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Based on observation, interview, and record review, nursing failed to supervise the care of each patient per policy and professional nursing standards of practice. Nursing staff:

a. failed to ensure three (3) patients wore the required identification bands ( Patient # 4, 10, 13) ;

b. failed to document implementation of physician orders in the patient medical record- [precaution levels]-.Patient ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13).

Findings included:

a. Patient identification bands:

Review of facility policy titled " Hospital Armbands," dated 4/1/2020, showed: Purpose: to establish guidelines to ensure patient safety..utilizing pre-printed color- coded wrist bands. All patients will have an ID band placed before treatment is initiated. The ID band is placed on the extremity ( preferably the arm).

Observation during initial tour of the nursing unit on 9/14/2022 between 9:20 AM an 10:15 AM showed the following:

-three (3) patients not wearing hospital identification bands: Patient IS #s # 4, 10, and 13.

During an interview with Staff J, LVN at the time of observation , she verified the three (3) patients did not have ID bands on and stated the ID bands were required.

b. Implementation of physician orders [precaution levels]:

Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document:
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;

Review of facility policy titled "Documentation," dated 02/01/2022, showed: Purpose:...to provide concise and comprehensive information as part of a legal document...Daily..Routine : The RN and or LVN documents the implementation and execution of physician and NP orders.

During the initial tour of the nursing unit on 9/14/2022 between 9:20 AM an 10:15 AM surveyor asked Staff E, Mental health tech (MHT) to see her patient observation sheets ( "q 15 minute obs"). The observation sheet did not show what current precautions were ordered for the patient. When asked how she knew what current precautions were ordered for her assigned patients, Staff E said the MHTs do a verbal shift report and precaution information was communicated . The shift report was documented on a handwritten paper.

Observation on 09/15/22022 showed an erasable white board posted on a back wall inside the nurses' station. The white board showed patient first names /initials and current precaution levels.

During an interview on 09/15/2022 at 4:30 PM with Staff B, Director of Nurses (DON), 13 patient records were reviewed by DON and surveyor [Patient ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]. Physician orders for all 13 patients were reviewed .

Review of a facility form titled "Admit Orders /Initial Plan of Care-Texas ") -showed the following choices listed for physician orders for precaution levels: "8). Precautions: Suicide; Violence/Homicide; Falls; CIWA/Detox; IC; Seizure; Bleeding; Choking; and Elopement." The DON verified this was the form used by the physicians to write patient admission orders. She also said precaution levels required a physician order.

When asked to show daily implementation of physician orders for precaution levels (Patient ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13), record review showed the following:

- Patient # 1: no daily documentation of nursing implementation of "Violence/Homicide" precautions, as ordered.
- Patient # 2: no daily documentation of nursing implementation of "Suicidal ideation, Elopement, or Choking " precautions, as ordered.
- Patient # 3: no daily documentation of nursing implementation of "Violence/Homicide" precautions, as ordered.
- Patient # 4: no daily documentation of nursing implementation of "Fall" precautions, as ordered.
- Patient # 5: no daily documentation of nursing implementation of "Violence/Homicide" precautions, as ordered.
- Patient # 6: no daily documentation of nursing implementation of "Falls and Seizure " precautions, as ordered.
- Patient # 7: no daily documentation of nursing implementation of "Violence/Homicide" precautions, as ordered.
- Patient # 8: no daily documentation of nursing implementation of "Violence/Homicide" precautions, as ordered.
- Patient # 9: no daily documentation of nursing implementation of "Violence/Homicide and Fall" precautions, as ordered.
- Patient # 10: no daily documentation of nursing implementation of "Violence/Homicide and Fall" precautions, as ordered.
- Patient # 11: no daily documentation of nursing implementation of "Violence/Homicide and Fall" precautions, as ordered.
- Patient # 12: no daily documentation of nursing implementation of "Violence/Homicide, Fall, & Elopement " precautions, as ordered.
- Patient # 13 :no daily documentation of nursing implementation of "Suicide Ideation; Fall, & Bleeding" precautions, as ordered.

During continued interview with the DON, she acknowledged the white board and and shift reports related to precaution levels were not part of the patient record to show on-going implementation of physician orders.

Based on record review and interview, the facility failed to ensure its policy for medication administration was specific to the patient population served.

Findings included:

Record review of facility policy titled: "Principles of Medication Administration," dated 09/01/2020, showed:

...6. The 5 "rights" of medication administration include:

"Patients-included checking name, date of birth, prescribing practitioner name on order, MAR, and patient identification band. Utilize 2 forms of identification prior to administering meds..."

During an interview in 09/15/2022 at 4:15 PM with the DON, she verified the facility medication administration policy did not specify forms of identification that were acceptable.

The DON acknowledged the behavioral health population can exhibit cognition issues related to their disease processes. Not all forms of "usual / routine" identification may be appropriate or valid.