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Based on interview and record review the facility failed to:

A. ensure nursing assessments were complete and follow-up evaluations were initiated timely. They failed to ensure there were complete assessments on patients with elevated vital signs, skin breakdown, respiratory complications, on psychotropic medications and at risk for suicidal/homicidal ideations. They failed to ensure documentation of nursing interventions before and after administration of chemical restraints. This was found in 6 of 6 patients (#s' 3, 5, 6, 7, 8, and 9).
Refer to C0296 for additional information.


B. ensure the nursing department supervised the delivery of the narcotic Morphine as prescribed by the physician. Nursing failed to accurately account for the amount of Morphine administered to patients.

Refer to C0297 for additional information.

Based on interview and record review the facility failed to ensure nursing assessments were complete and follow-up evaluations were initiated timely. They failed to ensure there were complete assessments on patients with elevated vital signs, skin breakdown, respiratory complications, on psychotropic medications and at risk for suicidal/homicidal ideations. They failed to ensure documentation of nursing interventions before and after administration of chemical restraints. This was found in 6 of 6 patients (#s' 3, 5, 6, 7, 8, and 9).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the clinical record of Patient #5 revealed he was 10 year old male who presented to the Emergency Department (ED) on 10/24/2015 at 1:17 a.m.
At 1:50 a.m. the following was documented in two nursing assessments:
Review of the Rapid triage assessment revealed Patient #5 presented with suicidal and homicidal ideation for over a week with behavior issues. Was recently evaluated for psych disorder. Mom was told that if he got worse he could be placed at a facility. Patient reports that he had thoughts of hurting himself and hurting his stepdad with a knife. Patient reports he would cut himself in the hands. Patient reports hearing things that are not there but cannot describe them. ....
Review of the initial nursing assessment completed at 1:50 a.m. revealed Patient #5's chief complaint was suicidal /homicidal ideation. The following symptoms were listed anger, hostility, hallucinations, auditory, homicidal thoughts, sleeping difficulty, and suicidal thoughts, alert, anxious and crying. Patient #5 was documented as being at risk of injuring himself or others. Patient #5 reported he was going to stab himself and the step dad in the hand. There was documentation that the suicide risk assessment scores him a low risk. Will document every hour and family at bedside.
Review of the clinical record revealed Patient #5 signed a no harm contract.
Review of the facility suicide risk assessment on Patient #5 revealed there was no current suicidal thought which was a contradiction to documentation on the nursing assessment. Patient #5 was given a score of 11 which was low risk (10-13). The form did not list interventions for patients at a low suicide risk. According to the suicide assessment form the following directives were listed on the form:
Level III required close observation. Document every hour.
Level II no harm contract signed, within eyesight at all time. Document every 30 minutes.
Level I observed within eyesight at all times. Document every 15 minutes.
There was no suicide observation log on the chart which included documentation of all three elements (the patient's location, activity and behavior). There was documentation found in the chart of hourly monitoring in the chart from 2:50 a.m. to 6:50 a.m. which did not consistently address the patient's activity at the time of the observations.
There was documentation in the record that the family was at the bedside. There was no documentation that a suicide safety plan was completed and explained to the family.
There was no documentation of every 15 minute monitoring as required for homicidal patients.
Patient #5 was discharged on 10/24/2015 at 7:45 a.m., to a psych facility.
During an interview on 10/26/2015 after 10 a.m., Staff #4 confirmed the inaccurate assessment and monitoring.
According to the facility's "Psychiatric Care Algorithm" for homicidal patients the staff was to document every 15 minutes.
Review of the policy named "SAFETY PLAN FOR PSYCHIATRIC PATIENTS" dated 09/25/2015 revealed the following:
"4. Nursing staff will complete the procedure MANAGEMENT OF PSYCHIATRIC EMERGENCIES 678-1001, complete the Suicide Risk Evaluation Assessment, complete the Suicide Safety Plan and document accordingly on the Suicide Observation Tool."


