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Based upon review of 1 of 6 medical records, hospital policies and procedures, and staff interview, the hospital failed to ensure the necessary medical information was sent with patient #4 when the patient was transferred to the Emergency Department of Hospital A on 12/10/10 for emergent care. Findings:

Review of the medical record for patient #4 revealed during the early morning hours of 12/10/10, the patient began complaining of chest pain. The patient was transferred to the Emergency Department (ED) of Hospital A by Emergency Medical Services Ambulance and subsequently admitted to the hospital. Review of the ED and in-patient medical record from Hospital A revealed the only information sent with the patient from Red River Behavioral Center when he was transfer was the Psychiatric Evaluation, History and Physical, admission face sheet and the Medication Administration Record.

Review of Policy 2.13A titled "Transfer of Patient To An Acute Care Facility", Section: Assessment of Patient, Purpose: To maintain the continuity of patient care by communicating to the receiving facility appropriate information. The Charge Registered Nurse (RN) or Staff RN duties included: Contact receiving facility's admissions department to communicate necessary information for acceptance; Obtains consent for release of confidential information for receiving facility; Copies face sheet, MAR, and all other specified parts of the chart; Completes the transfer form, keeps copy of transfer form in the patient record, sends the original to the receiving facility; Send written information to validate information communicated.

Interview with RN S3 on 01/06/11 at 2:20 PM revealed when questioned what information accompanied patient #4 when he was transferred to Hospital A on 12/10/10, she replied she sent copies of the admission face sheet, the MAR, the History and Physical, and the Psychiatric Evaluation. When asked if she had sent any information to Hospital A regarding the Physician Emergency Certificate and the Coroner's Emergency Certificate, RN S3 replied "no". When asked if she had completed a transfer form, RN S3 again replied "no".

Based upon review of 3 of 6 medical records, hospital policies and procedures, patient observations made on 01/03/11, and patient and staff interviews, the Registered Nurse failed to supervise and evaluate the nursing care provided to each patient as evidenced by: 1) failing to document an assessment of patient #2 after the patient fell and sustained an injury to the left knee, 2) failing to evaluate patient #4 for injuries after the patient became combative and required a physical take down to the floor on 12/09/10, and 3) failing to document an assessment of patient #6 after he sustained a fall on 12/03/10 and sustained skin tears to the left forearm after a physical take down on 12/27/10. Findings:

1) On 01/03/11 at 3:10 PM, patient #2 was observed sitting in a wheelchair in the TV room, awake and alert to person and place and watching TV. An ace wrap bandage was observed on the patient's left knee area which was loose, sliding down the leg and covering only half of the left patella region. Interview with the patient during the observation revealed during the early afternoon of 12/21/10, she was ambulating from the Dining Room back to her room and her shoe grabbed the floor causing her to loose her balance and fall onto her left knee. The patient stated when she got up she had some pain in her left knee and when she passed the nursing station, she told the staff she had fallen. According to the patient, the staff then placed a bandage (ace wrap) on her left knee.

Review of patient #2's medical record revealed the patient was admitted to the hospital on 12/20/10 with the diagnoses Major Depressive Disorder, recurrent, severe with psychotic features. According to the nursing admission assessment, the Registered Nurse (RN) identified the patient had an "unsteady gait at times". Review of the Nursing Progress Notes revealed on 12/20/11 at 3:45 PM, the RN documented the patient was a "fall risk" and the patient was "advised to not ambulate without a wheelchair". On 12/21/10 at 3:30 PM the RN documented on the Nursing Progress Notes "Patient is a fall risk. Precautions are in place. Will continue to monitor." There failed to be further documentation by the RN in the Nursing Progress Notes the patient sustained a fall on 12/21/10 and an assessment was conducted on the patient after the fall. The first documentation by the Registered Nurse related to the patient's fall and complaints of left knee pain were on the 11PM-7AM shift of 12/22/10.

Further review of patient #2's medical record revealed an x-ray was obtained of the patient's left knee and she was diagnosed with a non-displaced fracture of the left patella. On 12/23/10, the physician ordered for the patient to be "non-weight bearing on the left extremity" During interview with patient #2 on 01/03/11 she was asked about ambulation, the patient stated she moved around the facility in her wheelchair. When asked about putting weight on her left leg, the patient stated "yes, when I get up from the wheelchair to the bed and back, when I get dressed in the mornings, go to the bathroom and so on." There failed to be documented evidence the nursing staff ensured the patient followed physician S15's instructions and prevented the patient from bearing weight to the left extremity due to the fractured patella.

