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Based on observations, record review, and interviews, the hospital failed to ensure the physical environment at the main campus and off-site campus did not afford patients who were identified as a risk for injury to themselves or others opportunities for injury as evidenced by:
1) Having all patient beds at both campuses with 3 cranks at the foot of each bed to be used to raise and lower the bed that presented a potential ligature risk;
2) Having patients' entry door and bathroom door at both campuses secured with 3 hinges on each that were separated widely enough to facilitate potential ligature;
3) Having door handles on all patient entry and bathroom doors at the off-site campus positioned in a manner that presented a potential ligature risk;
4) Having elongated sink faucets in the patient bathrooms at both campuses that presented a potential ligature risk;
5) Having toilets in patient bathrooms at both campuses with exposed plumbing that presented a potential ligature risk;
6) Having a window screen in Room "b" at the main campus with a hole in the right lower corner that provided access for contraband to be entered into the hospital from the public sidewalk that was adjacent to the patient rooms;
7) Having holes in the wooden fence surrounding the outdoor area used by patients at both campuses that presented sharp edges that could be broken apart to use as a weapon or could cause an injury if a patient touched the edge;
8) Having the seclusion room at the off-site campus that did not provide full visual observation of the patient with the door closed while the staff member stood outside the closed door to observe a patient placed in seclusion.
Findings:

1) Having all patient beds at both campuses with 3 cranks at the foot of each bed to be used to raise and lower the bed that presented a potential ligature risk:
Observations on 01/11/16 at the main campus from 9:40 a.m. through 10:35 a.m. with S1ADM and S7EOC present revealed all patient beds had 3 hand cranks at the foot of each bed to be used to raise and lower the bed. Further observation revealed the cranks provided a potential ligature risk.

Observations on 01/12/16 at 9:15 a.m. with S12RN present revealed all patient beds had 3 hand cranks at the foot of each bed to be used to raise and lower the bed. Further observation revealed the cranks provided a potential ligature risk.

In an interview on 01/11/16 at 9:50 a.m., S1ADM confirmed the bed cranks could be a ligature risk to patients who were identified as a risk for injury to themselves or others.

2) Having patients' entry door and bathroom door at both campuses secured with 3 hinges on each that were separated widely enough to facilitate potential ligature:
Observations on 01/11/16 at the main campus from 9:40 a.m. through 10:35 a.m. with S1ADM and S7EOC present revealed all patients' entry door and bathroom door had 3 hinges on each that were separated widely enough to facilitate potential ligature.

Observations on 01/12/16 at 9:15 a.m. with S12RN present revealed all patients' entry door and bathroom door had 3 hinges on each that were separated widely enough to facilitate potential ligature.

In an interview on 01/11/16 at 9:50 a.m., S1ADM confirmed the hinges with spaces between them provided a ligature risk.

3) Having door handles on all patient entry and bathroom doors at the off-site campus positioned in a manner that presented a potential ligature risk:
Observations at the off-site campus on 01/12/16 at 9:15 a.m. with S12RN present revealed all patient entry and bathroom doors at the off-site campus were positioned in a manner that presented a potential ligature risk. Further observation revealed S12RN tied a bed sheet around the door handle of the bathroom in Room "t", placed the tied sheet over the top of the door to hang on the other side of the door, and pulled on the sheet. Observation revealed the tied sheet did not give and release from the handle. Further observation revealed the door to Room "t" was closed upon arrival, and Patient #R3 was seated on his bed upon entering the room.

Review of Patient #R3's medical record revealed he had been admitted the previous evening (01/11/16) at 9:10 p.m. under a Physician's Emergency Certificate due to being a danger to himself and gravely disabled.

In an interview on 01/12/16 at 9:15 a.m., S12RN confirmed the position of the door handles presented a ligature risk.

4) Having elongated sink faucets in the patient bathrooms at both campuses that presented a potential ligature risk:
Observations at the main campus on 01/11/16 from 9:40 a.m. through 10:35 a.m. with S1ADM and S7EOC present and on 01/12/16 at 9:15 a.m. at the off-site campus with S12RN presented revealed all patient bathrooms had elongated sink faucets that presented a potential risk.

In an interview on 01/12/16 at 4:00 p.m., S1ADM confirmed the faucets were a ligature risk and would have to be replaced.

5) Having toilets in patient bathrooms at both campuses with exposed plumbing that presented a potential ligature risk:
Observations at the main campus on 01/11/16 from 9:40 a.m. through 10:35 a.m. with S1ADM and S7EOC present and on 01/12/16 at 9:15 a.m. at the off-site campus with S12RN presented revealed the toilets in patient bathrooms had exposed plumbing that presented a potential ligature risk.

In an interview on 01/11/16 at 9:50 a.m., S1ADM confirmed the exposed plumbing in the patient bathrooms at both campuses presented a ligature risk.