Review of the clinical record of Patient #9 revealed he was a 32 year old male who presented to the ED on 10/25/2015 at 3:25 p.m. with a chief complaint of chest pain. Patient #9 had a pain level of 5 (0 meaning no pain and 10 meaning the worst pain).
Review of the physician screening revealed Patient #9 had a past medical history of anxiety and was positive as being anxious.
Review of physician orders dated 10/25/2015 revealed the following:
At 3:45 p.m., "Ativan 1 mg IV X 1."
At 5:00 p.m., "Repeat 1g Ativan IV x 1."
There was no documentation of the reason on the orders for usage of the anti-anxiety agent. The order written at 5:00 p.m. needed to be clarified because milligrams was not clear.
Review of the Medication administration record revealed the first dose of Ativan was given at 4:30 p.m. and the second dose at 5:01 p.m. without clarifying the order.
Review of nurse's notes revealed no documentation that Patient #9 was showing symptoms of anxiety at 4:30 p.m.
Review of nurse notes at 5:00 p.m. revealed Patient #9 stated he did not feel better, MD informed and the 2nd dose of Ativan ordered and given. There was no nursing documentation of an assessment of Patient #9 having anxiety or still having pain.
Review of the discharge assessment at 5:45 p.m. revealed Patient #9 had a pain level of 2. Patient #9 was given discharge instructions for atypical chest pain and anxiety.


Review of the clinical record of Patient #8 revealed she was a 28 year old female who presented to the ED on 10/26/2015 at 9:07 a.m... with a complaint of anxiety.
At 9:10 a.m., Patient #8 reported she "feel like I'm being squeezed to death". Patient #8 had an elevated blood pressure of 129/108 (ranges being 90-140/60-90). Patient #8 was described as being tearful and was not making eye contact.
Review of medication administration record revealed Patient #8 was given the antianxiety agent Ativan 2 milligrams at 9:58 a.m.
At 10:10 a.m. (11 minutes later) Patient #8 was discharged. There was no other documentation of treatment for the elevated blood pressure while at the hospital nor any mention at discharge. There was no documentation of a follow-up assessment after administration of the anti-anxiety agent.

Review of the clinical record of Patient #3 revealed he was an 86 year old male who presented to the ED on 10/11/2015 at 0018 midnight. Patient #3 presented with a low oxygen saturation of 85 percent (ranges being 90-100) on room air and temperature of 99.8 degrees Fahrenheit. Documentation revealed Patient #3 had a history of pneumonia and would be started on IV antibiotics. Nursing also documented Patient #3 had coarse lung sounds and hypoxia (oxygen deprived). Patient #3 was placed on oxygen at 4 Liters per nasal cannula. There was documentation of Patient #3 being on oxygen at 4 Liters throughout the ED stay.
Review of orders revealed the physician failed to write an order for the oxygen therapy and parameters of what level he wanted to keep the patient's oxygen saturation.
On presentation to the ED Patient #3 was also described as having a large sacral decubitus found on assessment and wound care photos were taken. Review of the photo taken on admission revealed a picture of someone holding part of the dressing back to expose half of the wound. The picture revealed packing inside the wound. There was no picture of the entire wound, with sizes of the entire wound and which gave of view of the wound bed.
Review of the physician's ED assessment revealed Patient #3 had diagnoses of Sepsis, Stage 3 sacral decub, acute renal failure and dehydration.
At 3:57 a.m. Patient #3 was admitted to the medical/surgical unit. An oxygen order was written for 2 Liters per nasal cannula and the patient was placed on skin precautions.
At 4:45 a.m., (over 4 hours after presenting to the ED) was the first documentation of an assessment of the wound. Patient #3 had a sacral wound, Stage 4 and was very deep. There was documentation that pictures were obtained and would be on the chart. The wound was approximately 3-4 inches deep and 7- 8 inches wide, skin and outer edge of wound look like it was dying and wound was not very clean when packing was removed from the wound. Smears of fecal matter was on the outer dressing.
During an interview on 10/26/2015 after 10 a.m., Staff #4 confirmed the inaccurate assessments and missing information.
During an interview on 10/26/2015 after 4:28 p.m., the Chief Nursing Officer (CNO) reported having no documentation of an inservice for assessment concerns that was mentioned in her plan of correction. She reported they started with the mental health issues and would include the other training later. The CNO reported the ED director was auditing ED charts for assessment and gathering information to be acted upon.



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On 10/26/2015 in the office of the Chief Nursing Officer medical records (MR) for patients (Pt/pt.) #6 and #7 were electronically reviewed and revealed the following:

Pt #6: was a 54 year old female patient who was brought by ambulance to the Emergency Department (ED) the ambulance was followed by police officers on 10/5/2015. An emergency detention warrant (EDW) was established 10/6/2015.

