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Based on interview, record review and review of the facility's Nursing Assessment and Documentation Policy, it was determined the facility failed to ensure the Registered Nurse (RN) evaluated and assessed one (1) of ten (10) patients (Patient #6) for a significant medical or psychiatric change. Patient #6 was transferred to a local hospital on 12/25/12 with significant changes in medical and psychiatric condition including a dislocated jaw. There was no documented evidence staff had identified or reported Patient #6's deteriorating condition to the Physician.

The findings include:

Review of the facility's policy titled Nursing Department Policies and Procedures, Section three (3), Assessment and Documentation (undated), revealed a patient assessment should be completed each shift addressing both psychiatric symptoms and pertinent medical issues. Further review of the facility's policy revealed, any significant changes may require additional documentation as a progress note entry. Additionally, any significant change in behavior or condition (psychiatric or medical) shall be documented by a licensed staff member in the Progress Notes.

Record review revealed the facility admitted Patient #6 on 12/21/12 at 4:15 AM. Patient #6 was admitted on a seventy-two (72) hour court ordered evaluation with diagnoses which included Anxiety State, Adjustment Reaction, Episodic Mood Disorder, Hypokalemia, Delirium and Personality Disorder.

Review of Patient #6's progress note of 12/21/12 at 4:20 PM, revealed Patient #6 had fallen asleep in his/her wheel chair and fell forward striking his/her chin on a table and then falling onto the floor. Further review of the progress notes revealed the Physician was notified and assessed Patient #6 on 12/21/12 at 4:25 PM.

Record review of the facility's Nursing Notes revealed Patient #6 had normal speech all three shifts of 12/21/12 and 12/22/12. Review of the Nursing Notes for 12/22/12 revealed Patient #6 was found in bed vomiting and acting bizarre at 1:15 AM. Further review of the Nursing Notes for 12/22/12 revealed at 7:30 PM, Resident #6 went limp while being assisted to the beside toilet, with documentation of the Physician being made aware. Review of the facility's Nursing Notes for 12/23/12 and 12/24/12 revealed a significant change in Patient #6's speech from normal to incoherent; however, no documented evidence was found that the Physician was notified of this significant change until 12/25/12.

Review of the Physician's note, dated 12/25/12 at 2:35 AM, revealed Patient #6 was lying in bed with mouth open, could not swallow, was unable to talk, could not stand and not able to follow all directions. Further review revealed Patient #6 was transferred to a local medical hospital for further evaluation.

Review of the Emergency Department notes from the medical hospital dated 12/25/12, revealed Patient #6 had a dislocated jaw that required medical intervention with conscious sedation to reduce to proper placement. Review further revealed Patient #6 was admitted to a medical bed for continued care.

Interview with the Charge Nurse, on 01/04/13 at 4:15 PM, revealed the nursing staff should have assessed the patient for both medical and psychiatric changes. Further interview revealed the Physician should have been notified of all significant changes.

Interview with the Unit Manager, on 01/04/13 at 2:40 PM, revealed the facility did not have a specific policy on Physician notification of medical issues with the exception of the Vital Sign Policy that listed abnormal values that should be called to the Physician. Further interview revealed her expectation was that the Physician would be notified for any significant change.



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Based on interview, record review and review of the facility's policy, it was determined the facility failed to administer medication in accordance with orders of the practitioner responsible for the patient's care and facility policy for one (1) of ten (10) sampled patients (Patient #6). On 12/21/12, the Physician for Patient #6 ordered Ciprofloxacin (Cipro) 500 mg (antibiotic) by mouth twice each day. Patient #6 did not receive the ordered morning dose of Cipro for the date of 12/24/12.

The findings include:

Review of the facility's policy titled General Hospital Policies, Section 11, Medication Management Policies, (undated), revealed when there was a time lapse for medication administration for clinical reasons longer than two (2) hours, the Physician must be notified. Further review revealed the staff should document in the Shift Assessment/Daily Note form the reason for being late or withholding the medication and instructions received from the Physician. The facility's policy on Medication Management further revealed when a patient refused a medication, staff should document in the Shift Assessment/Daily Note form the patient's reason for refusal, staffs attempts to encourage compliance, and notification of the Physician.

Record review revealed the facility admitted Patient # 6 on 12/21/12 at 4:15 AM. Patient #6 was admitted on a seventy-two (72) hour court ordered evaluation with the diagnoses which included Anxiety State, Adjustment Reaction, Episodic Mood Disorder, Hypokalemia, Delirium and Personality Disorder.

Review of the Physician Orders for Patient #6, dated 12/21/12, revealed Ciprofloxacin (antibiotic) 500 mg was to be given by mouth twice each day.

Review of Patient #6's Progress Notes, dated 12/25/12 at 12:40 AM, revealed Patient #6 had missed a dose of Ciprofloxacin on 12/24/12 at 9:00 AM. There was no documented evidence found in the nursing notes or progress notes for the date of 12/24/12 that the dose had been missed per the facility's Medication Management Policy. Additionally, there was no documented evidence found that the ordering Physician was notified that an ordered medication was not given per the facility's Medication Management Policy. Additionally, there was no documented evidence found identifying the reason that the dose of medication was not given to the patient per the facility's Medication Management Policy.

Interview with Registered Nurse (RN) #3, on 01/04/13 at 3:00 PM, revealed one of her duties was to given medications to the patients. RN #3 stated when a patient refused to take a medication, she would tell the charge nurse. Interview further revealed RN #3 thought the charge nurse was the staff responsible for informing the Physician of the refusal or if the medications were not given and the reason they were not given.

Interview with the Unit Manager, on 01/04/13 at 2:40 PM, revealed there was a facility policy that addressed a missed dose of medication. Interview further revealed, the policy and her expectation was to notify the Physician for missed doses of medication and to document the date, time, medication missed, reason, the Physician notification and any new orders given per the facility's policy.