6) Having a window screen in Room "b" at the main campus with a hole in the right lower corner that provided access for contraband to be entered into the hospital from the public sidewalk that was adjacent to the patient rooms:
Observations at the main campus on 01/11/16 from 9:40 a.m. through 10:35 a.m. with S1ADM and S7EOC present revealed the window screen in Room "b" at the main campus had a hole in the right lower corner. Further observation revealed the window could be raised approximately 3 inches for outside ventilation. Further observation revealed the patient's bedroom was located next to a public sidewalk that led from the driveway to the area used for intensive outpatient treatment and provided a means for entry of contraband into the hospital.

In an interview on 01/11/16 at 10:36 a.m., S7EOC confirmed the window screen in Room "b" was torn and presented a safety risk.

7) Having holes in the wooden fence surrounding the outdoor area used by patients at both campuses that presented sharp edges that could be broken apart to use as a weapon or could cause an injury if a patient touched the edge:
Observations at the main campus on 01/11/16 from 9:40 a.m. through 10:35 a.m. with S7EOC present and on 01/12/16 at 9:15 a.m. at the off-site campus with S12RN presented revealed the wooden fence surrounding the outdoor area used by patients at both campuses had holes in the fence with sharp edges that could be broken apart to use as a weapon or could cause an injury if a patient touched the edge. Both observations were confirmed at the time of the observation by S7EOC at the main campus and S12RN at the off-site campus.

8) Having the seclusion room at the off-site campus that did not provide full visual observation of the patient with the door closed while the staff member stood outside the closed door to observe a patient placed in seclusion:
Observations at the off-site campus on 01/12/16 at 9:15 a.m. with S12RN present revealed the seclusion room did not provide a full visual view of the inside of the room the the window on the door with the door closed.

In an interview on 01/12/16 at 9:15 a.m., S12RN indicated staff would stand outside the closed door of the seclusion room when a patient was in the room. She confirmed that the patient could not be seen in all areas of the room when staff stood outside the closed door to observe the patient.

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to have a RN assess and follow hospital policies and procedures for providing emergency care to a patient choking and in acute distress for 1 (#1) of 1 record reviewed for patients requiring emergent life-saving interventions from a total sample of 5 patients and 3 random patients;
2) The RN failed to assess and document a patient's episodes of diarrhea that resulted in the need for PRN (as needed) medication (#2), an assessment and documentation that included measurements of developed breaks in skin integrity and a report to the physician for treatment orders (#2), a neurovascular assessment in accordance with hospital policy for a patient who sustained a fall resulting in a head injury requiring sutures (#5), failed to assess and evaluate the cause of a patient's weight loss of 10 pounds in 20 days (#2), and an assessment of vital signs upon a patient's return from the ED (emergency department) for treatment of complaints of Chest Pain and Syncope (#R2) for 3 (#2, #5, #R2) of 8 patient records reviewed for RN assessment from a total sample of 5 patients and 3 random patients;
3) The RN failed to implement a choking risk plan for patients identified as at risk for choking as evidenced by failing to implement a nursing care, designate on the white board in the nursing station (used to list all patients with their diagnosis, level of observation, and precautions), and document on the MHT observation record the choking precaution for 3 (#3, #4, #R3) of 3 patient records reviewed with an identified choking risk from a total sample of 5 patients and 3 random patients;
4) The RN failed to ensure that patients were weighed as ordered by the physician for 4 (#2, #3, #4, #5) of 4 patient records reviewed for weights from a total sample of 5 patients and 3 random patients;
5) The RN failed to clarify physician orders for medications that were not addressed on the medication reconciliation form as to whether to administer or stop administration for 2 (#2, #3) of 4 (#2, #3, #4, #5) patient records reviewed for clarification orders from a total sample of 5 patients and 3 random patients; and
6) The RN failed to obtain physician orders to transfer a patient to the ED and upon the patient's return from the ED for 3 (#3, #5, #R2) of 7 (#1, #2, #3, #4, #5, #R1, #R2) patient records reviewed who were sent to the ED for evaluation from a total sample of 5 patients and 3 random patients.
Findings:


