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Based on record review, interviews and policy review, the facility failed to ensure the interdisciplinary plan of care (IPOC) goals and interventions reflected the individual needs for two of 10 patients' (P)1 and P3) IPOC's reviewed to ensure each patient's individualized needs for care and safety. This has the potential to affect what nursing care and interventions were initiated to meet each individual patient needs for care and safety for all 25 patients currently receiving care in the Geriatric Behavioral Health unit (one of four Behavioral Health Units in the hospital).

Findings Include:

Review of the facility's policy titled, "Patient Assessments and Reassessments" dated 07/29/20 revealed, "Registered Nurses [RN] are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. The RN may delegate aspects of data collection to LPN [Licensed Practical Nurse], can [Certified Nursing Assistant], or Behavioral Health Tech [Technician]. The RN must then analyze the data and set care priorities, formulate diagnosis, plan of care, and initiate referrals. "Reassessments ate documented whenever there is: 1. A significant change in the patient's condition or status; 2. A significant response to a procedure / intervention; and 3. At specified time intervals a progress note is entered by."

Review of the facility's policy titled, "Patient Assessments and Reassessments" dated 07/29/20 showed ...Interdisciplinary Plan of Care (for admitted patients). Each admitted patient will have a comprehensive, integrated, multidisciplinary plan of care, which is developed from the initial patient assessment. This plan of care will include, at a minimum, physician, and nursing components. Initial patient assessments provide the baseline of the patient at the time of admission. From these assessments, the needs of the patient are identified, and the plan of care is developed.

A. The plans of care focus on:

1. Immediate needs. The RN assessment results in a listing of patient problems, needs or nursing diagnoses.

2. The patient's needs for education regarding the diagnosis, treatment, and continuing management of health care problems and the maintenance of health; and discharge planning.

B. How often is the plan of care reviewed? RN's are expected to review the plan of care at least daily

C. Updates or modifications to the plan of care occur whenever there is:

1. A significant change in the patient's condition or status...


Review of the facility's policy titled, "Fall Risk" revised 09/02/20, showed, Policy: Goal of Ascension Via Christi Hospitals that all patients remain free from injury while in the facility ... ...f. Incorporate high fall risk status in the patients Individual Plan of Care (IPOC) when appropriate.


Review of the hospitals document title "Job Description as of November 17, 2021" showed the RN job Responsibilities included: Implements and monitors patient care plans. Monitors, records, and communicates patient condition as appropriate. Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders ..."


Patient 1

During a telephone interview of 11/15/21 at 6:47 PM, P1's Family (F) 11 stated, P1 was brought into the Emergency Room (ER) for evaluation because of increased activity/behaviors. Family (F) 11 stated "I was in the emergency room with [name of P1] on 10/14/21." F11 described P1's behavior during the time in the ER, was like "running after a toddler and redirecting." F11 stated that P1 paced in their ER bay or hallway and would often walk into other patient's ER bays and had to be redirected by F11 or ER staff.

Review of P1's Electronic Medical Record (EMR) showed that on 10/14/21 at 3:37 PM, F11 brought P1 to the ER. P1 was experiencing increase aggression, confusion, and hallucinations. Review of the "ER note" dated 10/14/21 showed P1 was aggressive with staff at the memory care facility.

Review of "ER Nursing Notes" showed no documentation of P1 intrusive behaviors walking in other patient bays or staff or family redirection as described by Family 11, until 5:26 PM when 2 milligrams (mg) of Haldol (antipsychotic medication) was given orally for patient's agitation.

During an interview on 11/16/21 at 10:14 PM, Geriatric Behavioral Health (GBH) Registered Nurse (RN) Manager 5 stated that there were no other ER nursing notes for P1. GBH RN Manager 5 stated the ER Nursing Notes do not document the same picture as described by F11.

Review of P1's "laboratory results" dated 11/16/21 at 10:14 PM, GBH RN Manager 5 confirmed P1 had a Urinary Tract Infection (UTI).

