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Based on review of literature and review of 1 of 3 clinical records documentation did not include information necessary to monitor the patients condition.
Findings:

Citing patient #2, a 66 year old male admitted to the facility on 12/16/2010. The patient was transferred from an acute care hospital and records from this hospital were transferred with the patient. Review of the records from the acute care hospital reflected the patient was brought to their facility after an overdose and admitted to ICU in respiratory failure. The record reflected the patient had "Syndrome of Inappropriate Antidiuretic Hormone Secretion" (SIAH) which causes hyponatremia per literature review. The record reflected the patient had been self-administering the medication DDAVP for urinary incontinence. per literature review DDAVP also causes hyponatremia.. Noted by the nephrology physician was strong advice to the patient not to take DDAVP.

However, upon admission to the psychiatric hospital the attending psychiatrist ordered DDAVP 0.1mg QHS. On 12/26/2010 DDAVP was increased to QAM and QHS. Although the patient had an admission axis III diagnosis of hyponatremia no tests for sodium were ordered and no documentation to explain the order for DDAVP and no order for sodium testing.

On 1//1/2011 the patient was transferred to a local ER for suspected fracture of the shoulder and the patient was subsequently admitted. This record reflected that one of the admission diagnosis was severe hyponatremia; Sodium level was 108.