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Based on interview and record review the hospital failed to ensure the parent and/or guardian for 1 of 5 adolescent/children (Patient #4) was involved and/or participated in the treatment planning process. The hospital further failed to ensure 1 of 16 adult patients (Patient #21) was involved and/or participated in the treatment planning process.

Findings Included:

1) (Patient #4's) History and Physical dated 03/21/13 reflected, "The patient was admitted to...for psychosis has been assaultive towards his father...has been having audio and visual hallucinations..."

The Interdisciplinary Treatment Plan/Update-Inpatient with a review/revised date of 03/21/13 reflected, "Axis I to IV left blank...patent progress/lack of progress toward goals...needs family session ASAP (as soon as possible)...estimated length of stay left blank...discharge plan section left blank...no legal guardian and/or parent signature..."

The Interdisciplinary Treatment Plan Update-Inpatient with a review/revised date of 03/26/13 reflected, "Axis I to IV left blank...patient progress...appears more clear..." No patient and/or legal guardian signature. No documentation which indicated the parent/guardian was involved in the treatment planning process.

On 05/10/13 at 12:15 PM, Personnel #13 was interviewed. Personnel #13 was asked where it was documented in the medical record that the parent/family is involved in the treatment planning process. Personnel #13 stated she did not know. Personnel #13 stated patient/family members do not attend treatment team meetings.

On 05/10/13 at 01:30 PM Personnel #2 was asked to show the surveyor evidence that (Patient #4's) guardian was involved in the treatment planning process. Personnel #2 verified the patient/and/or guardian involvement in the treatment team meeting was not documented.

2) (Patient #21"s) Integrated Assessment dated 05/02/13 timed at 13:05 PM reflected, "Undifferential Schizophrenia, experiencing high level of depression...panic attacks...suicidal thoughts..."

The Interdisciplinary Individual Treatment Plan dated 05/02/13 reflected, "Identified problem...alteration in mood/potential for self-harm..." No patient signature and/or documentation indicating (Patient #21) was involved in his treatment plan.

A document entitled. "Treatment Team Meeting" dated 05/07/13 reflected, "Schizophrenia...patient mood unstable...isolative and withdrawn...reason for continued stay...medication stabilization...treatment team signatures...nurse, physician, utilization review and social service..." No documentation was found which indicated (Patient #21) was involved in the treatment plan.

On 05/14/13 at approximately 02:45 PM Personnel #2 reviewed (Patient #21's) medical record and verified there was no documentation which indicated the patient was involved in the treatment planning process.

The policy and procedure entitled, "Master Treatment Plan" with a revision date of 03/20/12 reflected, "It is the policy of...that each patient will have an individualized treatment plan that is coordinated by the interdisciplinary treatment team...the treatment team will in collaboration with the patient and identified family members develop a Master Treatment Plan that addresses the problems identified...patients and family members signature...the program therapist...is responsible for reviewing the completed plan with the patient and family member..."

Based on interview and record review the hospital failed to ensure 1 of 1 RN (Registered Nurse) Staff #23 evaluated (Patient #3) after an altercation with (Patient #14) on the PICU (psychiatric intensive care unit) on the evening of 03/22/13.

Findings Included:

1) (Patient #14's) History and Physical dated 03/23/13 reflected, "Patient is a 68 year old gentleman...found at a bus stop with his pants off, paranoid, rambling with pressured speech, and speaking nonsensically...initially very uncooperative and attempted to leave the unit... "

The Initial Nursing Assessment dated 03/22/13 timed at 17:00 reflected, "Patient brought to the PICU (Psychiatric Intensive Care Unit) actively psychotic, delusional, confused, speech rambling, disorganized...difficult to assess...monitored every fifteen minutes...at 20:30 PM patient (Patient #14) approached another male patient/removed his eye glasses witnessed by MHT (mental health technician)...redirected and moved to another area...reminded to not touch other patients or get in their personal space..."

2) (Patient #3's) Integrated Assessment dated 03/22/13 timed at 13:30 PM reflected, "Patient walked over from...patient is still having thoughts about killing..."

The physician's orders dated 03/22/13 timed at 01:00 PM reflected, "Admit to Adult..."

The Initial Nursing Assessment dated 03/22/13 timed at 14:50 PM reflected, "60 year old wears glasses...I think they want to change my medications...skin assessment...scar on midline back and midline abdomen...says doctor says he needs his medications adjusted...denies suicidal ideations or homicidal ideations...denies hallucinations and delusions...unit rules explained..."

It was noted no nursing documentation regarding an altercation between (Patient #3) and (Patient #14) was found in (Patient #3's) medical record on the evening of 03/22/13. No documentation was found which indicated (Patient #3) was evaluated for injuries.

