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Based on medical record reviews, review of facility policies and interviews for two of ten Patients (Patients #1 and #2), the facility failed ensure a safe environment for Patient #2. The findings include:

Patient #1 had a diagnosis of dementia with delusions and paranoia and was roommates with Patient #2. Patient #1's assessment dated 2/2/13 identified that the patient had a history of physical aggression, mood was anxious and utilized a walker for gait. The plan of care dated 2/1/13 indicated that the patient had a mood problem related to paranoid delusions and interventions included to monitor for safety and alarms on at all times.

Patient #2's diagnoses included Alzheimer's disease and altered mental status with delirium. The assessment dated 2/7/13 identified that the patient had visual hallucinations prior to admission and was alert and confused. The patient's plan of care was reviewed with RN #1 on 1/21/13 and interview indicated a problem with altered mood related to anxious behavior and to monitor for safety.

Nursing narratives and/or the facility investigation dated 2/8/13 and/or staff interviews on 2/19/13, 2/20/13 and 2/21/13 identified that on 2/8/13 at 4:40 AM, Patient #1 was out of bed, tried to barricade the door with a chair, and although the patient's bed alarm was on and working prior to the incident, the alarm did not sound. Patient #1's progress notes by APRN #1 dated 2/8/13 indicated that Patient #1 admitted to physically assaulting Patient #2 stating "I did not hit him/her, I strangled him/her" and that the patient believed that "people on the outside were going to kill us." Patient #1 assaulted Patient #2 prior to the attempt to barricade the door.

Patient #2's nursing narratives dated 2/8/13 identified that the patient had a restless sleep at times and was found unresponsive, with cyanotic hands and feet, labored respirations and a bruise to the left side of the face. Patient #2 was sent to the emergency room per physician's order on 2/8/13. Patient #2's acute care record dated 2/8/13 identified that the patient's chief complaint was "assault." The patient was awake, without labored respirations, had ecchymosis to the left cheek, and required reassurance that he/she was okay and safe. Patient #2 was admitted to the hospital with diagnoses that included new onset of atrial fibrillation, syncope and seizures.

Interview with CNA #1 on 2/21/13 at 10 AM noted that s/he had to turn off Patient #1's bed alarm twice when the patient went to the bathroom, the alarm automatically resets when the patient goes back to bed and s/he did not know why the alarm did not sound at 4:40 AM on 2/8/13. Review of the alarm check sheet indicated that Patient #1's alarm was checked at the beginning and end of the shift on 2/8/13 and the alarm was working. Interview with RN #1 on 2/21/13 at 9:45AM identified that staff tried to move the patient's alarm out of reach because the patient could turn off the alarm. RN #1 further indicated that the patient must have shut the alarm off on 2/8/13 before the alarm could be heard by staff. Review of the patient's plan of care with the VP of Nursing on 2/21/13 at 2:50 PM noted that the patient's plan of care did not identify the patient's non-compliant behavior with alarm safety devices and/or contain new interventions to monitor patient activity, to maintain safety. Subsequent to the event, Patient #1 was placed on 1 to 1 monitoring. Interview with the VP of Nursing on 2/21/13 at 2:50 PM identified that the facility was reviewing the possibility of purchasing different safety alarms.

In addition, close observation sheets dated 2/1/13 to 2/8/13 noted that observations of the patient were recorded every 15 minutes and included if the patient was awake or asleep and the location of the Patient. Although review of the facility observing/close monitoring policy directed that the observation/documentation include behavior and activity of the patient as well as location and level of consciousness, activity and behavior had not been documented. Interview with the VP of Nursing on 2/12/13 at 10:20 AM and/or 10:45 AM indicated that the unit was a 22 bed unit, and every patient was monitored every 15 minutes unless the patient was placed on 1 to 1 monitoring for safety. Interview with the Administrator on 2/19/13 at 1:00 PM noted that following this incident, the facility had begun the process to revise the observation/monitoring sheets to include more information.
The facility patient rights policy identified that the patient had the right to be free from physical abuse or harm.

Based on medical record reviews, review of facility policies and interviews for two of ten Patients (Patients #1 and #2), the facility failed ensure that the patients were adequately supervised. The finding includes:

Patient #1 had a diagnosis of dementia with delusions and paranoia and was roommates with Patient #2. Patient #1's assessment dated 2/2/13 identified that the patient had a history of physical aggression, mood was anxious and utilized a walker for gait. The plan of care dated 2/1/13 indicated that the patient had a mood problem related to paranoid delusions and interventions included to monitor for safety and alarms on at all times.