31048

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to have a RN assess and follow hospital policies and procedures for providing emergency care to a patient choking and in acute distress for 1 (#1) of 1 record reviewed for patients requiring emergent life-saving interventions from a total sample of 5 patients and 3 random patients;
2) The RN failed to assess and document a patient's episodes of diarrhea that resulted in the need for PRN (as needed) medication (#2), an assessment and documentation that included measurements of developed breaks in skin integrity and a report to the physician for treatment orders (#2), a neurovascular assessment in accordance with hospital policy for a patient who sustained a fall resulting in a head injury requiring sutures (#5), failed to assess and evaluate the cause of a patient's weight loss of 10 pounds in 20 days (#2), and an assessment of vital signs upon a patient's return from the ED (emergency department) for treatment of complaints of Chest Pain and Syncope (#R2) for 3 (#2, #5, #R2) of 8 patient records reviewed for RN assessment from a total sample of 5 patients and 3 random patients;
3) The RN failed to implement a choking risk plan for patients identified as at risk for choking as evidenced by failing to implement a nursing care plan, designate on the white board in the nursing station (used to list all patients with their diagnosis, level of observation, and precautions), and document on the MHT observation record the choking precaution for 3 (#3, #4, #R3) of 3 patient records reviewed with an identified choking risk from a total sample of 5 patients and 3 random patients;
4) The RN failed to ensure that patients were weighed as ordered by the physician for 4 (#2, #3, #4, #5) of 4 patient records reviewed for weights from a total sample of 5 patients and 3 random patients;
5) The RN failed to clarify physician orders for medications that were not addressed on the medication reconciliation form as to whether to administer or stop administration for 2 (#2, #3) of 4 (#2, #3, #4, #5) patient records reviewed for clarification orders from a total sample of 5 patients and 3 random patients; and
6) The RN failed to obtain physician orders to transfer a patient to the ED and upon the patient's return from the ED for 3 (#3, #5, #R2) of 7 (#1, #2, #3, #4, #5, #R1, #R2) patient records reviewed who were sent to the ED for evaluation from a total sample of 5 patients and 3 random patients. Findings:

1) Failing to have a RN assess and follow hospital policies and procedures for providing emergency care to a patient choking and in acute distress for 1 (#1) of 1 record reviewed for patients requiring emergent life-saving interventions:
Review of the LSBN's (Louisiana State Board of Nursing) "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.
A review of a policy and procedure entitled TX-SPEC-11: Early Response Intervention to Deteriorating Patient Condition/Change in Condition, presented by S1ADM as the current policy and procedure in place, revealed, in part: "Policy: It is the policy of the facility to improve recognition and response to changes in a patient condition. This facility identifies unexpected acute illnesses which pose life threatening situations for our patients. . . . As required by 42CFR 482.23(b), an RN is immediately available as needed to provide bedside care to any patient and that RN is also qualified, through a combination of education, licensure and training to conduct an assessment that enables the RN to recognize the fact that the patient may need emergency care."

A review of a policy and procedure entitled, PC-13: Provision of Emergency Services, presented by S1ADM as the current policy and procedure in place, revealed, in part: "Procedure: Inpatient: Nurse: ... If the patient is not transferred out to the emergency department and his/her condition continues to deteriorate per the RN's clinical assessment, the RN is to update the attending or on-call physician . . . At any time during this process, if the patient's condition continues to deteriorate and is deemed emergent based on the RN's clinical assessment, the RN is to activate the Code Blue Response policy (TX.Spec:-13) and 911 is activated . . . Obtains emergency cart with available medical supplies . . . CPR is initiated as appropriate while other staff activates Code when appropriate ... "

A review of the policy and procedure entitled, TX-SPEC-13: Code Blue Response, presented by S1ADM as the current policy and procedure in place, revealed, in part: "Procedure: Physician/ Nurse /Clinician /MHT /or other CPR Trained (first to victim) . . . a. places a disposable mouth barrier or Ambu bag mask over victim ' s mouth and nose, forming a seal with mask and gives two (2) full breaths into victim. If using Ambu bag, connect Ambu bag to oxygen source. . . .(If applicable): Follow AED policy. Applies AED Pads and allows AED to check cardiac rhythm. Follows AED prompt for shock and continues CPR. . . . Additional Respondent: Obtains disposable mouth barrier/Ambu bag, AED and brings to first respondent. Instructs additional staff to notify attending physician, Director of Nursing, emergency family contact, Administrator, and Clinical Director."

Patient #1
A review of the medical record revealed Patient #1 was a 76-year-old female who was admitted to the hospital on 11/17/15 from a nursing home. Diagnoses included Unspecified Dementia with Behavioral Disturbances.

A review of an Incident/Accident Report form signed and dated by S21RN as "Person preparing report" revealed the following documentation, in part: Time of Incident/accident was 10:58 a.m., Location of incident was the dining room; Type of first aid administered was CPR (no documentation of person who provided the CPR), and the place documented on the form where the CPR was administered was the hospital's name, with the date documented as 11/22/15 and the time documented as 10:45 a.m. Times of Notification of Patient #1's physician was documented as 11:10/11:13 a.m.; Times physician responded was documented as 11:10/11:13 a.m. Time of notification of Patient #1's spouse was documented as 11:15 a.m., and time Patient #1's spouse responded was documented as 11:15 a.m.

Further review revealed the following documentation in a narrative format: "Patient in dining room eating snack started to choke on yogurt and sandwich MHT and LPN at table with patient Heimlich times 2 Patient placed on floor mouth cleared No pulse CPR started 911 activated CPR continued patient has pulse EMS on unit EMS with patient No pulse CPR EMS intubated patient has pulse loaded on stretcher and brought to an acute care hospital (actual name of hospital on document)." The Incident/Accident Report was signed by S1ADM, S2DON, and the hospital's medical director.

