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Based on interview and record review, the facility failed to ensure nursing had blood drawn as ordered for Patient #5, #7, and #9, failed to perform a thorough neurological assessment following a patient enduring convulsions (Patient #9), and failed to perform clinical institute withdrawal assessment as ordered for Patient #1. The sample size was nine patients, the census was 89 patients.

Findings include:

1. The medical record review for the Patient #5 was completed on 02/23/17. The review revealed a psychiatric evaluation dictated on 09/23/16 that stated the patient was nonverbal. The evaluation stated the patient had a history of developmental delay and was referred to the facility for increased agitation behaviors. She was diagnosed with intellectual disability, unspecified bipolar and related disorder, and epilepsy, among other diagnoses.

A review of the admission order revealed on 09/23/16 at 11:10 AM a valproic acid level was to be drawn prior to administering Depakote, and a complete blood count with differential, thyroid hormones, and a metabolic panel were to be drawn.

The medical record review did not reveal where the thyroid hormones or metabolic panel or valproic acid levels had been drawn at any time during her stay.

On 02/23/17 at 11:00 AM in an interview, Staff B and C confirmed the blood work had not been done, and further explained if the phlebotomist had been unable to obtain the blood, there would be no record of that.

The medical record review revealed nursing notes dated 09/23/16 at 6:20 PM, 6:30 PM, 6:35 PM, 6:45 PM, that state the patient was having a seizure, with at note at 7:00 PM stating, "Post ictal at times appears to be resting quietly then small seizure noted lasting approximately 30 to 45 seconds."

The medical record review revealed a nursing note dated 09/23/16 at 6:30 PM that stated the advanced practice nurse was notified, an order for Ativan was received and administered.

The medical record review revealed a nursing note dated 09/23/16 at 6:45 PM that stated the advanced practice nurse was again notified, an order for Ativan was received and administered five minutes later.

The medical record review revealed a nursing note dated 09/23/16 at 7:50 PM that stated emergency medical services left with the patient for the hospital.

The medical record review did not reveal where any type of neurological assessment was completed between 6:20 PM when the seizures began to 7:25 PM when the patient left the facility.

On 02/23/17 at 11:00 AM in an interview, Staff B confirmed no detailed neurological assessment had been performed and documented during the patient's seizure activity.

2. The medical record review for Patient #7 was completed on 02/23/17. The review revealed the patient came to the facility on 02/15/17 at 1:50 PM. The medical record review revealed a psychiatric evaluation dated 02/19/17 that stated the patient attempted suicide by overdosing on medications.

The medical record review revealed medical admission orders on 02/16/17 at 12:00 PM, that directed staff to draw blood work for a complete blood count, a metabolic panel, and thyroid hormones.

The medical record review revealed that the blood had not been collected until 02/20//17 at 3:20 PM.

On 02/23/17 at 11:00 AM in an interview, Staff B confirmed the blood had not been collected until 02/20//17 at 3:20 PM.

3. The medical record review for Patient #9 was completed on 02/23/17. The review revealed the patient came to the facility on 01/16/17 at 12:00 PM. The review revealed a psychiatric evaluation dictated on 01/17/17 that stated the patient was suicidal because the pastor was leaving her church and the anniversary of her boyfriend's suicide was near.

The medical record review revealed a medication reconciliation order form that revealed psychiatric admission orders that stated to draw a valproic acid level prior to administering Depakote, signed by psychiatry on 01/17/17, and physician orders signed on 01/17/17 at 10:00 AM that stated to draw blood for a complete blood count, a metabolic panel, and thyroid hormones, among other things.

The review revealed the blood had not been collected until 01/29/17. The review revealed a medication administration record that stated the Depakote had been given each day from 01/16/17 to 01/29/17.

On 02/23/17 at 11:00 AM in an interview, Staff B and C confirmed the blood work had not been done, and further explained if the phlebotomist was unable to obtain the blood, or the patient refused to have blood drawn, there would be no record of that.


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4. Record review of Patient #1 revealed an admission date of 02/21/17 at 2:30 P.M. Patient #1 was placed in the Hospital Intensive Care Unit (ICU) as "High Risk." Patient had a past medical history to include Major Depressive Disorder.

Record review of the Clinical Institute Withdrawal Assessment (CIWA) dated and signed by the physician on 02/21/17 at 2:30 P.M., ordered the assessment of Patient #1 to be completed by nursing staff and the assessment score and subsequent intervention be placed in the patient's medical record. An assessment score would indicate the medical intervention (if needed) and the next time a CIWA assessment would be performed.

Record review of Patient #1 revealed a CIWA assessment, with related score, was completed on 02/22/17 at 6:30 A.M. The CIWA score was zero, indicating no medical intervention was necessary and vital signs, pulse oximeter, and CIWA assessment was to be performed in four hours, at 10:30 A.M.

Record review on 02/22/17 at 2:48 P.M. revealed a CIWA assessment for Patient #1 was completed on 02/22/17 at 2:15 P.M. The CIWA score was two, indicating no medical intervention was necessary and vital signs, pulse oximeter, and CIWA assessment was to be performed in four hours, at 6:15 P.M.

Interview on 02/23/17 at 10:12 A.M. with Staff #A stated/confirmed a CIWA assessment should have been done, but was not completed on Patient #1 at 2:30 P.M. on 02/21/17, 6:30 P.M. on 02/21/17, 10:30 P.M. on 02/21/17, and 2:30 A.M. on 02/22/17.

