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Based on interview and record review, the hospital failed to have a nursing service that provided care to patients in a safe manner.

1. Although the hospital had knowledge of patient #2's outpatient antipsychotic medication management of Invega Trinza, the patient received an additional dose of a long acting antipsychotic medication and 14 doses of a third antipsychotic medication, Risperdal. Staff failed to assess the patient for potentially life-threatening extrapyramidal symptoms (EPS) including neuroleptic malignant syndrome. Immediately after discharge the patient developed EPS and required outpatient medical intervention.

2. On two occasions patient #2 was administered a medication without a doctor's order.

3. Patient #2 was discharged with a 30 pill medication bottle of a psychotropic medication that belonged to a different patient.


Cross Refer A392 and A405

Based on interview and record review the facility failed to have a nursing service that provided adequate numbers of licensed nurse to care for all patients as needed in that 1 of 1 patients (Patient #2) was given a second dose of a long acting antipsychotic medication before it was due, was given 2 doses of a medication without a doctors order, had a medication dosage changed without a doctors order, nursing failed to document the date and time of a medication that was given, nursing staff failed to monitor the patient for life threatening side effects of the antipsychotic medications he was receiving, and was discharged with a bottle of an antipsychotic medications that did not belong to them.

Findings included:

Patient #2 was a 47-year-old male with a history of schizophrenia. The patient was admitted to the facility on 05/14/21 on an emergency detention order. The facility was aware that the patient had been on the long acting antipsychotic medication Invega Trinza. On 05/17/21 at 0902, Personnel from the outpatient clinic where the patient received treatment emailed Personnel #6 and Personnel#7 the clinics notes for Patient #2's last injection of Invega Trinza. Personnel #7 forwarded the information to Personnel #1, Personnel #4, and Personnel #9. Personnel #1 and #4 failed to make sure the information was provided to the nurses and physicians that were responsible for the direct care of Patient #2.

The Practitioners Order Sheet dated 05/18/21 at 0525 reflected an order for Invega Sustenna 234mg IM (intramuscularly) 1 dose. The Medication Administration Record (MAR) reflected the following, Risperdal 2mg tab BID (twice daily) to be given at 0900 and 2100. The 2mg dose was given twice daily from 05/17/21 through 05/24/21. The dose of Risperdal was changed to 3mg BID on 05/24/21 at 1159, the 3mg dose was given at 0900 and 2100 on 05/25/21 and 05/26/21. The MAR then reflected a dose of Risperdal 2mg BID was given at 0900 and 2100 on 05/27/21 and at 0900 on 05/28/21. There was no order to decrease the dosage. The MAR reflected on 05/20/21 that Vistaril 50mg PO (by mouth) every 4 hours as needed for anxiety. It is charted that the medication was given at 1530 and 2030 with no order being given by the physician for this medication. The MAR also reflected Invega Sustenna 234mg IM X1 dose on 05/18/21. The same medication is listed on the MAR for 05/20/21 with an order date of 05/19/21 and a consent date of 05/20/21 with a note out to the side due 06/19.

The Nursing Assessment dated 05/26/21 at 1700 reflected ..."Mouth movements noted. ..."

The undated Record of Brought in Medications with (Patient #2)'s name label reflected ..."Abilify 20mg, bedtime 30 tablets ..."


During an interview on 06/02/21 at 1219 in the Conference Room, Personnel #1 stated, she had been made aware that Patient #2 had been discharged with someone else's prescription for Abilify. Personnel#1 stated, she was unsure how this happened. Personnel #1 stated, she had spoken to Personnel #5 that day regarding the Invega Sustenna. Personnel #1 verified, she had recieved the email from the outpatient clinic that was forwarded by Personnel #7.

The facility was just now starting it's investigation. Personnel #1 verified that Vistaril 50mg PO had been administered without a physicians order. Personnel #1 verified that on 05/26/21, the patient developed signs of extrapyramidal symptoms and the nursing staff did not obtain an AIMS (Abnormal Involuntary Movement Scale) score. Personnel #1 stated, there was a separate assessment sheet that should have been on the chart that would have been done daily when the patient developed symptoms. During a follow-up interview via telephone on 06/07/21 at 0924, Personnel #1 stated, both the pharmacist and the nurse on the unit had verified that the Invega Sustenna had been administered to the patient on 05/20/21, but she did not see the time and date documented on the MAR. Personnel #1 also verified that there was no order to lower the dose of Risperdal from 3mg BID to 2mg BID on 05/27/21.

During an interview on 06/02/21 at 1356, Personnel #4 verified that she had received the email from Personnel #7 with information of Patient #2's last injection of Invega Sustenna. Personnel #4 stated, she did not give the information to the nursing unit.