Review of the "Suicide Precautions Flowsheet" revealed the following: documentation begins at 1315 in the afternoon. Documentation was provided by a personal care attendant (PCA) as follows:

1:15 p.m. calm: using bath room
1:30 p.m. calm: off to X-ray
1:45 p.m. calm: in bed talk to me
2:00 p.m. resting
2:15 p.m.-3:30 p.m. asleep
3:45 p.m. calm: Roaming in ER (emergency room)
4:00 p.m. calm: sitting up in bed
4:15 p.m. calm: sitting up in bed
4:30 p.m. calm: using bathroom
4:45 p.m. calm: eating
5:00 p.m.-6:45 p.m. sleeping


Review of the physician's ED medication orders are a follows:
10/5/2015 1:10 p.m., Geodon 10 mg IM (intra muscular) x 1. "Done"
10/5/2015 KLC (Potassium Chloride) 40 mEq (milliequivilant) po (By mouth) x 1 " Done"
10/5/2015 3:46 p.m., Geodon 10 mg IM now "Done"
10/5/2015 4:00 p.m., Ativan 1 mg IV (intravenous) now "Done"
10/6/2015 8:00 a.m., Atenolol 50 mg po "given at 0900"
10/6/2015 8:00 a.m., Benzotropine12.5 mg po "Home med given"
10/6/2015 8:00 a.m., Geodon 10 mg IM "done 1048"

Review of electronic ED nursing note revealed the following:
10/5/2015 at 1:30 LVN staff took intake interview from pt. #6 husband who described pt. ' s deteriorating ability to control her behavior. Spouse described pt. #6 stripping off her cloths in yard, laying down in the street, yelling and cussing at family, hitting and swinging at them.

10/5/2015 at 1600 "Geodon given for agitation (sic), pt. pacing the hallway talking about Jerry, escorted to room tolerated injection well, K-lyte 50 mg po (by mouth)given for hypokalemia (low potassium), tolerated well, sitter at bedside".

Complete review of pt. #6's MR revealed there was no documentation found in the nurse ' s note to justify the use of three (3) IM doses of Geodon and one (1) IM dose of Ativan. Neither the "Suicide Precautions Flowsheet" nor the ED nurses notes described any dangerous, violent or aggressive behavior exhibited by pt. #6.


Review of Pt #7's MR revealed the following:
Pt #7 was a 62 year old male patient who was transported from an assisted living facility for agitation and physically aggressive behavior. Review of the physician's order reads as follows:
Geodon 10 mg IM "done 1940 (7:40 p.m.)"
Medically stable 7:31 a.m.

A review of pt #7's ED lab work revealed pt. #7 had a low Hemoglobin of 12 (normal low is 18). Pt #7's Urinalysis was positive at 2 plus for leukesterase and blood. A microscopic exam was recommended. No microscopic exam was ordered. Pt #7 was positive for Benzodiazepine and opiates. Pt #7 routinely took Norco for pain and Xanax for anxiety.

Review of the ED nurses notes revealed: " Pt #7 arrived on 10/22/2015 at 5:28 p.m.
Pt assisted to room via wheel chair. Spouse reports pt. has increased agitation and violent behavior today. Rep from Oceans had contacted ER and advised to medically clear for inpt admit to their facility. Pt obeys commands. Pt will grit his teeth and show frustration. On occasion pt. will reach out to grab staff".

No nurse or physician documented evidence of violent or aggressive conduct exhibited by pt. #7 while in the ED. Pt #7 was given Geodon 10 mg IM at 7:39 p.m., transported to a Behavioral unit in another town. No documentation was evident of treating pt. #7 for the urinary tract infection that his lab indicated.



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Based on interview and document review the nursing department failed to supervise the delivery of 1 of 1 narcotic pain medication as prescribed by the physician.

This deficient practice had the likelihood to cause harm in all patients receiving narcotics.
Findings include:


On 10/26/2015 at 10:00 a.m. at the nurse's station on the medical surgical unit, the Chief Nursing Officer (CNO) provided hand written notes from the most recent Nursing Staffing Advisory Committee (NSAC) meeting. Found in this documentation was a patient control analgesia (PCA) pump error. The error indicated a 5 mg (milligram) to 1 ml (milliliter) drug error for the schedule 2 controlled drug morphine had occurred. No other information was identified within the notes.

On 10/26/2015 at 10:15 a.m. at the nurses station an interview with the CNO confirmed an error with the PCA had occurred, but was determined to be an under dosing of morphine for pain control rather than an over dose. She indicated she could not make sense of the documentation.