A review of a document entitled CPR Sheet completed by S21RN on 11/22/15 at 12:00 p.m. revealed, in part: Code was called by S9LPN; Date was 11/22/15; Time was 11:00 a.m.; CPR was checked off; Respiratory Arrest was checked off; Cardiac Arrest and Ambu Bag was not checked off. EMS called at 10:59 a.m.; EMS arrived at 11:05 a.m.; Patient #1 was transferred by EMS at 11:29 a.m. Review of the narrative "Notes" revealed: Patient sitting at table in dayroom eating snack yogurt and sandwich and talking to roommate. S8MHT in dayroom turned around and noted yogurt coming out of patient's nose and called for help. S9LPN came and performed Heimlich. Patient was gagging and vomiting. Turned blue and became unresponsive. Chest compressions started and oxygen placed, continued to perform Heimlich and mouth sweeps. 911 called. EMS and fire department arrived by 11:10 a.m. and took over chest compressions and intubated patient. They had a pulse by 2:25 p.m. and transported via stretcher to (name of acute care hospital) by 11:29 a.m. Husband (named here) notified, S14MD notified, and (name of nursing home here) notified of patient's transport to hospital. S2DON notified."

A review of a form entitled "Multi-Disciplinary Note" documented by S21RN at the entry dated 11/22/15 at 12:00 p.m., and a time of 10:45 a.m. entered under the "Problem" column, revealed, in part: "Patient was sitting at table in dining room eating snack talking to her roommate. She was eating yogurt and a sandwich. MHT and LPN in dining room with patients. MHT noted yogurt coming out of her nose and called for help. S9LPN came in to assist and performed Heimlich maneuver for choking. Patient began gagging and vomiting. Her face started to turn blue and she was lowered to the floor. Other patients removed from the room. 911 called at 11:00 a.m. and CPR started per S8MHT and S9LPN. Oxygen applied per nasal cannula, chest compressions started per S9LPN. Kept turning patient to side to perform Heimlich and clearing mouth and nose. EMS arrived on unit at 11:10 a.m. and took over."

In a telephone interview on 01/13/16 at 1:20 p.m., S21RN indicated she heard a call for help in the dining room, so she proceeded to the dining room. Upon entry into the dining room, S21RN witnessed S9LPN performing the Heimlich maneuver on Patient #1 and S8MHT assisting S9LPN with attempting to place Patient #1 on the floor. S21RN indicated she left the dining room at that point and went into the nurse's station to call 911. When asked if she had performed an assessment on Patient #1, S21RN replied, "no." When S21RN was asked if she had delegated the care of Patient #1who was choking and in acute distress, she replied, "I felt the patient was in capable hands with S9LPN and S8MHT because they knew the patient." S21RN indicated after she called 911, she returned to the dining room from the nurse's station and the patient was on her side, was receiving oxygen, and stated the patient's color had improved, and the patient was breathing. S21RN indicated she then left the dining room again to return to the nurse's station to go call Patient #1's physician(s) and S2DON. When S21RN returned to the dining room again, she stated she witnessed EMS personnel at Patient #1's side providing emergency care. S21RN confirmed she did not perform an assessment on Patient #1 at any time during the event, and S21RN also confirmed the emergency code cart which contained equipment and supplies for cardiopulmonary resuscitation (suction machine and supplies; respiratory assistive devices such as a mouth piece with a one-way valve and ambu bag for rescue breathing of a patient; an AED which monitors and identifies the patient's cardiac rhythms and provides cardiogenic shocks for the appropriately identified cardiac rhythms) was not brought or utilized by the hospital staff during the emergency care and CPR care for patient #1. When S21RN was asked why the emergency cart had not been brought to Patient #1, she stated that Patient #1 was still breathing when she left the dining room, and when she returned, EMS personnel was at Patient #1's side providing care. When asked about the discrepancies in the documentation regarding the cardiopulmonary arrest event, S21RN confirmed she did not actually witness S9LPN initiate and/or perform CPR on Patient #1, and that all of the information regarding the CPR care by the hospital staff documented on the Incident/Accident Report form, the CPR form, and the Multi-Disciplinary Note sheet was documented "after-the-fact" and was obtained verbally from the hospital's staff who actually provided and witnessed all of the emergency care and cardiopulmonary resuscitative care provided to Patient #1.

In an interview on 01/13/16 at 2:50 p.m., S2DON indicated she and S1ADM had investigated the incident regarding Patient #1. S2DON confirmed S21RN was the RN charge nurse on the unit when the event occurred. S2DON indicated the hospital has an emergency cart with equipment and supplies needed for cardiopulmonary resuscitation which does include an AED. S2DON confirmed there was no documentation in the medical record that S21RN performed an assessment on Patient #1 at any time during the event. S2DON also confirmed there was no documentation that the emergency cart with all of the equipment and supplies that were available for use during CPR, except for the oxygen, were brought and utilized by the hospital staff while emergency care and CPR care was being provided to Patient #1. S2DON agreed and confirmed that the hospital staff did not follow policies, procedures, and protocols for providing emergency care and cardiopulmonary resuscitative care to Patient #1, and the staff should have followed the policies, procedures, and protocols.