On 10/14/21 at 9:30 PM P1 was admitted to the GBH inpatient unit. Review of the "RN assessment and admission history and physical" at 11:22 PM by RN 17, showed, P1 was a score of 50 on the "Falls Morse Scale" (Greater that 45 is "High Risk for Falls") and was admitted with increased confusion, agitation, and suspected UTI.

Review of P1's "Nursing Progress Note" dated 10/15/21 at 3:32 AM revealed, "requires frequent orienting."

Review of P1's "Group Therapy Note" dated 10/15/21 at 9:15 AM, revealed, "confused and unable to provide responses, very intrusive and had to be redirected on many occasions."

Review of P1's IPOC showed:

Goal #1: Patient will decrease confusion by discharge: BH (Behavioral Health) Impaired -Thought, that included staff assessing patients' ability to verbalize needs, follow instructions and change in mood, staff should observe patients' ability to demonstrate safe behaviors.

Goal #2: Patient will be without fall or injuries while on SBH (Senior Behavioral Health also referred to as the GBH Unit). Interventions included a general "falls Risk Bundle."

The IPOC did not include goals or interventions to address P1's UTI, Goal #1 was not individualized for P1 and the interventions for Goal #2 were not individualized to address the pacing, intrusive behaviors and need for redirection.

During an interview on 11/16/21 at 10:14 PM, GBH RN Manager 5 confirmed there was no goal or interventions to address P1's UTI. GBH RN Manager 5 stated that Goal #1 was not individualized for P1 and confirmed P1 had dementia, and was admitted for increase aggression, confusion, and hallucinations. GBH RN Manager 5 further stated that Goal #2, the interventions were not individualized for P1 to address the pacing, intrusive behaviors and need for redirection for P1, related to P1s inability to make good judgment. The GBH RN Manager 5 stated that these interventions were a part of the Falls and Impaired Behavioral Health Bundle and not individualized for P1.


Patient 3

Review of P3's EMR showed that P3 was transferred from a nursing care facility to the ER on 09/21/21 at 10:25 PM, after stumbling, falling into a wall and suffering a laceration to the eyebrow. Review of P3's "ER history" showed that P3 had a history of dementia and Parkinson's disease, was unable to complete the mental exam, was confused and had history of frequent falls.

Review of P3's GBH "admission assessment" dated 09/23/21 showed, P3 had a right eyebrow laceration (repaired with skin adhesive) and left posterior upper arm (dressed with Coban) and entered the facility with coccygeal (bony area of buttocks) ulcer 0.7 cm (centimeter) length x width 0.8 cm x depth 0.2 cm "unstageable pressure injury vs moisture associated dermatitis (skin irritation)."

Review of P3's IPOC revealed the following:

Goal #1 Patient will be fall free while on the unit

Goal #2 Patient will improve mood while on the unit

Goal #3 Patient will participate in activities while on the unit

The IPOC failed to include goals for skin integrity related to P3's eyebrow laceration, abrasion or coccygeal ulcer and did not include interventions for wound or skin care.

During an interview on 11/16/21 at 1:30 PM, Clinical Informatics Specialist (CIS) 12 confirmed there was no goal for skin integrity related to P3's eyebrow laceration, or the coccygeal ulcer. Further interview with CIS 12 revealed the IPOC lacked interventions and wound care related to P3's coccygeal ulcer and incontinence, and confirmed no skin interventions, monitoring or goal for the right eyebrow laceration, and left posterior upper abrasion.

During an interview on 10/17/21 at 8:10 AM, GBH RN Manager 5 (also in the room was CIS 12) stated that they recognized there was room for improvement with the nursing documentation.

Based on observation, interviews, record review, job description review and facility's surveillance video review, the facility failed to ensure nursing staff accurately documented the care and patient responses in the Nursing Notes and on Nursing Flowsheet's for three of 10 patients (P) (P1, P3 and P9). This has the potential to affect how care is provided and interventions initiated for patient care and safety for all 25 patients currently receiving care in the Geriatric Behavioral Health unit (one of four Behavioral Health Units in the hospital).