On 10/26/2015 at 2:00 p.m. in the registration office the Medical Record (MR) for patient #10 was reviewed and revealed the following: The Perioperative M.A.R. (Medication administration Record) revealed "Morphine 4 mg/ 0.4 ml intravenous PRN for moderate pain (Pain scale 8-10) state and then routine for 1 days, Clinical Direction: Q (every) 5 minutes up to 20 mg FOR USE IN PACU (Post Anesthesia Care Unit) ONLY". Documentation indicated this order was given.
Review of the "Post Anesthesia Care Unit (PACU)" orders reflected multiple strength orders for pain control for patient #10 after surgery. Those orders were identified as follows:
"Morphine 2 mg /0.2 ml PRN (as needed) Moderate pain (Pain scale 5-7) intravenous (IV) Q (every) 5 minutes up to 20 mg FOR USE IN PACU ONLY start date 8/17/2015 at 15:05 (3:05 p.m.) and 23:59(11:59 p.m.)."
"Morphine 4 mg / 0.4 ml PRN severe pain (Pain scale 8-10) Q 5 minutes up to 20 mg FOR USE IN PACU ONLY state date 8/17/2015 at 15:05 (3:05 p.m.) and 23:59 (11:59 p.m.)".
The physician ordered pain managment drugs to be given after assessment with the least necessary narcotic to be offered first.
Review of the nurses Q 5 minute assessment that began at 1:42 p.m. through 2:17 p.m.
8/17/2015 at 1:42 p.m. pain scale "0"
8/17/2015 at 1:47 p.m. Pain scale "0"
The following documentation was found on the "Peri-Operative Note at 8/17/2015 at 1:57 p.m. at Comment: Morphine 4 mg IV with flush". No pain assessment was found after 1:47 p.m.
Pt #10 was discharged from PACU at 2:20 p.m. awake, without drainage or bleeding and without nausea or vomiting, pain level controlled.
Pt #10 was transferred to the medical surgical unit. The attending physician ordered the following: "PCA Patient Control Analgesia Morphine PCA 1 mg/ml Load 2 mg. PCA dose 1 mg over 8 minutes lockout. Not to exceed 24 mg/4 hours continuous IV (Intravenous access) 30 mg/30 ml. dated 8/17/2015 at 1514 (3:14 p.m.)".
Review of the PCA Flow sheet revealed the following: Morphine Sulfate 1 mg/ml- 30 ml PCA syringe. PCA dose 1 mg /8 minutes, continuous dose interval not to exceed 24 mg/4 hours.
The PCA flow sheet instructions read: USE NEW SHEET WITH EACH NEW SYRINGE (30 mg/ml). The form contained the following columns: Date/time of use, mg infused per shift, indication the pump was cleared at the end of each shift. Two nurses signed the document each time an entry was made.
8/17/2015 3:10 p.m. 2 mg (Initial dose) 8/17/2015 6:25 p.m. 8 mg 8/18/2015 6:05 a.m. 20 mg 8/18/2015 6:00 p.m. 39 mg 8/19/2015 6:05 a.m. 36 mg 8/19/2015 1:25 p.m. 30.6 mg
All of the above documentation was on one PCA Flow Sheet totaling 135.6 mg/ml delivered from 8/17/2015 at 3:10 p.m. through 8/19/2015 at 1:25 p.m.

The Following PCA Flow Sheet began on 8/19/2015 at 1:28 p.m. with no loading dose and lockout in progress. The following doses were documented on the flow sheet:
8/19/2015 6:04 p.m. 11.0 (this was marked through and 2.2 was written next to the 11.0 dose)
8/29/2015 5:15 a.m. 25 mg (this was marked out and 5 mg was written over the 25 mg dose)
8/20/2015 6:54 p.m. 3.6 mg
8/20/2015 7:30 p.m. 0.2 mg
The PCA was discontinued and the "Total mg infused was 11.0 with a total wasted - 20" .

Each morphine syringe holds 30 ml. The corrected total of morphine administered to Patient #10 from 8/19/2015 through 8/20/2015 was 11 mg/ml. The nursing staff documented destruction of 20 mg/ml, more morphine than records indicate were available.

Review of the nursing documentation indicates only one (1) 30 ml syringe was loaded into the PCA pump, however the total accumulation of morphine the documentation indicated as given was 146.6 mg/ml. That number indicated 4.89 syringes was loaded into the PCA. The destruction amount would have been 0.11 mg/ ml.

On 10/26/2015 at 4:00 p.m. interview with the CNO confirmed the nurses failed to use the PCA flow sheet properly as each new syringe should have been documented on a new form. She also confirmed she could not determine how much morphine was given or destroyed.

On 10/26/2015 at 4:30 p.m. interview with staff nurse #12 confirmed she could not determine how much morphine was given or destroyed from the PCA Flow Sheet.




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