The Centers for Medicare and Medicaid Services (CMS) cited Kingwood Pines Hospital for several deficiencies following an unannounced survey. CMS found that the facility failed to maintain the medical records necessary to monitor a patient’s condition. CMS found that one 66-year old patient was transferred from an acute care hospital with hyponatremia (low blood sodium) because he was self-administering a medication called DDAVP prior to arrival, which is known to cause hyponatremia. The physician at the hospital advised the patient to stop taking DDAVP. Upon admission to Kingwood, the patient’s psychiatrist ordered him to continue the medication without documenting the justification or ordering a low sodium blood test. A week after being admitted to Kingwood, the patient was transferred to a local emergency room for a suspected fracture of the shoulder, where he was diagnosed with severe hypnoatremia.