Patient #2's diagnoses included Alzheimer's disease and altered mental status with delirium. The assessment dated 2/7/13 identified that the patient had visual hallucinations prior to admission and was alert and confused. The patient's plan of care was reviewed with RN #1 on 1/21/13 and interview indicated a problem with altered mood related to anxious behavior and to monitor for safety. Nursing narratives and/or the facility investigation dated 2/8/13 and/or staff interviews on 2/19/13, 2/20/13 and 2/21/13 identified that on 2/8/13 at 4:40 AM Patient #1 was out of bed, tried to barricade the door with a chair and although the patient's bed alarm was on and working prior to the incident, the alarm did not sound.

Patient #1's progress notes by APRN #1 dated 2/8/13 indicated that Patient #1 admitted to physically assaulting Patient #2 stating "I did not hit him/her, I strangled him/her" and that the patient believed that "people on the outside were going to kill us." Patient #1 assaulted Patient #2 prior to the attempt to barricade the door.

Patient #2's nursing narratives dated 2/8/13 identified that the patient had a restless sleep at times and was found unresponsive, with cyanotic hands and feet, labored respirations and a bruise to the left side of the face. Patient #2 was sent to the emergency room per physician's order on 2/8/13. Patient #2's acute care record dated 2/8/13 identified that the patient's chief complaint was assault. The patient was awake, without labored respirations, had ecchymosis to the left cheek, and required reassurance that he/she was okay and safe. Patient #2 was admitted to the hospital with diagnoses that included new onset of atrial fibrillation, syncope and seizures.

Interview with CNA #1 on 2/21/13 at 10 AM noted that s/he had to turn off Patient #1's bed alarm twice when the patient went to the bathroom, the alarm automatically resets when the patient goes back to bed and s/he did not know why the alarm did not sound at 4:40 AM on 2/8/13. Review of the alarm check sheet indicated that Patient #1's alarm was checked at the beginning and end of the shift on 2/8/13 and the alarm was working. Interview with RN #1 on 2/21/13 at 9:45AM identified that staff tried to move the patient's alarm out of reach because the patient could turn off the alarm. RN #1 further indicated that the patient must have shut the alarm off on 2/8/13 before the alarm could be heard by staff. Review of the patient's plan of care with the VP of Nursing on 2/21/13 at 2:50 PM noted that the patient's plan of care did not identify the patient's non- compliant behavior with alarm safety devices and/or new interventions to monitor patient activity to maintain safety. Subsequent to the event, Patient #1 was placed on 1 to 1 monitoring. Interview with the VP of Nursing on 2/21/13 at 2:50 PM identified that the facility was reviewing the possibility of purchasing different safety alarms.

In addition, close observation sheets dated 2/1/13 to 2/8/13 noted that observations of the patient were recorded every 15 minutes and included if the patient was awake or asleep and the location of the Patient. Although review of the facility observing/close monitoring policy directed that the observation/documentation include behavior and activity of the patient as well as location and level of consciousness, activity and behavior had not been documented. Interview with the VP of Nursing on 2/12/13 at 10:20 AM and/or 10:45 AM indicated that the unit was a 22 bed unit, and every patient was monitored every 15 minutes unless the patient was placed on 1 to 1 monitoring for safety. Interview with the Administrator on 2/19/13 at 1PM noted that the facility had begun the process to revise the observation/monitoring sheets to include more information.
The facility patient rights policy identified that the patient had the right to be free from physical abuse or harm.

Based on medical record reviews, review of facility policies and interviews for ten of ten Patients (Patients #1 through #10), the facility failed to develop an individualized plan of care and/or revise the patient's plan of care. The finding includes:

a. Patient #1 had a diagnosis of dementia with delusions and paranoia and was roommates with Patient #2. Patient #1's assessment dated 2/2/13 identified that the patient had a history of physical aggression and mood was anxious. The plan of care dated 2/1/13 indicated that the patient had problems that included deficiencies in sleep pattern and interventions included alarms (bed/chair) on at all times. Nursing narratives and/or the facility investigation dated 2/8/13 and/or staff interviews on 2/19/13, 2/20/13 and 2/21/13 identified that Patient #1 was out of bed, tried to barricade the door with a chair and although the patient's bed alarm was on and working prior to the incident, the alarm did not sound. The investigation and/or progress notes by APRN #1 dated 2/8/13 indicated that Patient #1 admitted to physically assaulting Patient #2 (bruise under left eye) prior to the attempt to barricade the door. Interview with CNA #1 on 2/21/13 at 10 AM noted that s/he had to turn off Patient #1's bed alarm twice when the patient went to the bathroom, the alarm automatically resets when the patient goes back to bed and s/he did not know why the alarm did not sound at 4:40 AM on 2/8/13. Review of the alarm check sheet indicated that Patient #1's alarm was checked at the beginning and end of the shift on 2/8/13 and the alarm was working. Interview with RN #1 on 2/21/13 at 9:45AM identified that staff tried to move the patient's alarm out of reach because the patient could turn off the alarm. RN #1 further indicated that the patient must have shut the alarm off on 2/8/13 before the alarm could be heard by staff. Review of the patient's plan of care with the VP of Nursing on 2/21/13 at 2:50 PM noted that the patient's plan of care did not identify the patient's non- compliant behavior with alarm safety devices and/or new interventions to monitor patient activity to maintain safety.