Findings Include:


Review of facility's policy titled, "Patient Assessments and Reassessments" dated 07/29/20 revealed, "Registered Nurses are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. The RN may delegate aspects of data collection to LPN, CNA (Certified Nursing Assistant), or Behavioral Health Tech [Technician]. The RN must then analyze the data and set care priorities, formulate diagnosis, plan of care, and initiate referrals. "Reassessments are documented whenever there is: 1. A significant change in the patient's condition or status; 2. A significant response to a procedure / intervention; and 3. At specified time intervals a progress note is entered by."


Review of the facility's policy titled, "Behavioral Health, Behavioral Health -Patient Management" dated 05/03/19 revealed, "Patient Observation Levels BH (behavioral health) inpatients will be placed on an observation level based on the safety needs of the patient." ... "E. Documentation is at 15-minute increments."


Patient 1

During a telephone interview of 11/15/21 at 6:47 PM, P1's family (F)11 stated that P1 was brought to the Emergency Room (ER) for evaluation because of increased activity/behaviors. F11 stated, "I was in the emergency room with [name of P1] on 10/14/21" F11 described P1's behavior during that time in the ER, like "running after a toddler and redirecting." F11 stated during the entire six hours in the ER, P1 paced in their ER bay or hallway, and would often walk into other patient's ER bays and had to be redirected by F11 or ER staff.

Review of P1's Electronic Medical Record (EMR) showed the "ER Physicians Note" showed P1s chief complaint for being seen, was increase aggression, confusion, and hallucinations. The note also showed P1 was aggressive with staff at the living facility. P1 was brought in for evaluation.

There was no nursing documentation that described P1s pacing or inability to understand personal space was identified as described by F11. Review of P1's EMR for the inpatient geriatric behavioral health (GBH) unit "Physician Orders" required P1 to be monitored as a Level 1 (Periodic Observation (SO)- Level 1 requires 15-minute checks are conducted in varied incremental patterns within the set time parameters).


Review of P1's "Nursing Progress Note" dated 10/15/21 at 3:32 AM showed P1 "requires frequent orienting."

Review of P1's "Group Therapy Note" dated 10/15/21 at 9:15 AM showed, "confused and unable to provide responses, very intrusive and had to be redirected on many occasions."

Review of the surveillance video showed on 10/15/21 at 8:17 PM to 8:20 PM, P1 pacing the floor, appeared agitated trying to remove his/her shirt, and walking into another patient's room.

Review of Hospitalist's 16's (Medical Doctor) note dated 10/15/21 at 8:42 PM (two minutes after the fall) showed, "On my eval [evaluation] he/she was laying on the floor. He/She is able to move both lower extremities, pain over anterior R [right] hip pain with movement/ROM [Range of Motion]"

Review of P1's "Nursing Flowsheet' for 10/15/21, showed nursing staff document the following for 15-minute checks:

8:14 PM Hallway, walking, calm.
8:29 PM Hallway, walking calm
8:44 PM Hallway, sitting no behavior noted
8:59 PM Hallway, sitting, calmly
9:14 PM Hallway, sitting, calmly
9:29 PM to 10:14 PM, Patient's room, Laying down calm
10:29 PM to 11:13 PM, Laying down, awake, calm


During an interview on 11/16/21 at 10:14 PM, while reviewing P1 medical record, GBH RN Manager 5 agreed that the 15-minute checks documentation did not describe a picture of P1's pacing behavior and intrusive behaviors as described by F11. GBH RN Manager 5 stated, there is definitely room for improvement with documenting behaviors.

During an interview on 11/17/21 at 7:40 AM, Clinical Informatics Specialist (CIS) 12 confirmed P1 was pushed and sustained a hip fracture on 10/15/21 at 8:20 PM and was uncertain as to why staff documented in P1's nursing flow sheet for the 15-minute checks that P1 was "hallway walking, calm" after the P1 sustained a hip fracture. CIS 12 confirmed the face to face 15-minute checks on 10/15/21 was performed by Licensed Practical Nurse (LPN) 9, who was in charge of P1's care on 10/15/21.

Further review of the "Nursing Flowsheet's" dated 10/16/21 at 2:39 AM documented by LPN 9 described P1 as "Independent and Up at Lib [up as desired]."