Further interview with the Director of Nursing on 01/03/11 at 3:00 PM revealed when asked if the Registered Nurse conducted an assessment of patient #2 after she fell on 12/21/10, the DON provided an incident/accident report for review and stated the patient fell in her room and did not tell anyone until the next day on 12/22/10. Review of the incident/accident report revealed there was no documentation on the report an assessment of the patient was conducted. Even though the DON stated the patient did not report the fall to any nursing staff on 12/21/10, someone was aware due to the fact an x-ray of the patient's left knee was obtained on the same day the patient stated she reported the fall to the nursing staff. There failed to be any documentation of this event in the Nursing Progress Notes.

2) Review of the medical record for patient #4 revealed on 12/09/10 at 6:30 AM, Recreational Therapist S4 documented on the Interdisciplinary Progress Notes the patient was upset, agitated and attempting to break the glass out of the hallway doors. The patient was moved away from the doors and taken to his room to allow patient to calm down. At approximately 7:30 AM, S4 further documented the patient continued to curse while trying to punch staff. In an attempt to escort the patient back to his room, the patient pinned S4 against the wall and continued to swing his arms towards S4. The patient was taken to the floor by S4 using the MOAB Technique. Once the patient was calm, S4 documented the patient was assisted to the standing position and escorted to the patient room without further incident. Review of the Nursing Progress Notes for 12/09/10 revealed there failed to be documented evidence the Registered Nurse assessed patient #4 for injury after RT S4 had to implement a physical take of patient #4 due to the combative behaviors exhibited by the patient.

On 12/10/10, patient #4 was transferred and admitted to Hospital A, an acute care facility, for complaints of chest pain. Review of the nursing admission assessment from Hospital A dated 12/10/10 at 9:17 AM, the RN documented "Bruises all over arms-says was held at Red River Behavioral Med during a scuffle-sore healing right hand".

There failed to be documented evidence patient #4 was assessed by the RN to ensure there was no injury caused to patient #4 from the physical take down that occurred on 12/09/10.

3) Review of patient #6's medical record revealed this 76 year old male was admitted to the hospital on 11/30/10 with the diagnoses of Dementia with confusion and alcohol dependence. Review of the physician admission orders revealed precautions were to be implemented for "falls". On 12/03/10, the Psychiatrist S13 ordered "x-ray right hip, 1:1 observation due to high risk of falls, Notify primary MD". Review of the radiological reports revealed the patient's right hip was x-ray on 12/03/10 with the impression "No acute fracture, dislocation, or destructive bony lesions are identified." Review of the Nursing Progress Notes dated 12/03/10 revealed the following:
"6:15 AM: skin tear noted to left arm"
"7A shift: skin tear to forearm"
"3:30 PM: in D/R (Dining Room), alert to name only, confused and disoriented. High risk for falls, MHT (Mental Health Technician) on close observation."
12/24/10: "11P shift Wounds purplish bruise to bilateral forearms - fall on 12/3 - 1:1 with MHT at bedside."

The Registered Nurse failed to document in the Nursing Progress Notes patient #6 was assessed after a fall on 12/03/10 even though an x-ray had to be attained to rule out the patient had a fractured hip.

Further review of patient #6's medical record revealed on 12/27/10 at 1:00 PM, the Licensed Practical Nurse (LPN) S12 documented "Patient became extremely agitated and aggressive, kicking and cursing at staff. Patient given PRN Ativan and was restrained using MOAB technique until calm. Patient received skin tear to left forearm which was about 4 x 4 cm (centimeter). Skin tear cleansed and bandage placed over it." The LPN failed to identify what type of restraint was used other than referring to "restrained using MOAB technique". The LPN further documented a skin tear to the patient's forearm was found after the patient was released from the restraint; however, there failed to be evidence the RN conducted an assessment related to how the patient sustained a 4cm x 4cm skin tear during the restraint procedure.