The Monitoring for Abnormal Involuntary Movements Policy dated 08/2020 reflected..."4.3 Routine Monitoring 4.3..2 a) (1) The treatment team will monitor the patient using an approved standardized side effects scale. b) After the psychiatrist's review with the treatment team, the signed form shall be placed in the patient's clinical record..."

The Medication Administration and Records Policy dated 08/2020 reflected..."2.7 Medications are ordered to treat a patient's condition or symptom. Orders for medication shall be complete and understandable...4.2 Medication Administration Procedure...4.2.4 Site location will be documented for all injections...4.3 Computer-Generated MAR...4.3.1.5 Prior to using a paper MAR, a twenty-four (24) hour check of licensed practitioner's orders compared against the computerized MAR will be performed. This will be done nightly by nursing to assure accuracy of transcription and accurate computer entry by the Pharmacy Department...".

The Medication Reconciliation policy dated 10/01/20 reflected..."Procedure...2. The Physician will write or give a telephone order to the admitting Nurse of any new medication orders for the patient. These will be compared with the home medication list and any discrepancies clarified with the physician prior to any medications being administered".

Based on interview and record review, the facility failed to administer drugs in accordance with nationally accepted standards of practice, on orders of the practitioner in that 1 of 1 patient (Patient #2), was given 2 doses of a medication without a doctor's order, had a medication dosage changed without a doctor's order.

Findings included:

Patient #2 was a 47-year-old male with a history of schizophrenia. The patient was admitted to the facility on 05/14/21 on an emergency detention order...

The Medication Administration Record (MAR) reflected the following: Risperdal 2mg tab BID (twice daily) to be given at 0900 and 2100. The 2mg dose was given twice daily from 05/17/21 through 05/24/21. The dose of Risperdal was changed to 3mg BID on 05/24/21 at 1159, the 3mg dose was given at 0900 and 2100 on 05/25/21 and 05/26/21.

The MAR then reflected a dose of Risperdal 2mg BID was given at 0900 and 2100 on 05/27/21 and at 0900 on 05/28/21. There was no order to decrease the dosage. The MAR reflected on 05/20/21 that Vistaril 50mg PO (by mouth) every 4 hours as needed for anxiety. It is charted the medication was given at 1530 and 2030 with no order being given by the physician for this medication.


During an interview on 06/02/21 at 1219 in the Conference Room, Personnel #1 verified that Vistaril 50mg PO had been administered without a physician's order. During a follow-up interview via telephone on 06/07/21 at 0924 Personnel #1 also verified there was no order to lower the dose of Risperdal from 3mg BID to 2mg BID on 05/27/21.


The Medication Administration and Records policy dated 08/20 reflected..."2.7 Medications are ordered to treat a patient's condition or symptom. Orders for medication shall be complete and understandable...4.2 Medication Administration Procedure...4.3 Computer-Generated MAR...4.3.1.5 Prior to using a paper MAR, a twenty-four (24) hour check of licensed practitioner's orders compared against the computerized MAR will be performed. This will be done nightly by nursing to assure accuracy of transcription and accurate computer entry by the Pharmacy Department..."

Based on record review and interview, the facility failed to ensure appropriate arrangements for post-hospital care were made prior to discharge in that 1 of 1 patients (Patient #2) was discharged without a place to stay.

Findings included:

Patient #2 was discharged on 05/28/21 to a cousin's home that had not agreed to help the patient find lodging. The Case Managers Progress Note dated 05/24/21 at 1650 reflected, Personnel #6 had spoken to Patient #2 about staying in a hotel but the patient was not completely agreeable to the plan. Personnel #6 had spoken to Patient #2's cousin and the cousin had stated, she would not put herself out for the patient and she would do the least amount possible for him. The patient was then taken to the outpatient clinic where he receives services and left there.

During an interview with Personnel #6 on 06/02/21 at 1320, Personnel #6 stated, Patient #2's cousin had never verbally agreed for the patient to be discharged to her home. Personnel #6 stated, she told the van driver to take the patient to the outpatient clinic and leave him there.

Via email on 06/02/21 at 1356, Personnel #14 stated, they did not tell Personnel #6 to take the patient to the clinic. Personnel#14 stated, they did not know about situation until they were notified by the clinic that Patient #2 was there.

The Discharge Planning and Process policy dated 06/25/20 reflected..."Procedure...4. Discharge planning and coordination includes contact with necessary agencies and other providers to make needed arrangements...6.2 Clinical Services Staff are responsible for disposition and aftercare activities by planning and arranging services necessary to support the patient's participation in the continuum of treatment process..."