2) The RN failed to assess and document a patient's episodes of diarrhea that resulted in the need for PRN (as needed) medication (#2), an assessment and documentation that included measurements of developed breaks in skin integrity and a report to the physician for treatment orders (#2), a neurovascular assessment in accordance with hospital policy for a patient who sustained a fall resulting in a head injury requiring sutures (#5), failed to assess and evaluate the cause of a patient's weight loss of 10 pounds in 20 days (#2), and an assessment of vital signs upon a patient's return from the ED (emergency department) for treatment of complaints of Chest Pain and Syncope (#R2):
Review of the hospital policy titled "Comprehensive Interdisciplinary (CIA), CIA Update, and Multi-Treatment Integration," presented as the current policy by S1ADM, revealed that a comprehensive assessment is performed on all admissions in order to effectively identify patient symptomology and formulate an effective treatment plan. The admitting nurse receives the admission order and reconciles medications with the physician. The admit assessment is completed within 8 hours of admission to complete the Nursing Part of the CIA. The RN will assess weight, vital signs, dental screen, visual status, nutritional screen, sensory/motor function, safety risk factors, infectious potentials, current medications prescribed, and family medical history. Any screens, such as visual, dental, nutritional, that identifies high risk factors triggers physician notification and order for consult. The admitting nurse formulates the initial treatment plan with goals and interventions to meet patient transition/safety/discharge planning needs, reviews the same with the patient, and orients the patient to his/her surroundings.