Review of P1's "Medication Administration (MAR) record" and "nursing flow sheets" revealed no pain assessment was documented for P1 from 8:20 PM on 10/15/21 (time of the fall) to discharge for emergency surgery on 10/16/21 at 3:31 AM. P1's "MAR" revealed P1 received a one-time dose of 600 milligrams (mg) of Ibuprofen (pain medication for mild to moderate pain) at 9:46 PM. No assessment or reassessment was documented for the one-time administration. No other as needed (PRN) pain medication was documented until 10/16/21 at 3:31 AM, when P1 was transferred to surgery and given 5 mg of Norco (Hydrocodone) (pain medication to relieve moderate to severe pain).

During an interview on 11/17/21 at 7:40 AM, CIS 12 confirmed that the nursing flowsheet inaccurate, P1 could not have been independent or up at lib after the hip fracture, and most likely was not calm, based on the MD's notes about P1s pain. CIS 12 stated there should have been pain assessment documented after the fall that resulted in P1s right hip fracture and should have had a pain assessment and reassessment after the Ibuprofen pain medication was administered according to facility policy.



Patient 3

Review of P3's admission "Interdisciplinary Plan of Care (IPOC)" dated 09/23/21 to the GBH unit, revealed P3 was admitted with a Coccygeal (bony area of buttocks) ulcer 0.7 cm (centimeter) length x width 0.8 cm x depth 0.2 cm and two laceration "unstageable pressure injury vs [verses] moisture associated dermatitis", interventions for Coccygeal ulcer and incontinence required "Turn Q (every) 2 hours." Review of "Nursing Notes and Nursing Flowsheet's" revealed, two hours turning, and repositioning was documented as follows starting 09/23/21 at 5:00 PM:

09/23/21 from 5:00 PM until midnight no turning or repositioning was documented

09/24/21 at 2:51 PM once in a 24-hour period 2-hour turning, and repositioning was documented but did not include P3's position.

09/25/21 at 11:56 AM and 8:05 PM twice in a 24-hour period 2-hour turning, and repositioning was documented but did not include P3's position.

09/26/21 at 10:52 AM once in a 24-hour period 2-hour turning, and repositioning was documented but did not include P3's position.

09/27/21 at 9:20 AM and 8:00 PM twice in a 24-hour period 2-hour turning, and repositioning was documented but did not include P3's position.

09/28/21 at 12:55 PM once in a 24-hour period 2-hour turning, and repositioning was documented but did not include P3's position.

09/29/21 at 6:26 AM and 11:43 AM twice 2-hour turning, and repositioning was documented but did not include P3's position.


During an interview on 11/16/21 at 2:10 PM, CIS 12 confirmed the turning and repositioning defined in P3's interventions were not documented per IPOC. CIS 12 stated, I agree with GBH RN Manager 5, nursing documentation needs some improvements.


Patient 9

Observation on 11/15/21 at 10:15 AM, during tour of the GBH, P9 was walking in and out of rooms and looked upset. P9 stopped and asked to talk and while standing, shifting posture back and forth. P9 appeared agitated, and stated he/she was very upset, feeling forced to sign consents and stay at the facility for mental health problems when he/she needed medical healthcare. P9 was shifting from side to side during the conversation, using arms/hands in an expressive motion. Also, observing P9's behavior and conversation was Senior Behavioral Manager 7 and Senior Behavioral RN Manager 5.

Review of P9's "Nursing Flowsheet" dated 11/15/21, during the observation period on the floor, showed:

10:14 AM P9 in room, lying down, calm

10:15 AM hallway visiting. No behavior was documented.

10:34 AM hallway visiting. No behavior was documented.


During an interview on 10/17/21 at 9:10 AM, GBH RN Manager 5 (also in the room was CIS 12) stated that the staff should be documenting behaviors accurately and there is an opportunity for narrative text in the electronic Nursing Flowsheet. Without a clear picture of a patient's behavior, how can the RN or the interdisciplinary team make decision and coordinator patient plan of care for patient safety on the behavioral health unit. GBH RN Manager 5 and CIS 12 stated that they recognized there was room for improvement with the nursing documentation.