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Based on medical record reviews, review of facility documentation and interview for one of three patients reviewed for dietary choices (Patient #1), the hospital failed to ensure that the patient's fluid preferences were incorporated into the patient's plan of care. The finding include:

Patient #1 was readmitted to the hospital on 4/18/11 with psychiatric diagnoses of acute schizoaffective disorder and personality disorder and medical diagnoses that included obesity, hypertension, diabetes and hyperlipidemia. Physician orders dated 11/9/11 identified regular diet without documented restrictions and Level 1 privileges. Nursing progress notes dated 11/17/11 indicated that the patient was banging on the kitchen window demanding a glass of juice and was informed by the Mental Health Assistant that the patient could have water or Crystal Lite as per unit policy. The B3N unit food ordering form identified that the unit could have up to 12 cans each of cranberry, apple, orange, pineapple, and prune juice on the unit and available to patients. Patient #1 indicated on 11/30/11 at 9:55 AM and/or 11:00 AM that when s/he asked for juice, staff refused to provide the juice and indicated that s/he was allergic to Crystal Lite and did not wish to drink water from the unit water fountain. Interview with the B3N Unit Director on 11/30/11 at 10:07 AM noted that fruit juices were served on meal trays from the main kitchen and water/Crystal Lite were available/provided daily because of the low sugar content. S/he further noted that patients who had Level 2 privileges and above, could purchase bottled water at the canteen. Review of the handbook utilized on the B3N unit lacked documentation regarding fluid availability/requests. The hospital ethics, rights, and responsibilities policy identified that patients will be given the opportunity to participate in their own care.

Based on medical record reviews and review of hospital policy for one of three patients reviewed for nursing assessment after a change in medical condition, (Patient #11), staff failed to consistently assess the patient's ear pain during and following antibiotic therapy. The finding include:

Patient #11 had diagnoses of schizoaffective disorder and borderline personality disorder. Nursing progress notes dated 11/2/11 identified that the patient complained of left ear pain that worsened over the past 2 days. Physician orders dated 11/2/11 directed Auralgan ear drops three times a day for 5 days (reduces pain, inflammation and facilitates loosening of cerumen). Nursing progress notes dated 11/3/11 indicated that the patient continued to complain of left ear discomfort. Review of the patient's record was conducted on 12/1/11 with the Director of Nursing for General Psychiatry and although the patient received the Auralgan as ordered after 11/3/11, further assessment of the patient's ear pain was not documented. The nursing assessment/reassessment policy identified that whenever there is a significant change in the patient's condition, the nurse will document reassessment findings in the physical health progress notes for medical conditions.

Based on medical record reviews, review of patient documentation, review of hospital policy and interview for one of three patients reviewed for privilege levels and/or possible/actual infection (Patient #1), the hospital failed to promote daily opportunities for fresh air per the physician's order/facility policy and/or to obtain a urinary specimen as ordered. The finding includes:

1a. Patient #1 was readmitted to the hospital on 4/18/11 following dangerous behavior towards others with diagnoses of acute schizoaffective disorder and personality disorder. Physician orders dated 10/20/11 directed Level 3 privileges. Progress notes dated 10/24/11 and 10/25/11 indicated that the patient displayed abusive, loud, disruptive, threatening behaviors that required medication administration. Physician orders dated 10/25/11 directed Level 1 privileges. The physician order and/or progress notes did not direct restriction to the unit and/or cessation of fresh air opportunities. Although the patient received fresh air breaks on 11/18/11 at 1:30 PM and 2:20 PM, facility sign- out sheets and/or the patient's record lacked documentation that the patient received and/or was offered additional fresh air opportunities from 10/25/11 to 11/23/11. Physician orders dated 11/23/11 directed Level 2 privileges and that the patient could receive fresh air opportunities with other patients. Interview with the Director of Compliance noted that a patient on Level 1 restriction would receive opportunities for fresh air but, with the accompaniment of 1 staff member instead of with a group of patients. The hospital patient privilege policy identified that patients restricted to Levels 1 through 3 will be provided with opportunities for fresh air daily, unless clinically contraindicated and documented by a physician's order and progress note.