Review of the hospital policy titled "Skin/Wound Care Protocol," presented as a current policy by S1ADM, revealed the purpose of the policy is to identify patients at risk for skin breakdown and pressure ulcer formation and provide guidelines for the prevention, assessment, and treatment. All patients admitted will be evaluated using the Braden Scale Risk Assessment upon admission and as needed. A weekly skin assessment is completed by the nurse on all patients. Pictures of wounds should be placed on each patient's wound assessment form. The nurse will use the wound assessment guidelines to describe and document the wound. Other skin abnormalities such as skin tears and abrasions will be identified upon admit using the nursing assessment process. Pictures of skin abnormalities should be taken upon admit as identified and as needed thereafter and placed on the wound assessment form. Description of the skin abnormality should be described on the wound assessment form. Further review revealed the wound care procedure included the following: 1. If a patient is identified to have a wound, a picture is taken, and documentation of the wound is completed on the hospital wound assessment form. 2. The nurse opens a wound care treatment plan. 3. Places picture of the wound in the patient's medical record. 4. Passes on in report all patients that are currently on wound prevention protocol. 5. Updates with ongoing pictures, treatment, and orders as indicated. Further review revealed the wound is to be measured in centimeters weekly and recorded using clock descriptions. Wound drainage and wound bed description is to be documented.
Review of the hospital policy titled "Early Response Intervention to Deteriorating Patient Condition/Change in Condition," presented as a current policy by S1ADM, revealed early warning signs that could be present during a patient's change in condition included the following: 1) a patient has a weight loss of 2 pounds or greater; 2) a patient has diarrhea for more than a 24 hour period. Further review revealed for a patient who has diarrhea for more than a 24 hour period, the Infection Control nurse should be consulted, and contact precautions may be implemented depending on the recommendation from the Infection Control nurse or the charge nurse. The early intervention plan would include the following: 1) staff will notify the nurse who will in turn notify the medical physician on site or on call; 2) the nurse will call the attending psychiatrist; 3) the nurse should ask for a second nursing assessment and opinion and may call the DON if a second nurse is not available; 3) implement physician orders, and keep the physician abreast of significant changes. Further review of the policy revealed no documented evidence that the policy required the assessment of a patient with a change in condition to be conducted by a RN.
Review of the hospital policy titled "Neurological Assessment," presented as a current policy by S1ADM, revealed a neurological assessment is performed to determine a patient's baseline level of neurological function and is used to help plan and evaluated the patient's care. Neurological assessments is performed after, but not limited to, the following changes in the patient's condition: level of consciousness, motor strength, pupils, speech, and gait and is indicated after any head injury. Further review revealed upon initial finding of potential head injury/neurological trauma, the Neurological Assessment Checklist is completed as follows: upon initial finding then every 15 minutes after the initial assessment times 4, then every 30 minutes times 2, then every 60 minutes times 2, then once per shift for 72 hours unless indicated by the physician. All neurological assessments should include vital signs which will be documented in conjunction with the medical record.
Patient #2 Review of Patient #2's medical record revealed she was admitted on 12/18/15 with diagnoses of Psychosis and Major Depression. Review of her "Physician Order/Admission Medication Reconciliation" received by verbal order from S17MD on 12/18/15 at 9:10 p.m. revealed an order for Lomotil 2.5 mg (milligrams) by mouth with no documented evidence of the frequency at which the Lomotil was to be administered. Further review revealed an order to weigh on Monday and Thursday.
Review of Patient #2's MAR (medication administration record) revealed Lomotil 2.5 mg oral was to be administered PRN with no documented evidence of the interval of time before the dose can be administered.
Review of Patient #2's MAR revealed she was administered Lomotil 2.5 mg on 01/04/16 at 5:00 p.m. and on 01/06/16 at 9:00 p.m. Review of the "Daily Nurse Note" and the "Multidisciplinary Note" revealed no documented evidence of an assessment by the RN of why Lomotil was administered either day.
Review of Patient #2's "Physician Progress Notes" documented by S18NP on 01/08/16 at 11:14 a.m. revealed that "staff reports Diarrhea" and care was discussed with S14MD who said to send Patient #2 to the ED for further evaluation and treatment.
Review of Patient #2's "Daily Nurse Note" of 01/03/16 at 10:00 a.m. revealed S22RN documented "sacral area (with) a small red area (with) a small tear." Further review revealed on 01/06/16 at 10:00 a.m. S22RN documented "reddened area to (left) buttock." There was no documented evidence of a completed wound assessment form with pictures and a measurement of the skin break.
Review of Patient #2's "Nursing Assessment" documented on 12/18/15 at 8:30 p.m. revealed she weighed 215 pounds. Review of her "Vital Signs and I&O (intake and output)" revealed her weight on 12/28/15 ws 200 pounds, 203 pounds on 01/05/16, and 205 pounds on 01/07/16. Further review of her medical record revealed no documented evidence of a RN's assessment of Patient #2's weight to determine the cause of a 10 pound weight loss in 20 days.
In an interview on 01/12/16 at 3:25 p.m. with S1ADM and S2DON present, S2DON confirmed the medical record had no documented evidence of an assessment of Patient #2's episodes of Diarrhea that warranted administration of Lomotil. She further confirmed there was no RN assessment of Patient #2's break in skin integrity that included measurements, no wound assessment form was completed, and no photographs were taken. S2DON indicated any weight gain or loss of 3 pounds should be reported to the physician.
Patient #5 Review of Patient #5's medical record revealed she was admitted on 01/06/16 at 11:00 p.m. with a diagnosis of Dementia with Behavioral Disturbances. Review of an incident report documented on 01/09/16 at 5:45 p.m. revealed Patient #5 fell forward from her wheelchair and hit her head on the floor.
Review of Patient #5's "Multidisciplinary Note" revealed an entry on 01/09/16 at 5:45 p.m. by S4RN that Patient #5 hit her head on the floor causing a 1 cm (centimeter) by 1 cm laceration and swelling to the right side of her forehead, no complaints of pain noted, and vital signs were within normal limits. There was no documented evidence of the results of the vital signs and a neurovascular assessment by the RN. Further review revealed Patient #5 was transferred to the ED at 6:25 p.m. by ambulance and returned to the hospital at 10:30 p.m. Review of the nursing notes and "Multidisciplinary Note" revealed vital signs were documented upon her return by S19RN with no documented evidence of a neurovascular assessment. Review of the entire record revealed no documented evidence that a neurovascular assessment was performed by the RN in accordance with the hospital's policy. No RN assessments were performed after 10:30 p.m. until the following morning about 7:00 a.m. Further review revealed no documented evidence a physician's order was received to transfer the patient to the ED and upon her return to the hospital from the ED.
In an interview on 01/12/16 at 12:15 p.m., S12RN confirmed neurovascular assessments were not performed as required by hospital policy following a head injury and confirmed there were no documented physician's order to transfer the patient to the ED and upon her return to the hospital from the ED.
Patient #R2 Review of Patient #R2's medical record revealed he was admitted on 11/12/15 with a diagnosis of Dementia. Review of an incident report dated 11/29/15 at 12:10 p.m. revealed he became unresponsive while sitting at the dining room table and awakened complaining of chest pain. He was transported to the ED by ambulance at 12:30 p.m. Further review revealed Patient #R2 returned from the ED on 11/30/15 at 8:45 p.m. Review of S15RN's documentation revealed no documented evidence of an assessment of Patient #R2 upon his return from the hospital that included vital signs.
In an interview on 01/12/16 at 3:25 p.m. with S1ADM and S2DON present, S1ADM indicated an assessment should be conducted by the RN upon a patient's return from the hospital.
3) The RN failed to implement a choking risk plan for patients identified as at risk for choking:
Review of the hospital policy titled "At Risk for Choking," presented as a current policy by S1ADM, revealed that all patients will be screened for the potential of being at risk for choking upon admission with the nurse using the Choking Risk Screening tool score sheet. Patients identified as a moderate risk on admit will be rescreened weekly thereafter for the need to implement further interventions. All patients identified as being at high risk will have all choking interventions applied. Further review revealed the patient scoring included patients scoring 1 to 3 would be at minimal risk, patients scoring 4 to 6 would be at moderate risk, and a score of greater than 7 would be high risk. If choking precautions are identified, a High Risk of Choking Treatment Plan is initiated by the RN who is responsible to ensure the Choke Risk Prevention Interventions are implemented and carried out by the assigned staff. Interventions to be implemented for moderate risk of choking included the following: 1. Complete screen on admit and weekly. 2. Dietary Evaluation to determine if dietary modification is required. 3. Choking Alert Sticker to be placed on patient's meal ticket and Report Sheet/Kardex. Interventions to be implemented for high risk of choking included the following: 1. Screen on admission and in the event of a change in status. 2. All moderate risk interventions. 3. Staff assisted eating utilizing feeding table for direct visual observation.
Patient #3
Review of Patient #3's medical record revealed he was assessed to be at moderate risk risk for choking on 12/28/15 with a score of 4 and a score of 5 on 01/02/16 and 01/09/16.