The nursing progress notes dated 03/23/13 timed at 08:45 AM reflected, "patient complaining of bruising on upper arm says he was grabbed by an orderly....left upper arm examined...has a small red spot on left upper arm...no other discoloration noted..."

On 05/14/13 at 03:00 PM Staff #23 was interviewed. Staff #23 was asked to review (Patient #3's) medical record. Staff #23 was asked if she evaluated (Patient #3) after the altercation with (Patient #14). Staff #23 stated she thought she documented her assessment. Staff #23 acknowledged after review of the medical record there was no documentation regarding (Patient #3's) condition after the altercation with (Patient #14) which required staff intervention.

The policy entitled, "Patient reassessment" with a review date of July 2012 reflected, "Reassessment occurs on an ongoing basis via daily assessment by RN...change in condition..."

Based on interview and record review the hospital failed to ensure drugs and/or biologicals were prepared and administered in accordance with the orders of the practitioner and accepted standards of practice. 1) Medication administration documentation was not completed for 4 of 12 patients (Patient #9, #10, #13, and #15). 2) No start/stop date was transcribed to MAR (medication administration record) for 1 of 12 patients (Patient #9). 3) Accurate medication administration and/or ordered medication was not administered for 2 of 12 patients (Patient #16 and #20).

Findings Included:

1a) (Patient #9's) History and Physical dated 03/17/13 reflected, "Delusional...TV (television) sucks thoughts out of your head...had suicidal ideations..."

The physician's orders dated 03/17/13 timed at 02:00 AM reflected, "Cogentin 2 mg (milligrams) po (by mouth) BID (twice daily)."

The MAR reflected, no documentation indicating the 21:00 PM dose on 03/22/13 was administered.

1b) (Patient #10's) History and Physical dated 03/23/13 reflected, "Bipolar Disorder..inability to function, deteriorating...progressively suicidal with plan to overdose on medication..."

The physician's orders dated 03/23/13 timed at 14:50 PM reflected, "Increase Risperdal 0.5 mg po every morning and 1.5 mg po HS (hour of sleep)."

The MAR reflected, no documentation indicating the 1.5 mg dose of Risperdal was administered at the hour of sleep on 03/23/13 and 03/24/13. The Risperdal 0.5 mg po every morning was not documented as given until 03/26/13 at 09:00 AM.

1c) (Patient #13's) History and Physical dated 03/22/13 reflected, "Angry presentation...wants to hurt anyone...wakes up at night and sees blood on the walls and cannot sleep..."

The physician's orders dated 03/21/13 timed at 17:47 PM reflected, "Seroquel 300 mg po BID and Hydrocodone 10/325 one po TID (three times a day)."

The MAR reflected, Seroquel 300 mg po BID was not signed as given on 03/23/13. The Hydrocodone 10/325 one po TID was not signed as given on 03/22/13 at 13:00 PM and on 03/23/13 at 09:00 AM, 13:00 PM and 21:00 PM.

1d) (Patient #15's) History and Physical dated 05/12/13 reflected, "Patient is singing, yelling and animated...states she is a ...cheerleader...people trying to kill her and the police shot her with an AK-47..."

The physician's orders dated 05/10/13 reflected, "Ibuprofen (Motrin) 200 mg po every four hours prn (as needed) for pain (adult-2 tabs)."

The Pyxis Report dated 05/13/13 revealed, Personnel #28 removed Motrin 200 mg tablets (2) from the pyxis at 06:39 AM.

(Patient #15's) MAR revealed no documentation indicating the Motrin was administered on 05/13/13 to (Patient #15).

(Patient #15's physician's orders dated 05/10/13 reflected, "Triamterene and Hydrochlorothiazide 37.5/25 mg po in the morning."

The Pyxis Report dated 05/13/13 reflected, Personnel #28 signed out the above medication at 04:52 AM.

The MAR dated 05/13/13 reflected, the medication was scheduled for 09:00 AM. Handwritten in was "refused."

The same Pyxis Report dated 05/13/13 reflected Personnel #22 removed the Hydrochlorothiazide 37.5/25 at 18:04 PM to administer to (Patient #15).

The MAR, nursing notes and physician's orders did not reveal any documentation which indicated the reason Personnel #22 removed the medication from the pyxis.

2) (Patient #9's) physician's orders dated 03/22/13 timed at 11:00 AM reflected, "Zyprexa 30 mg po at HS."

The MAR was incomplete and revealed no start and/or stop date.

3a) (Patient #16's History and Physical dated 05/07/13 reflected, "Patient has had increased depression...has suicidal ideation..."

The physician's orders dated 05/09/13 timed at 09:00 AM reflected, "Seroquel 50 mg po every morning, noon and 150 mg po at HS."