In addition, Patient #1's assessment dated 2/2/13 identified that the patient was medication compliant. The plan of care dated 2/1/13 incorrectly identified a problem with medication compliance, directed to monitor for medication compliance and add to care plan the most effective means to ensure medication compliance. The physician order dated 2/4/13 directed Zyprexa 2.5mg by mouth at hour of sleep. The medication record noted that the Zyprexa was administered to the patient on 2/4/13, 2/5/13, and 2/6/13 at 8 PM. Although the medication record identified that Patient #1 refused the Zyprexa from 2/7/13 through 2/12/13 and the facility had initiated the assistance of the court for medication administration, the plan of care had not been updated. Interview with RN #1 on 2/21/13 at 11:30 AM noted that the patient's plan of care should identify medication refusal when a pattern of refusal was identified.

b. Patient #2's diagnoses included Alzheimer's disease and altered mental status with delirium. The assessment dated 2/7/13 identified that the patient had visual hallucinations prior to admission and was confused. The patient's plan of care was reviewed with RN #1 on 1/21/13 and identified the following: A problem of behavior management and the space to identify the inappropriate behavior was left blank. The problem of complex pharmacology (Patient on Risperdal) lacked the number of days that the patient will take the medication without side effects (was left blank). The problem of combative or aggressive behavior was incomplete and left blank for the behavior exhibited by the patient and the number of days that the patient would not exhibit the behavior. The problem of unstable medical conditions was also identified and interventions were not documented. Alteration in mood was noted as a problem and the "related to", "as evidenced by" and number of days the patient's mood would remain stable were not completed and were left blank. Interview with RN #1 on 1/21/13 at 11:15 AM indicated that the patient had anxious behaviors, would push or slap staff hands lightly during the administration of personal care, mood was sad and depressed and the patient's history and physical and medical record from 2/5/13 to 2/21/13 did not identify any unstable medical conditions.
c. Patient #3's diagnoses included dementia and probable manic depressive disorder. The patient's physician's orders and plan of care initiated on 2/12/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient was not on antipsychotic medications, therefore the intervention that the team would attempt psychotropic medication dose reduction did not apply.
d. Patient #4's diagnoses included schizophrenia. The patient's plan of care initiated on 1/25/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had altered mood related to the schizophrenia as evidenced by paranoia, hallucinations and assaultive behavior and the goal for the number of days that the patient would remain stable was left blank. The problem of combative or aggressive behavior lacked the behavior that the patient exhibited and was left blank.
e. Patient #5's diagnoses included bipolar disorder. The patient's physician's orders and plan of care initiated on 2/16/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient was on multiple antipsychotic medications and although the problem of complex pharmacology was noted on the patient's plan of care, the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete. The problem of combative or aggressive behavior lacked the behavior that the patient exhibited and was left blank.
f. Patient #6's diagnoses included Alzheimer's disease with depression. The patient's plan of care initiated on 1/25/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. The plan of care indicated that the patient had a problem with complex pharmacology (psychotropic medications). Interview with RN #1 on 1/20/13 at 1:40 PM noted that this problem did not apply as the patient's antipsychotic medication had been discontinued on 2/3/13.
g. Patient #7's diagnoses included schizoaffective disorder and anxiety. The patient's plan of care initiated on 2/15/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited and number of days the patient would not exhibit the behavior was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. Although the plan of care indicated that the patient had a problem with complex pharmacology (psychotropic medications), the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete.
h. Patient #8's diagnoses included bipolar disorder and dementia. The patient's physician's orders and plan of care initiated on 1/30/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. Although the patient's medications included Abilify and care plan included the problem of complex pharmacology (psychotropic medications), the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete.
i. Patient #9's diagnoses included dementia with behavioral disturbances and schizophrenia. The patient's plan of care initiated on 2/1/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited and number of days the patient would not exhibit the behavior was left blank and incomplete. Alteration in mood was noted as a problem and the "related to", "as evidenced by" and number of days the patient's mood would remain stable were not completed and were left blank.
j. Patient #10's diagnoses included dementia with behavioral disturbances. The patient's plan of care initiated on 2/15/13 was reviewed with RN #1 on 2/20/13 at 1:40 PM and identified a problem of behavior management and the inappropriate behavior exhibited by the patient was left blank. Interview with RN #1 on 2/20/13 at 1:40 PM identified that although the patient had hit others with a cane prior to admission, the patient did not exhibit the behavior since admission on 2/14/13.
Interview with the Vice President of Nursing on 2/20/13 at 10:25 AM noted that upon admission, twelve standard problems are uploaded to the every patient's plan of care and the nurse was responsible to individualize the plan of care and/or delete problems that don't apply and this had not been done. S/he further indicated that potential problems had to be entered as actual problems or computer prompts for continuous monitoring and documentation of these potential problems would not be done. The VP of Nursing identified that the facility was in the process of reverting back to paper charting of care/treatment plans until the computer problem could be solved.
The facility policy for interdisciplinary treatment plans directed that the plan be initiated within 24 hours and problems are listed on the plan as they are identified. The policy also identified that interventions are individualized and relate to the specific objectives which are derived from the identified/presenting problems.
The facility submitted a corrective action plan dated 2/12/13 to include policy review and the development of a committee to evaluate the observation monitoring sheet for future revision. However, the corrective action plan failed to address the known problem (10/2012) with the computerized care plans effecting patient problems and interventions.