Based upon review of 1 of 6 medical records, Policy Addendum for physician prescribe/order medication privileges, and staff interview, the Registered Nurse failed to ensure drugs were administered in accordance with the practitioner's orders as evidence by administering the Intramuscular medication Geodon without a physician's order and administering oral pain medication without an order from a member of the hospital's medical staff (patient #6). Findings:

Review of patient #6's medical record revealed on 12/27/10 at 2:00 PM, the Psychiatrist S13 ordered for the patient to receive one dose of Geodon 20 milligrams Intramuscular for agitation. Review of the Medication Administration Record revealed on 12/27/10 the Geodon was administered to the patient at 2:15 PM. Further review of the Medication Administration Record revealed on 12/28/10 at 10:10 AM, the Geodon 20 milligrams Intramuscular was repeated; however, review of the physician orders for 12/27/10 and 12/28/10 revealed the physician had not ordered for the patient to receive a second Geodon injection. Interview with the Director of Nursing S2 confirmed there was no physician order for the second dose of Geodon administered to the patient on 12/28/10.

Further review of patient #6's medical record revealed on 12/22/10 the patient was sent to the Emergency Department of Hospital A for evaluation of a foreign body in the right foot that was discovered on an x-ray. After the evaluation, the patient was transferred back to Red River Behavioral Center along with a hard copy prescription from the ED Physician at Hospital A for the pain medication Percocet. Review of the Medication Administration Record revealed the nursing staff administered the Percocet daily to the patient from 12/22/10 to 01/04/11; however, review of the physicians orders from 12/22/10 to 01/04/11 revealed a physician from the hospital's medical staff failed to write an order for the Percocet. There failed to be documented evidence the patient's primary care physician was notified by the Registered Nurse the ED physician at Hospital A had discharged the patient from their ED with a prescription for the Percocet pain medication. Interview with the Director of Nursing (DON) on 01/05/11 at 1:15 PM, confirmed the Percocet pain medication order was transcribed onto the Medication Administration Record, not from a written physician order, but from a hand written prescription by the ED physician at Hospital A.

Review of the Policy Addendum 7.21C titled "Prescribe/Order Medication Privileges" revealed the ED Physician from Hospital A failed to be identified as one the medical staff members who were privileged to prescribe medication orders at Red River Behavioral Center.

Based upon review of 1 of 6 medical records (#3), hospital policies and procedures and staff interviews, the hospital failed to ensure each member of the treatment team developed clinical interventions related to the problems identified by the Psychiatrist during the psychiatric evaluation and the Registered Nurse during the nursing admission assessment process. Findings:

Review of patient #3's medical record revealed the patient was admitted to the hospital on 09/22/10 for Dementia, Alzheimer's Type with psychosis and mood lability. Psychiatrist S13 identified on the Psychiatric Evaluation that upon admission the patient was delusional, paranoid, and threatening Suicidal Ideation and Homicidal Ideation.

Review of the Multidisciplinary Integrated Treatment Plan developed for patient #3 revealed the following six problems were identified: 1) Health Maintenance, 2) Cognitive Impairment, 3) Mood Lability, 4) Psychotic Symptoms, 5) Suicidal Ideation, and 6) Homicidal ideation. Review of the clinical interventions for these problems revealed the Psychiatrist and the RN failed to identify any interventions.

Review of Policy 2.1A titled "Treatment Plan Procedure" Section: Assessment of Patient, Purpose: The treatment plan will also reflect observable and behavioral traits, purposeful and goal directed interventions which reflect individualized treatment goals. Procedure: #5. A formal weekly treatment plan meeting will be held with all disciplines present, including the Psychiatrist, Nursing Services, Social Services, and Recreational Therapy. The patient will also be present in these meetings to discuss progress toward treatment goals, Each discipline shall speak to each problem listed on the problem list as well as any problems to be added to the treatment plan.

Interview with the RN S3 and RN S8 on 01/06/10 at 2:30 PM revealed after reviewing the Treatment Plan for patient #3, they confirmed there were no clinical interventions developed by the Registered Nurse and the Psychiatrist.

Based upon review of 1 of 6 medical records, hospital policies and procedures, and staff interviews, the hospital failed to ensure the Registered Nurse documented in the Nursing Progress Notes the specific therapeutic treatment modalities utilized prior to the administration of an anti-anxiety medication on an as needed basis when patient #6 exhibited agitated behaviors. Findings:

Review of patient #6's medical record revealed the patient was admitted to the hospital on 11/30/10 for Dementia with associated confusion and alcohol dependency. On 12/25/10, Psychiatrist S13 ordered Ativan 1 milligram by mouth as needed for agitation. Review of the Medication Administration Record (MAR) revealed from 12/26/10 to 01/03/11, the patient received the Ativan 1 to 3 times a day.