The Pyxis Report dated 05/13/13 reflected, "Personnel #29 removed Seroquel 100 mg tablet (1) and Seroquel 50 mg tablet (1) at 07:54 AM." It was noted the scheduled dose at 09:00 AM was 50 mg. Personnel #29 signed the MAR as given. Personnel #29 signed out 100 mg over the ordered dose with no explanation addressing the excess dose of medication recorded on the Pyxis Report.

The Pyxis Report dated 05/13/13 reflected, Personnel #30 removed "Seroquel 100 mg tablets (2) which equals 200 mg at 19:01 PM. The scheduled administration time was the hour of sleep (21:00 PM). Personnel #30 signed the MAR as given and exceeded the scheduled dose by 50 mg.

(Patient #16) received 150 mg in total over the ordered dose for 05/13/13 per the Pyxis Report.

3b) (Patient #20's) Psychiatric Evaluation dated 05/02/13 reflected, "The patient is in process of psychotic illness...has regressed and currently in a psychotic state...suffers from chronic schizophrenia..."

The physician's orders dated 05/13/13 timed at 01:03 PM reflected, "Risperdal 2 mg po every morning and 2 mg BID."

The Pyxis Report dated 05/13/13 reflected, Personnel #31 did not remove the 21:00 PM dose of Risperdal and did not sign the MAR as administered. No documentation was found which indicated the reason the drug was not administered to (Patient #20).

On 05/15/13 at approximately 10:30 AM Personnel #1 reviewed the above medication administration records, physician's orders and Pyxis Records. Personnel #1 verified and acknowledged the above findings. Personnel #1 stated nursing personnel are aware of proper procedures for medication administration, documentation and transcription.

The hospital policy and procedure entitled, "Medication Administration-General Guidelines with an original policy date of 01/15/13 reflected, "Medications are not given without a physician's orders...the eight rights of medication administration will be followed...the right patient, right medication, right dose, right route, right time, right documentation, right reason and the right response...the nurse will not double or pre-pour medicines (does not set up later in the day doses)...medication not given for any reason, that are still in their blister pack, will be returned to the Pyxis for credit...the minimum and maximum doses for medication given should be known...if a nurse renders it necessary to hold a medication then the physician must be notified immediately...the physician will then let the nurse know if he/she should change, continue, stop or hold further doses...an order will be given by the physician...the effectiveness of all PRN (as necessary) medications should be charted on the MAR...nurses who administer medications are responsible for their own actions..."

The policy entitled, "Transcribing of Physician's Orders/MAR with a revision date of 05/2012 reflected, "All medication orders should include, name of medication, dose frequency, route, indication or use, date and time order written...night nurse is responsible for checking all orders written during the previous twenty-four hours to ensure transcription was accurate..."

Based on interview and record review the hospital failed to ensure 2 of 23 patients (patient #1's and Patient #4's) medical record were accurately written and completed.

Findings Included:

1) (Patient #1's) History and Physical dated 03/14/13 reflected, "Patient brought in by...police...threatening to kill herself...has been starving herself...medications...levothyroxine (synthroid, name brand) 0.025 po (by mouth) daily and synthroid (levothyroxine generic brand) 0.025 mcg (micrograms)..."

The physician's orders dated 03/15/13 reflected, "Levothyroxine 0.025 mcg po (by mouth) daily and Liothyronine (Cytomel) 0.25 mcg po daily...may use home medications..."

On 05/24/13 at 12:30 PM Staff #15 was interviewed. Staff #15 was asked to review (Patient #1's) medical record which included, physician's orders, medication administration records and history and physical. Staff #15 stated (Patient #1's) history and physical was not accurate in reference to synthroid/levothyroxine medications. Staff #15 stated (Patient #1) was on Levothyroxine 0.25 mcg daily and Liothyronine (Cytomel) 0.25 mcg daily. Staff #15 stated the physician documentation on the history and physical was inaccurate.

2) (Patient #4's) History and Physical dated 03/21/13 reflected, "The patient was admitted to...for psychosis...has been assaultive towards his father...has been having audio and visual hallucinations..."

The Interdisciplinary Treatment Plan/Update dated 03/21/13 reflected, "Need family session..."

The Registration Desk Sign in Record for 03/22/13 timed at 09:00 AM revealed (patient #4's) guardian arrived for a family session.

The group progress notes dated 03/20/13 through 03/27/13 were reviewed. No documentation was found which indicated a family session was conducted with (Patient #4) and his guardian.

On 05/09/13 at 02:35 PM Personnel #2 was interviewed. Personnel #2 was asked to review (Patient #4's) medical record for evidence of the family session scheduled for 03/22/13. Personnel #2 stated it was not in the chart and was not documented.

On 05/10/13 at 12:15 PM Personnel #13 was interviewed. Personnel #13 was asked by the surveyor if she could provide the family session note for (Patient #4) held on 03/22/13. Personnel #13 stated she wrote the family session note and thought it was filed in the medical record. Personnel #13 stated she could not provide the family session note.