The condition of Medical Records has not been met as evidenced by the facilities failure to address known problems (10/2012) with the computerized medical record in regards to care plan development, identification of patient problems, and establishing and updating interventions.
Please see A449.

Based on medical record reviews, review of facility policies, and interviews for ten of ten Patients (Patients #1 through #10), the facility failed to include documentation of patient behavior and activity for behavioral health unit patients with the standard every 15 minute monitoring and/or 1 to 1 monitoring, and failed to develop/document an individualized plan of care and/or revise the patient's plan of care. The finding includes:

a. Patient #1 had a diagnosis of dementia with delusions and paranoia and was roommates with Patient #2. Patient #1's assessment dated 2/2/13 identified that the patient had a history of physical aggression and mood was anxious. The plan of care dated 2/1/13 directed to monitor for safety. Nursing narratives and/or the facility investigation dated 2/8/13 and/or staff interviews on 2/19/13, 2/20/13 and 2/21/13 identified that Patient #1 was out of bed at 4:40 AM on 2/8/13, admitted to physically assaulting Patient #2 (bruise under Patient #2's left eye) and then tried to barricade the door with a chair. Subsequent to the incident, Patient #1 was placed on 1 to 1 monitoring. Close observation sheets dated 2/1/13 to 2/21/13 noted that observations of the patient were recorded every 15 minutes and included if the patient was awake or asleep and the location of the Patient. Although review of the facility observing/close monitoring policy directed that the observation/documentation include behavior and activity of the patient as well as location and level of consciousness, activity and behavior had not been documented. Interview with the VP of Nursing on 2/12/13 at 10:20 AM and/or 10:45 AM indicated that the unit was a 22 bed unit, and every patient was monitored every 15 minutes unless the patient was placed on 1 to 1 monitoring for safety. Interview with the Administrator on 2/19/13 at 1 PM noted that the facility had begun the process to revise the observation/monitoring sheets to include more information.

In addition, interview with RN #1 on 2/21/13 at 9:45 AM identified that staff tried to move the patient's alarm out of reach because the patient had turn off the alarm in the past. RN #1 further indicated that the patient must have shut the alarm off on 2/8/13 before the alarm could be heard by staff. Review of the patient's plan of care with the VP of Nursing on 2/21/13 at 2:50 PM noted that the patient's plan of care did not identify the patient's non- compliant behavior with alarm safety devices and/or new interventions to monitor patient activity to maintain safety.