1b. Patient #1 had psychiatric diagnoses of acute schizoaffective disorder and personality disorder and medical diagnoses that included obesity, hypertension, diabetes, and hyperlipidemia. Physician orders dated 10/28/11 directed to obtain a urinalysis and culture. Progress notes dated 10/28/11 indicated that the patient agreed to the urine testing. The urine testing reports dated 10/28/11 identified a small amount of white blood cells, possible infection and to repeat the urine culture. The treatment plan dated 11/2/11 identified that the patient refused, in part, laboratory testing. Physician orders dated 11/7/11 directed to repeat the urinalysis and culture as the recent specimen (10/28/11) was contaminated. A phone interview with Patient #1 on 11/16/11 indicated that the patient had a bladder condition. Review of the integrated progress notes from 11/7/11 to 11/29/11 noted that the patient was transferred to the B3N unit from the B3S unit on 11/9/11, the urine testing was not completed and the record lacked evidence that the lack of testing was due to patient refusal.

Based on medical record reviews and review of hospital policy for three of three patients reviewed for privilege level (Patients #1, #9, #10), staff failed to document the patient's criteria for level progress in the patient's treatment plan and/or failed to document the safety rational when the patient's privilege level was increased. The finding includes:

1. Patient #1 was readmitted to the hospital on 4/18/11 with diagnoses of acute schizoaffective disorder and personality disorder. Physician orders dated 10/20/11 directed Level 3 privileges. Progress notes dated 10/24/11 and 10/25/11 indicated that the patient displayed abusive, loud, disruptive, threatening behaviors that required medication administration. Physician orders dated 10/25/11 directed Level 1 privileges. Although physician orders dated 11/23/11 directed Level 2 privileges a physician progress note regarding the decision to increase the patient's privilege level was not documented. Review of the patient's integrated treatment plans dated 9/22/11 and 11/2/11 noted that the plans did not include the patient's level progress. The hospital patient privilege policy identified that the clinical criteria upon which the patient progresses through various privilege levels will be documented in the patient's multidisciplinary treatment plan. The policy further noted that the rational for privilege changes will be documented by the patient's attending psychiatrist or covering physician in the progress note section of the patient's medical record.

In addition, Patient's #9 and #10 were reviewed for privilege level progression on 12/1/11 and although Patient #9 was increased to Level 1 on 10/25/11 and Patient #10's level was increased on 8/18/11, corresponding notes by the patients' psychiatrist/physician were not documented related to the privilege level change. Interview with the Director of Nursing for General Psychology on 11/30/11 at 2:05 PM indicated that a corresponding progress note would be documented for any patient privilege level change. The hospital patient privilege policy identified that the rational for privilege changes will be documented by the patient's attending psychiatrist or covering physician in the progress note section of the patient's medical record.

Based on review of hospital policy/documentation, observations and interviews, the hospital failed to ensure that acceptable food temperatures were maintained in one of the campus buildings. The finding includes:

Documentation from Patient #1 dated 10/31/11 identified that foods were not served hot. Observations during the noon meal on 11/30/11 and/or 12/1/11 noted that food temperatures were taken prior to tray line service, hot food temperatures were within acceptable ranges and the trays were then placed on open carts. The filled carts were then placed in the dining room for unit pick- up. Observations on 12/1/11at 11:45AM indicated that the cheese on 2 hamburgers was only slightly melted. Observation at 11:47 AM noted that the B3S tray cart was filled with patient trays in the dining room and as of 1:10 PM the cart had not been brought to the unit. Further observation identified that the temperature of a hamburger, taken by dietary staff at this time, was 100 degrees Fahrenheit and the hamburger tasted cold. Interviews with Patients #1 and #6 on 11/30/11 after the noon meal indicated that food was cold and/or warm and that the Patient #6 would have liked the food a little hotter. Although food was cooked to the proper temperature prior to removing from the cooking medium, the hospital system for tray delivery to the units did not adequately maintain food temperatures/palatability.

Based on medical record review, review of hospital documentation, observations and interviews the hospital failed ensure that fruit juices were available on the B3N unit in accordance with the hospital's unit food ordering form. The findings include:

A tour of the BN3 unit was conducted with the Director of Regulatory Compliance on 11/30/11. Observation of the unit kitchen noted that the only juice available was prune juice. Review of the Unit Food Ordering Form noted that the unit could have up to 12 cans each of cranberry, apple, orange, pineapple, and prune juice on the unit and available to patients. Interview with the Unit Director on 11/30/11 at 10:07 AM indicated that s/he did not know when juices, other than prune, became unavailable. Interview with the Infection Preventionist on 11/30/11 at 11:35 AM identified that 2 cans of each juice were ordered last week and would be delivered today. Interview with the Unit Clerk on 11/30/11 at 11:07 AM noted that the night shift reordered stock weekly for the following week and would reorder stock tonight based on levels. Interview with the Director of Regulatory Compliance indicated that the current ordering schedule was not practical and that staff could reorder any stock item when needed.