Review of Patient #3's nursing care plan for risk for choking revealed interventions included utilizing a choking alert sticker, assigning a visual monitor at meal time daily, and removing environmental hazards from his room and surroundings.

Review of his MHT "Close Observation Check Sheet" (documented by MHTs every 15 minutes) from 12/28/15 through 01/11/16 revealed no documented evidence that he was identified as being on choking precautions as evidenced by the box before the word "Choking" not being checked.

Observation in the dining room at the main campus on 01/11/16 at 12:10 p.m. revealed Patient #3 was seated at the dining table eating lunch. Further observation revealed 1 LPN and 2 MHTs were standing in the dining room with their backs to Patient #3 while he was eating. There was no observation of a visual monitor assigned to Patient #3 during his meal.

Observation of the white board in the nursing station used to list patients with their diagnosis, precautions, and observation level on 01/12/16 at 2:20 p.m. revealed no documented evidence that Patient #3 was listed as being on choking precautions.

In an interview on 01/12/16 at 2:20 p.m., S2DON confirmed Patient #3 was not identified on the white board as being on choking precautions, and his MHT observation sheets didn't designate that he was on choking precautions.

Patient #4
Review of patient #4's medical record revealed he was assessed to be at moderate risk for choking on 01/01/16 with a score of 5. Review of his nursing care plan revealed choking risk was documented as a problem, but no care plan was developed for choking. Review of his MHT observation sheets from 01/01/16 through 01/12/16 revealed no documented evidence that he was identified as being on choking precautions as evidenced by the box before the word "Choking" not being checked.

Observation of the white board in the nursing station and the MHT observation sheets on 01/12/16 at 10:50 a.m. revealed no documented evidence that Patient #4 had been identified as being at risk for choking.

In an interview on 01/12/16 at 10:55 a.m., S12RN confirmed Patient #4 was not designated as a risk for choking on the white board in the nursing station, and his MHTs notes did not have him listed as being on choking precautions.

Patient #R3
Review of Patient #R3's medical record revealed he was identified at admit on 01/11/16 as being at moderate risk for choking and had a score of 4. Review of his MHT observation sheet on 01/12/16 revealed no documented evidence that he was identified as being on choking precautions as evidenced by the box before the word "Choking" not being checked. Further review revealed no documented evidence that a nursing care

Based on record reviews and interview, the hospital failed to ensure each patient had an individualized nursing care plan developed that included interventions for all diagnoses for which the patient was being treated for 2 (#2, #4) of 5 (#1 - #5) patient records reviewed for nursing care plans from a total sample of 5 patients and 3 random patients.
Findings:

Review of the hospital policy titled "Treatment Planning; Integrated/Multidisciplinary", presented as a current policy by S1ADM, revealed that the admitting nurse formulates the initial treatment plan based on physician's orders and findings and conclusions from the Pre-admission Assessment, the Nursing Assessment, and family/significant other information within 8 hours of admit or sooner if patient's needs warrant immediate action.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 12/18/15 and was receiving medications to treat Hypertension, Hypothyroidism, and Diarrhea. Further review revealed no documented evidence that a nursing care was developed and implemented for Hypertension, Hypothyroidism, and Diarrhea.

In an interview on 01/12/16 at 3:25 p.m. with S1ADM and S2DON present, S2DON confirmed Patient #2's medical record had no documented evidence of a care plan being developed and implemented for Hypertension, Hypothyroidism, and Diarrhea. She also confirmed that Patient #2 was receiving treatment for these medical conditions during her admission.