b. Patient #2's diagnoses included Alzheimer's disease and altered mental status with delirium. The assessment dated 2/7/13 identified that the patient had visual hallucinations prior to admission and was confused. The patient's plan of care was reviewed with RN #1 on 1/21/13 and identified the following: A problem of behavior management and the space to identify the inappropriate behavior was left blank. The problem of complex pharmacology (Patient on Risperdal) lacked the number of days that the patient will take the medication without side effects (was left blank). The problem of combative or aggressive behavior was incomplete and left blank for the behavior exhibited by the patient and the number of days that the patient would not exhibit the behavior. The problem of unstable medical conditions was also identified and interventions were not documented. Alteration in mood was noted as a problem and the "related to", "as evidenced by" and number of days the patient's mood would remain stable were not completed and were left blank. Interview with RN #1 on 1/21/13 at 11:15 AM indicated that the patient had anxious behaviors, would push or slap staff hands lightly during the administration of personal care, mood was sad and depressed and the patient's history and physical and medical record from 2/5/13 to 2/21/13 did not identify any unstable medical conditions.
c. Patient #3's diagnoses included dementia and probable manic depressive disorder. The patient's physician's orders and plan of care initiated on 2/12/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient was not on antipsychotic medications, therefore the intervention that the team would attempt psychotropic medication dose reduction did not apply.
d. Patient #4's diagnoses included schizophrenia. The patient's plan of care initiated on 1/25/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had altered mood related to the schizophrenia as evidenced by paranoia, hallucinations and assaultive behavior and the goal for the number of days that the patient would remain stable was left blank. The problem of combative or aggressive behavior lacked the behavior that the patient exhibited and was left blank.
e. Patient #5's diagnoses included bipolar disorder. The patient's physician's orders and plan of care initiated on 2/16/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient was on multiple antipsychotic medications and although the problem of complex pharmacology was noted on the patient's plan of care, the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete. The problem of combative or aggressive behavior lacked the behavior that the patient exhibited and was left blank.
f. Patient #6's diagnoses included Alzheimer's disease with depression. The patient's plan of care initiated on 1/25/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. The plan of care indicated that the patient had a problem with complex pharmacology (psychotropic medications). Interview with RN #1 on 1/20/13 at 1:40 PM noted that this problem did not apply as the patient's antipsychotic medication had been discontinued on 2/3/13.
g. Patient #7's diagnoses included schizoaffective disorder and anxiety. The patient's plan of care initiated on 2/15/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited and number of days the patient would not exhibit the behavior was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. Although the plan of care indicated that the patient had a problem with complex pharmacology (psychotropic medications), the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete.
h. Patient #8's diagnoses included bipolar disorder and dementia. The patient's physician's orders and plan of care initiated on 1/30/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited was left blank and incomplete. Altered mood was identified as a problem and the areas for " related to" and "as evidenced by" were left blank and incomplete. Although the patient's medications included Abilify and care plan included the problem of complex pharmacology (psychotropic medications), the number of days that the patient would remain on the lowest dose of psychotropic medication without side effects was left blank and incomplete.
i. Patient #9's diagnoses included dementia with behavioral disturbances and schizophrenia. The patient's plan of care initiated on 2/1/13 was reviewed with RN #1 on 1/20/13 at 1:40 PM and identified that the patient had combative or aggressive behavior and documentation for the behavior exhibited and number of days the patient would not exhibit the behavior was left blank and incomplete. Alteration in mood was noted as a problem and the "related to", "as evidenced by" and number of days the patient's mood would remain stable were not completed and were left blank.
j. Patient #10's diagnoses included dementia with behavioral disturbances. The patient's plan of care initiated on 2/15/13 was reviewed with RN #1 on 2/20/13 at 1:40 PM and identified a problem of behavior management and the inappropriate behavior exhibited by the patient was left blank. Interview with RN #1 on 2/20/13 at 1:40 PM identified that although the patient had hit others with a cane prior to admission, the patient did not exhibit the behavior since admission on 2/14/13.
Interview with the Vice President of Nursing on 2/20/13 at 10:25 AM noted that upon a patient's admission, twelve standard problems are uploaded to the patient's plan of care. The nurse was responsible to individualize the plan of care and/or delete problems that don't apply and this had not been done. S/he further indicated that potential problems had to be entered as actual problems or computer prompts for continuous monitoring and documentation of these potential problems would not be done. The VP of Nursing identified that the facility was in the process of reverting back to paper charting of care/treatment plans until the computer problem could be solved.
The facility policy for interdisciplinary treatment plans directed that the plan be initiated within 24 hours and problems are listed on the plan as they are identified. The policy also identified that interventions are individualized and relate to the specific objectives which are derived from the identified/presenting problems.

The facility submitted a corrective action plan dated 2/12/13 to include policy review and the development of a committee to evaluate the observation monitoring sheet for future revision. However, the corrective action plan failed to address the known problem (10/2012) with the computerized care plans effecting patient problems and interventions.