment team meetings, but he did not sign the meeting documentation, as he was not involved in the direct care of a patient. APRN D stated she did not know of any documentation MD C signed or completed for any patient in the acute hospital. During interview on 11/20/23 at 2:40 P.M. MD C stated that patients were required to be seen within 24 hours by a licensed provider. MD C stated he tried to see each patient as much as possible depending on the patient’s stays. MD C stated he would see patients at the request of the APRNs. MD C stated that he did not document on patients that he was asked to see by APRNs, he had APRNs do the documentation. MD C stated he was at the facility two to three times a week. MD denied seeing Patient #2 during Patient #2’s length of stay. MD C stated he was in a support and collaboration position.”