Patient #4
Review of patient #4's medical record revealed he was admitted on 01/01/16. Review of his psychiatric evaluation revealed diagnoses of Seizure Disorder and history of Stroke. Further review revealed he was assessed to be at moderate risk for choking. Review of Patient #4's nursing care plan revealed choking was listed as a problem on the problem
list. There was no documented evidence that a care plan had been developed and implemented for choking risk and Seizure Disorder.

In an interview on 01/12/16 at 12:10 p.m., S12RN confirmed that Patient #4's care plan did not include a plan for choking and Seizure Disorder.

Based on record reviews and interview, the hospital failed to ensure medications were administered in accordance with physician orders as evidenced by S19RN informing S14MD that she had given Nitrostat 0.4 mg (milligrams) sublingual (SL) prior to receiving a physician's order and not administering Nitrostat as ordered by the physician for 1 (#4) of 1 patient record reviewed with orders for Nitrostat from a total of 5 (#1 - #5) patient records reviewed for medication administration from a total sample of 5 patients and 3 random patients.
Findings:

Review of the hospital policy titled "Medications" presented as a current policy by S1ADM, revealed that before administering a medication, the individual administering the medication verifies that the medication is correct based on the physician's medication order.

Review of Patient #4's "Multidisciplinary Note" dated 01/09/16 at 3:30 a.m. by S19RN revealed "informed (S14MD) patient given Nitrostat 0.4 mg SL and oxygen per nasal cannula at 3L (liters)/nasal cannula."

Review of Patient #4's physician orders revealed a verbal order documented as received from S14MD by S19RN on 01/09/16 at 3:35 a.m. to give Nitrostat 0.4 mg SL every 5 minutes times 3.

Review of Patient #4's MARs (medication administration record) and nursing notes revealed no documented evidence that he was administered any Nitrostat 0.4 mg SL as ordered by S14MD.

In an interview on 01/12/16 at 10:55 a.m., S12RN reviewed Patient #4's medical record and confirmed there was no documented evidence that Nitrostat 0.4 mg SL was administered to Patient #4 as ordered.

Based on observations and interviews, the hospital failed to maintain the physical plant and overall hospital environment in such a manner that the safety and well-being of patients were assured as evidenced by having clean equipment used for patients stored in the room used to store patients' belongings brought from home and in a shower stall, having cracked, peeling paint and sheetrock and peeling glue on the walls at both campuses, having cracked floor tiles, having no screens on windows that can be raised, having a toilet in the seclusion anteroom at the main campus stained with brown and pink residue, having an odor in rooms "h" and "o," having torn leather on furnishings at both campuses, having a dirty floor, collection of dust on exposed wires, and a dirty floor hopper in the housekeeping room at the main campus, and having clean linen stored on a shelf that was not covered to prevent dust collection.
Findings:

Observations at the main campus on 01/11/16 at 9:40 a.m. through 10:37 a.m. with S1ADM and S7EOC present revealed the following environmental issues:
1) Two wheelchairs and one walker were stored in the Storage Room that was used to store patients' belongings brought from outside the hospital;
2) Room "c" had loose floor molding at the bed nearest the window with exposed sheetrock, and the wall behind the bed had cracked, peeling sheetrock;
3) Room "v" with cracked floor tile next to the wall when entering the room;
4) Room "e" with peeling glue on the wall across from Bed A;
5) Room "f" with peeling paint on the right door frame and chipped wood and peeling paint on the left door frame; 14 chairs with torn leather seats or backs; 4 windows that are able to be opened with no window screens in place; the water/ice machine grill with caked-on dust;
6) Outdoor area used by patients with a rotten area on the wooden hand rail;
7) Room "g" bathroom with a toilet stained with brown and pink residue;
8) Room "h" with 4 trash cans with one can uncovered; odor noted upon entering the room;
9) Room "i" with a biohazard box with a red liner with no cover;
10) Room "j" with 2 gerichairs used for patients stored in the shower stall;
11) Room "k" with a sofa with torn leather on the arm of the sofa.
12) Housekeeping Room located inside the nursing station with a dirty floor, dust collected on exposed wiring in the room, and the floor hopper stained and dirty.

In an interview on 01/11/16 at 10:36 a.m., S7EOC confirmed the above observations.

Observations on 01/12/16 at the off-site campus at 9:15 a.m. with S12RN present revealed the following environmental issues:
1) Room "m" with 7 chairs with torn leather;
2) Peeling sheetrock and paint in several areas of hospital;
3) Room "o" with urine smell upon entering room;
4) Room "p" with a liner in the uncovered biohazard box;
5) Room "q" with a wheelchair with torn leather arm rests;
6) Room "s" with a gerichair with torn leather to the back and arm rests with exposed foam padding;
7) Room "u" with clean linen stored on shelves with no covering present to prevent dust exposure; the plastic covering was rolled and draped on top of the shelf;
8) Wheelchair in the Day Room with a torn leather seat.

All above observations were confirmed by S12RN at the time of the observation on 01/12/16 at 9:15 a.m.