Based on interview and medical record review, the facility failed to ensure care plans reflected Patient #5's communication challenges, the increased impairment to Patient #7's elbow, and Patient #9's self-cutting and the resultant skin impairment. The sample size was nine patients, and the census was 89 patients.

Findings include:

1. The medical record review for the Patient #5 was completed on 02/23/17. The review revealed a nursing admission assessment form that stated the patient arrived at the facility on 09/22/16 at 6:20 PM from an outside hospital for changes in her behavior. The assessment stated the patient was nonverbal and unable to answer questions and no family was present.

Corroborating this was a history and physical dictated on 09/23/16 that stated the patient was unable to provide a review of systems because she was nonverbal.

Corroborating that was a psychiatric evaluation dictated on 09/23/16 that stated the patient was nonverbal. The evaluation stated the patient had a history of developmental delay and was referred to the facility for increased agitation behaviors. She was diagnosed with intellectual disability, unspecified bipolar and related disorder, and epilepsy, among other diagnoses.

Although three clinicians had documented the patient as nonverbal, conscious and had the diagnosis of developmental delay and intellectual disability, the patient's nursing care plan did not address how best to communicate with the patient.

On 02/23/17 at 11:00 AM in an interview, Staff B and C confirmed the lack of care planning for the impairment in communication.

2. The medical record review for Patient #7 was completed on 02/23/17. The review revealed the patient came to the facility on 02/15/17 at 1:50 PM. The medical record review revealed a psychiatric evaluation dated 02/19/17 that stated the patient attempted suicide by overdosing on medications.

The medical record review revealed a nursing note dated 02/16/17 at 2:10 PM that stated his elbow was sore to the touch, red and swollen, and was sent to a local emergency department for evaluation.

The medical record review revealed a nursing note dated 02/16/17 at 8:00 PM that stated the patient returned with a diagnosis of cellulitis, an order for an antibiotic, and a sling.

The medical record review did not reveal where the nursing care plan had been updated to reflect the infection to the elbow.

On 02/23/17 at 11:00 AM in an interview, Staff B confirmed that the care plan had not been updated.

3. The medical record review for Patient #9 was completed on 02/23/17. The review revealed the patient came to the facility on 01/16/17 at 12:00 PM. The review revealed a psychiatric evaluation dictated on 01/17/17 that stated the patient was suicidal because the pastor was leaving her church and the anniversary of her boyfriend's suicide was near.

The medical record review revealed a nursing note dated 01/17/17 at 12:05 AM that stated the patient was walking down the corridor and went into her room with blood on her hands and face. The note continued to state the patient was observed in her room attempting to cut her scalp with the end of a plastic spoon. The note stated at 12:20 AM the patient was transported via emergency medical services to a local emergency department.

The medical record review revealed a nursing note dated 01/17/17 at 4:15 AM that stated the patient returned without stitches.

A review of the patient's care plan did not document how staff were to address the new skin impairment and the recent self-harm.

On 02/23/17 at 11:00 AM in an interview, Staff B confirmed the care plans did not reflect the recent events.

Based on interview and medical record review, the facility failed to administer medications as ordered for two out of nine patients, Patient #5 and #6. The facility's census was 89 patients.

Findings include:

1.The medical record review for the Patient #5 was completed on 02/23/17. The review revealed a psychiatric evaluation dictated on 09/23/16 that stated the patient was nonverbal. The evaluation stated the patient had a history of developmental delay and was referred to the facility for increased agitation behaviors. She was diagnosed with intellectual disability, unspecified bipolar and related disorder, and epilepsy, among other diagnoses.

The review revealed a medication reconciliation order form with three signature lines: one for the nurse completing the form, one for the medical practitioner to sign, and one for the psychiatrist to sign as physician orders.

Patient #5's form was completed by the nurse on 09/22/16 at 9:50 PM and on 09/23/16 at 11:12 AM the medical practitioner signed that line, and on 09/23/16 at 11:24 AM the psychiatrist signed that line.

On 02/23/17 at 11:00 AM in an interview, Staff B explained that when the nurse completed the form, she is creating a verbal order, which is later signed by the medical staff. She explained nursing staff are in the process of being educated to co-sign on the line for the medical practitioner as taking a verbal order.

A review of the patient's medication reconciliation order form revealed the patient was taking 12 maintenance medications, including levothyroxine and clorazepate dipotassium (an anticonvulsant). A review of the medication administration record revealed at no time were the meds given between when she arrived on 09/22/16 at 6:20 PM to when she departed on 09/23/16 at 7:50 PM.

On 02/23/17 at 11:00 AM in an interview, Staff B confirmed the medications had not been given.


2. The medical record review for Patient #6 was completed on 02/23/17. The review revealed the patient arrived to the facility on 02/05/17 at 10:35 PM. The review revealed a psychiatric evaluation dated 02/06/17.

The review revealed a medication reconciliation order form that stated the patient was on three maintenance medications, one for diabetes, and another for blood pressure. The advanced practice nurse took a phone order for these orders from the physician on 02/05/17 at 9:00 PM.

The review of the patient's medication administration records did not reveal where the patient received any medication on 02/06/17.

On 02/22/17 at 3:25 PM in an interview, Staff B confirmed the patient had not been given any medications on 02/06/17.