Review of the Nursing Progress Notes and the MAR for patient #3 revealed the following:
On 11/30/10 at 5:30 PM, the patient received a one time dose of Ativan 2 milligrams Intramuscular. Review of the Nursing Progress Notes revealed there was only one entry for the 3:00 PM to 11:00 PM shift of 11/30/10. This entry, completed by the Registered Nurse revealed "3:30 PM: Patient sitting wheelchair. Patient is anxious to get out of wheelchair with attempts to walk. Patient encouraged to stay in wheelchair due to being a fall risk. Patient cooperative at times." There was no documentation related to the patient's agitated behaviors which required an IM injection of the 2 milligrams of Ativan.
Further review of the Nursing Progress Notes and the MAR revealed the following:
12/26/10 at 1:30 PM, the Registered Nurse documented "Ativan 1 mg (milligram) PO (by mouth) and Percocet PO given for agitation and pain respectively. Pt (patient) very agitated continuously trying to get out of his chair and being aggressive towards staff. Will continue to monitor."
12/27/10 "1:00 PM: Patient became extremely agitated and aggressive, kicking and cursing at staff. Patient given PRN Ativan and was restrained using proper MOAB technique until calm. Patient received skin tear to left forearm which was about 4x4 cm circle. Skin tear cleansed and bandaged..."
12/28/10 "7:30 AM: Up in geri-chair in dining room. AAO x 1 to self. No complaint voiced. No acute distress noted. Calm at this time" "9:00 AM: increased agitation. PRN Ativan given." "10:00 AM: Patient still agitated, Geodon 20 mg IM to Left Deltoid given" "11:00 AM: Patient sitting quietly but is very confused." "2:30 PM: Patient is still agitated and given PRN Ativan"
12/30/10 at 5:30 AM, the Registered Nurse documented "Patient getting aggressive and resisting staff/care. PO (by mouth) Rx (prescriptive order) given."
01/11/11 "8:00 AM: Patient alert up in wheelchair and to dining room to eat. He eats well - still monitor him one on one for fall risk. He is confused - delusional at present. He is calm and cooperative. He is monitored for combative behavior..." "11:45 AM: Patient getting aggressive and resisting staff/care. PO RX (Ativan) given." "12:30 PM: Patient not as aggressive - Continues to want to get up."
01/02/11 "10:30 AM: Patient restless - agitated - difficult to manage - Rx PO given" "11:30 AM: Patient continues to be active but not as restless" "6:00 PM: Patient getting up and down - restless - instructed - one on one - Rx PO (Ativan) given."

The nursing staff failed to document the attempts to care for the patient in the least restrictive setting before progressing to administering the anti-anxiety medication Ativan for symptoms of agitation.

Review of the Multidisciplinary Integrated Treatment Plan revealed for problem #2: Mood Lability as evidenced by 1) anxious mood, 2) anxious affect, 3) agitation. The short term goals were 1) patient will have a decrease in anxiety within one week, 2) patient will have a decrease in agitation within one week. The objective of the goals were 1) patient will be med compliant within 3 days, and 2) patient will be easily redirected within 5 days. The clinical interventions identified by the Registered Nurse were "Will assess mood and report to MD x 5 days. RN will encourage med compliance and group participation."

Review of policy 3.12 titled "Progress Notes", Section: Care of the Patient, Policy: It is the policy of the Hospital that the course of treatment of every patient shall be described and documented in the Interdisciplinary Progress Notes. Purpose: To chronologically document the couse of hospitalization and to regularly record the patient's progress and current status in meeting the goals and objectives of their treatment plan. Procedure: #3. All entries involving subjective interpretation of the patient's progress will be supplemented with a description of the actual behavior observed.

The treatment plan failed to identify all active therapeutic efforts to include the least restrictive clinical interventions the staff were to implement for controlling patient #6's agitated and aggressive behaviors prior to the administration of the anti-anxiety medication Ativan.

There also failed to be evidence in the Registered Nurse followed policy and procedure and documented in the Nursing Progress Notes the demonstrated agitated behaviors patient #6 exhibited. On 12/27/10 at 1:00 PM, the nurse documented that due to agitated and aggressive behaviors the patient had to be restrained using the MOAB (Management Of Aggressive Behavior) technique; however, the type of restraint used on the patient was not identified. The nurse further failed to identify the least restrictive measures implemented prior to using the MOAB technique.